Tag Archives: therapy

A scar is not a wound: A metaphor for counseling

By Peter D. Ladd November 10, 2016

In the client-counselor relationship, describing traumas from past experiences can reveal unresolved suffering in which a client’s beliefs, emotions and behaviors are filled with deep negative images. Ideally, clients will share their trauma with therapists and how images from the past continue to affect them. By describing their trauma, many clients can normalize past experiences and are able to face future traumas with more positive attitudes.

However, as counselors, we realize how accessible these traumas become for clients who slowly drift back into old patterns when new trauma enters their lives. New trauma that is even remotely similar to past trauma can resurrect old beliefs, trigger negative emotions and generate compulsive patterns of behavior. The question becomes, how do counselors stop clients from drifting back into old traumatic patterns when new traumas enter their lives?

 

Using metaphors

One successful possibility is the use of metaphors. According to Judy Belmont, metaphors allow counselors to unlock a client’s way of thinking by creating flexibility and evoking emotion. They allow clients to visualize their thoughts and connect them to their feelings.

Neurologically speaking, metaphors allow the neuropathways of the brain to realign in a way where thinking and feeling bring into account a similar picture from a past incident. This leads to a more comprehensive understanding of experiences such as trauma, abuse, loneliness and loss.

Let’s look at one such example with elements that most people around the world would understand — namely, wounds and scars. It may be impossible to get through life without experiencing some form of physical or psychological wound that affect a person’s everyday experience. You trip and fall down the stairs, you are in an accident, someone close to you dies … these are examples of wounds that hopefully will heal. If they do heal, many times you are left with a scar that reminds you of the incident that took place.

But there can be confusion over the healing process and how the person perceives his or her wounds developing into scars, especially if they are psychological scars. My hope is that the metaphor “a scar is not a wound” will help clarify this healing process with an emphasis on psychological healing.

42 QmF1bUhlcnpJK0YrUysyTy5qcGc=When someone has a wound, the healing process can involve suffering that may feel worse than the initial acquiring of the wound. However, most people find this experience tolerable based on a belief that a certain level of suffering is required to allow the wound to heal. In turn, people with a healing wound assume that they are “on the mend.”

In many cases, a healed wound may leave a scar as a reminder that successful healing has taken place. Although the scar may be ugly, annoying, a topic of conversation or not as favorable as regular tissue, it is still an image of success signifying that a wound has healed. If the scar begins to throb or becomes painful at a future date, many people still tolerate it as a reminder of successful healing. They do not hold the scar to the same traumatic standard as they do the original wound.

At this point, it may be safe to say that, metaphorically speaking, a scar is not a wound.

 

An overview

When helping clients understand their past traumas, it may benefit therapists to describe these traumas as open wounds that need to heal. In mental health, when someone experiences a past mental wound, the healing process can be quite similar to that of a physical wound. For example, in therapy, when exposing past mental wounds, the associated suffering may feel worse than the suffering from the original traumatic experience.

Furthermore, mental health clients can confuse the difference between necessary and unnecessary suffering with these wounds. When experiencing a physical wound, it seems much easier to accept suffering as necessary. A mental wound may be harder to accept or tolerate, however. Even when clients work through the suffering associated with mental wounds, they may remain anxious about the possibility of the wound returning.

Many clients in mental health are at a disadvantage when it comes to the healing process, in part because they cannot look at their wounds and watch them heal. Instead, they must trust in the therapeutic alliance between client and counselor to form a belief about how the mental wound heals. Neither can these clients look at their wound and visualize growth and change.

For therapists who find meaning in the power of images, this may be an appropriate time to introduce the metaphor “a scar is not a wound” to help clients visualize their healing. When normalizing past traumas with clients, therapists can describe trauma as an open wound that needs to heal. Eventually, the client and therapist may want to discuss turning wounds into scars.

A scar can be used as a metaphor that reminds clients of past open wounds but in a positive manner. Helping clients transform wounds to scars is a metaphorical way of making past trauma meaningful and positive. Instead of clients looking at new trauma as a return to an open wound, they can use the metaphor of a scar as reassurance that they have gained resilience for future traumas in their lives.

This begs a question: Can mental scars be more than reminders of past wounds? Can they be viewed as products of successful healing? The scar metaphor creates growth and change by using the natural process of healing as a model for mental health. Such a model can be used when future traumas that are even remotely similar to those from the past might suggest a traumatic relapse. Recognizing the difference between a scar and a wound can stop a continued drift into old beliefs, emotions and behaviors.

The scar/wound metaphor is a clear and simple way of reminding clients with posttraumatic stress disorder, secondary traumatic stress reaction, apathy, abuse, loneliness or loss that traumatic experiences can sometimes create resilience. Therapists can help clients learn from their scars. They can be symbols of successful healing. They can be viewed as a source of wisdom, similar to what is found in many survivors of physical wounds. Scars are not wounds, and when a new trauma is experienced, counselors can help clarify the difference.

This metaphor follows a growth and change model for treating clients. Ironically, it also follows a medical model by explaining the process of healing that takes place when doctors treat a physical wound. More important, it references the natural healing process, whether mental or physical.

This provides clients with a more holistic view of healing. It also allows clients to rely on a schemata or map of healing that they know and understand. Finally, it puts traumas in a different light in which necessary suffering is viewed as a natural process that can have positive results.

 

Multicultural implications

Metaphors are used in most cultures, making them especially useful in the field of therapy. Universal themes that transcend cultural differences give certain metaphors more reliability and validity. The “scar is not a wound” metaphor leaves little room for cultural misrepresentation.

Furthermore, the image of a scar is a universal concept that has deep meaning from a cultural perspective. For example, some African cultures create scars on their faces and bodies as a statement of rank, courage or pride in their communities. The scar may signify going through some difficultly and coming out the other side intact.

The “scar is not a wound” metaphor, therefore, becomes multicultural because scars and wounds are viewed as universal phenomena that can be interpreted in many different ways, with most of these interpretations symbolizing a sense of healing.

 

Group supervision

Because supervision and instruction are often provided in a group format, the “a scar is not a wound” metaphor can encourage more dynamic and inclusive results. Some examples of questions for groups are:

1) When is an effective time to bring up the “a scar is not a wound” metaphor when discussing the group members’ past traumas?

2) What were your experiences of having a wound turn into a scar, either physically or mentally?

3) What are your beliefs regarding your physical and mental scars?

4) Do you know of any culture that views scars as a sign of success when working through a difficult time?

5) Do you think it is ethical to use examples from physical healing to describe mental healing?

 

Potential problems

For those looking for a more scientific explanation of healing, the “a scar is not a wound” metaphor may be viewed as too conceptual, with little use of facts to back up one’s description. This may be especially true with new supervisees who are looking for factual definitions for such phenomena as trauma, DSM-5 disorders and other natural scientific concepts that make up the lexicon of mental health counseling.

There also might be those who question whether clients who have experienced trauma want to look at their scars in such a positive light. These clients may view their scars as grim reminders of past traumas that should be buried and not revisited. They may view these scars with failure and embarrassment and not appreciate the intrinsic value in seeing scars as a “success story.”

In addition, those who are looking for a more linear, step-by-step approach to healing may find such a metaphor too esoteric and not fitting for mental health counseling. These clients may want cause-and-effect answers that help control their anxiety about the possibility of future traumas.

Some counselors may find the use of the metaphor too nondirective, preferring more control over the information they share with their clients. In addition, it may not appeal to those therapists who hold little interest in the workings of the unconscious mind.

 

Additional applications

This metaphor can work well with groups whose members have suffered “wounds” that have produced negative results in their lives. For example, many individuals struggling with addiction have a history of trauma ranging from intrapersonal to interpersonal and leading them to their individual addictions. Some of these traumas remain open wounds that go even deeper than the addictions themselves. Blame, shame and low self-esteem may haunt these clients. Their open wounds have not turned to scars and may be the major cause of any relapse that takes place. Sometimes the open wounds become their own emotional addictions. In fact, healing the individual’s physical addiction may require healing his or her emotional addiction. This phenomenon can take place in both addictions counseling and mental health counseling.

In addition, counselors can build a repertoire of other metaphors grounded in the “scars are not wounds” metaphor. For example:

  • “You can’t see the picture while inside the frame.” — A metaphor for a therapeutic alliance
  • “A counselor should focus on trauma not drama.” — Staying with the counseling process
  • “It is the broken helping the broken.” — Getting away from counselors as experts
  • “No client is as sick as his or her file.” — Looking for possibilities, not facts
  • “It takes more courage than brains to be an effective counselor.” — Being a model for change

 

 

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Peter D. Ladd is a licensed mental health counselor and the coordinator of the graduate mental health counseling Program at St. Lawrence University. His interests include existential and phenomenological counseling and conflict resolution. He has written 10 books from this perspective. Contact him at pladd@stlaeu.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Grief: Going beyond death and stages

By Laurie Meyers October 27, 2016

For many years, mental health practitioners labored under the assumption that grief was a relatively short-lived process that people navigated in an orderly and predictable fashion until they reached “closure” — the point at which the bereaved would move on and put the person they had been grieving in the past. Despite the continued prominence of Elisabeth Kübler-Ross’ “five stages” in the public lexicon, experts now know that grief does not move smoothly and predictably through a series of predetermined stages. In reality, it is a process that follows a different course for each individual.

Furthermore, the experiencing of grief isn’t exclusive to the loss of a loved one through death. As American Counseling Association member Kenneth Doka explains, grief is a reaction to the branding-images_griefloss of anyone or anything an individual is attached to deeply. Although society expects people to grieve the death of a family member, people also mourn events such as the passing of a pet, a divorce or the loss of a job, Doka says.

Licensed mental health counselor Beverly Mustaine, a private practitioner and an associate professor of counseling at Argosy University in Sarasota, Florida, has taught graduate-level courses in loss and grief for 20 years. She notes that she has helped clients cope with grief connected to experiences as varied as moving, losing contact with a friend, retiring and aging.

“Counselors are going to be working with grief and loss really in some regard with every client they see,” asserts Elizabeth Horn, an assistant professor of counseling at Idaho State University’s Meridian Health Science Center.

Doka, Mustaine and Horn agree that counselors who do not work regularly with issues of loss may need to rethink their concepts of grief.

“There’s so much outdated information about how we conceptualize grief and loss,” Horn says. “We’ve gone beyond the idea of ‘stages.’ We really see grief as a unique process for each individual.”

Regardless of the nature of the loss, Horn says she approaches grief work with the same goal in mind: to help clients experience and express their grief in a way that is natural for them.

It’s personal

“People react to loss in all kinds of ways,” says Doka, who has written numerous books on grief and loss, including his latest, Grief Is a Journey: Finding Your Path Through Loss, published earlier this year. Clients grieving a loss may feel sadness, yearning, guilt, anger or loneliness, but some may also feel a certain sense of relief or emancipation, particularly if they had a problematic relationship with the deceased, he explains. Whatever clients are experiencing, it is important for counselors to provide a safe place and to validate their losses, Doka says.

“We [counselors] have to communicate that we’re safe — that other people may not want to hear about this [loss] anymore, but we do,” says Mustaine, a member of ACA.

She likes to use Rogerian methods when helping clients process their grief. “I’m reflecting feelings, repeating, setting up a ‘holding’ environment where it’s OK to say the unsayable or mention the unmentionable, like ‘I hated my father, I’m glad he’s dead,’” she says. In addition to talk therapy, Mustaine often uses nonverbal tools such as sand trays or music to help clients evoke and express their emotions.

Horn, whose research focuses on grief and loss, says it is important for counselors to recognize that people have different coping styles when it comes to processing losses. Some people process loss affectively, which means they tend to express their grief verbally; others are more likely to process the loss cognitively, which means they rely more on thinking than feelings to work through their grief and tend to give expression to their grief through physical activity. In general, men are more likely to use cognitive coping styles and women affective coping styles, Horn says, but she cautions that this is not always the case.

Horn also warns that counselors shouldn’t label either coping style as the “right” way or the “wrong” way to process loss. “Within our field, we frequently have an affective or an emotional bias,” she says. “We are trained to elicit emotion and focus on emotion, and that’s great for people who grieve that way. But sometimes if we have someone who grieves in a more cognitive way, we might say that they are in denial … but that’s how they’re dealing.” She also notes that most people aren’t exclusively affective or cognitive while experiencing grief; instead, they use a mix of both coping styles.

That is one of the reasons that Horn is a proponent of helping clients design rituals, whether they involve holding a memorial ceremony or simply lighting candles in a counselor’s office, that will be meaningful and beneficial to them in processing their grief. Rituals can offer opportunities for both cognitive and affective grieving, she explains. For example, someone who copes cognitively might take charge of making all the practical arrangements, whereas someone with a more affective style might arrange for speakers or even speak himself or herself at the ceremony, Horn says.

The importance of rituals

“The ritual aspect is really important,” Horn explains further, “because frequently we have funerals, and for some folks that’s great for providing an outlet for mourning a loved one. On the other hand, it often happens so soon after [a person’s] death that there’s not a chance to really make it meaningful.”

Rituals can provide a very personal and ongoing way for family and friends to remember the deceased in a meaningful way. Horn shares a ritual that she describes as her favorite.

The son of one of Horn’s friends had died from an overdose. Although his family and friends remembered him with fondness, they felt it was important to also honor his ornery personality, so they developed a ritual based on an actual incident. At one point, the son had been asked to get his younger siblings some food from McDonald’s, but he didn’t want to. The task left him so agitated that when he returned home, he threw a cheeseburger at the wall in a fit of pique. So every year, a group of his family members and friends pick a date to get together, buy cheeseburgers from McDonald’s and throw them against the wall.

Doka tells the story of a good friend who died from amyotrophic lateral sclerosis (ALS). Before the ALS rendered him incapable of physical activity, Doka’s friend — who described himself as “an engineer by vocation but a bluegrass musician by avocation” — played with a band at various outdoors venues, which made the performances dependent on the weather. As a nod to this reality, the band always opened its sets with a song titled “Singing in the Sunshine.” When Doka’s friend was diagnosed with ALS, the band started opening instead with “Singing in the Rain” and telling the audience about their missing band mate. When he died, the band played the song at his memorial service.

Doka believes that when a child or teenager dies, it is important to get his or her friends and classmates involved in the memorial service. For instance, Doka, a Lutheran minister, presided over the funeral of a 13-year-old girl, and her family asked her friends and classmates to help design the service. The friends suggested having her school choir sing at her service. “It let the kids feel involved and was also very powerful for the family,” Doka says.

Children’s friends and classmates are the people who really know them best, says Judy Green, whose work as a private practitioner and school counselor in the Jacksonville, North Carolina, area has focused on grief and loss. She encourages children and adolescents to reach out to the families of friends or classmates who have died to share their memories. In her experience, Green says, families often find this helpful in mourning their child’s death. Both Green and Doka say it can also help the child’s friends and classmates better deal with the death.

Horn says it is important for counselors to talk to their clients about their cultural backgrounds and discuss any rituals that they might find helpful in grieving the loss of a loved one. Some rituals can even affect how clients verbalize their grief, she says. For instance, in certain Native American cultures, a person who has died is believed to be on the “spirit road,” which is an essential journey. Speaking a person’s name after death will take the deceased off the road, Horn notes.

Horn emphasizes that whatever a client’s background, grief is still very individual, so rituals should take whatever form is comfortable for the client. “We are all so very unique in the way that we interact with our culture, ethnicity and personal traditions,” she concludes.

Adjusting to the new normal

Rituals can also help grieving clients move on to what counselors call the “new normal,” a world in which the person, relationship or other object of loss is no longer with them, yet they continue to make a place in their lives for that connection. Counselors can assist clients in coming up with rituals that recognize the progression but also honor the relationship to the loss, Doka says.

As Doka explains, these might include a ritual of continuity, such as lighting a candle on the person’s birthday; a ritual of transition, such as a ceremony for a widow removing her wedding ring; a ritual of reconciliation, in which the client says, “I’m sorry” or “I forgive you”; or a ritual of affirmation, in which the bereaved says, “Thank you.”

“Creating a memory box with mementos from the loved one or creating a figure out of molding clay can be helpful to capture the grief and shift the sadness,” says Barbara Sheehan-Zeidler, a licensed professional counselor in Littleton, Colorado, whose practice specializes in grief and loss. “Sometimes clients write letters, poetry, songs, or draw pictures to their loved ones that they either save or we burn or shred together. Sometimes clients write letters to their future selves as an attempt of encouragement that the future will be different and they will be all right. I have also helped create a ritual, usually around the anniversary of the death, using candles, burning items, shredding old papers or burying artifacts like a time capsule.”

Sheehan-Zeidler encourages clients who desire a longer-lasting remembrance to volunteer or join a group that is connected to their loved one or to create an annual event in honor of the person.

Says Green, “When people realize that their relationship with the deceased did not end when the death occurred, but that the relationship will always be part of them, they will be well on their way to healing from the loss.” At the same time, Green urges counselors to let their clients know that grief isn’t linear. Months or even years after the loss originally happened, they might wake up and hear a song on the radio that reminds them of their loved one. And that experience might trigger a brief wave of grief, she says.

Green says many people do most of their active grieving within the first six to eight months of the loss. But she adds that grief cannot fully be processed until the client has lived at least a year without the loved one and gone through events such as birthdays, anniversaries and any holidays that were significant in their relationship.

Complicated grief

Complicated grief occurs when people become so debilitated by grief that they are unable to return to their daily activities, even after an extended period of time. The symptoms are similar to those of “uncomplicated” grief, but more intense and debilitating, and longer lasting, Green says.

“There is no specific time frame for grief to end,” she adds. “Everyone is different, so our reactions to loss will be unique to every individual. As a general rule, however, people usually work through their grief and can get back to their life tasks within six months of the loss.”

A variety of factors can contribute to the presence of complicated grief, Green says. These include the death of a child, the perception that the death was avoidable, an unhealthy or dependent attachment to the deceased, death following a prolonged illness, a client’s prior history of loss and a lack of social support.

Clients who are experiencing mental health issues at the time of the loss — or have experienced them in the past — are also at greater risk of being confronted with complicated grief, Doka says.

“Each of these factors can result in interrupting [the ability] or prolonging the grieving person’s inability to cope with the death,” Green says.

“Complicated grief can be likened to a wound that will not heal,” she continues. “In addition to emotional problems, a person who is experiencing complicated grief becomes at risk for health-related issues such as lack of adequate sleep, severe depression, suicidal ideation or behavior, substance abuse, suppressed immune system and stress that can lead to heart attacks or strokes.”

As for treating complicated grief in clients? “I have found that group counseling is one of the most healing methods for people suffering from complicated grief,” Green says. “Being able to share with others who have suffered a similar loss lets people know that they are not alone. By sharing a similar loss, people come to realize that there is hope for them even though they might be experiencing deep despair. By sharing experiences with others who have suffered similar losses, people learn that in allowing themselves to experience the pain of their loss, eventually the pain lessens as they learn to adjust to life without the deceased and begin to invest in their future without the loved one present.”

“This does not mean that they lose the connection with their deceased loved one,” Green explains. “Rather, they learn that their emotional connection with the deceased will go on forever; they learn how to embrace that and move on.”

An important consideration is that these groups be made up of people who have experienced the same kinds of losses, Green emphasizes. For example, a group for those who have lost a child, a group for those struggling with the aftermath of a loved one’s completed suicide and a group for those who have lost someone to a sudden and unexpected death.

Green finds group counseling so helpful for these clients that she often recommends they stay or rejoin another group once they have processed, or are well on their way to processing, their grief. “Their experiences can help others and they continue to heal further [themselves],” she says. “In fact, I have had many people ask to rejoin a new group or take training to lead the groups because they have found how therapeutic this modality is.”

She acknowledges that these groups aren’t offered as widely as they need to be. “However, my suggestion is that counselors build a network wherever they are so they know where grieving people might attend such groups,” she says. “First, I [would] begin with hospitals. Many run groups for the families of cancer victims, cancer patients themselves and parents who have lost babies through miscarriage or stillbirth, for example. Another great resource is local funeral homes. Many have a social worker or trained person on the staff who runs such groups, [which are] usually open to anyone, not just those who have used the services of that particular funeral home.”

In addition, cognitive behavior therapy (CBT) can be very beneficial for those who are struggling with complicated grief, Green says. It helps them “think about their situations from different points of view, thus altering how they feel and behave when thinking about the deceased,” she explains. “The structure provided using CBT techniques can help grieving individuals deal with their loss and provide a means to measure how much progress is being made each week.”

Green assigns her clients homework, such as journaling about feelings and memories connected to their loved one or developing lists (e.g., five things the client misses about the deceased). “These activities help clients focus on their relationship with the deceased rather than on the loss itself,” she says. “For example, having them make a list of things they enjoyed sharing with the deceased or writing a goodbye letter to the deceased, which is then shared with the counselor, is both cathartic and healing. This also helps clients begin the process of experiencing the pain of the loss that might otherwise remain unattended to. Stuffing down one’s thoughts and feelings is detrimental, so these activities help gently to bring the thoughts and feelings to the surface where they can be dealt with.”

Counselors should also help grieving clients work through any unfinished business, Green says, such as not having been able to say goodbye to the deceased or feeling guilty about something related to the deceased.

Doka has clients write letters to the deceased or engage in role-play to have conversations with the deceased. He gives the example of a boy who had carried guilt over the death of his father. When the boy and his family visited his father as he lay dying in the hospital, the father would always ask the boy for a hug before he left. The final time that the family visited, the boy didn’t want to give his father a goodbye hug before leaving because he had already hugged him earlier in the visit.

During a counseling session, Doka had the boy role-play with him and apologize to his father. He then asked the boy to move to the “father’s chair” to better imagine what his father might say to him. Doka says that as soon as the boy inhabited his father’s chair, he could imagine his father saying, “That’s what you’ve been worried about, sport?”

The boy realized his father would have been surprised that the incident was such a source of guilt to his son. What happened would not have stood out as a source of hurt for the father or been something that he held against his son.

Sheehan-Zeidler uses a similar method, asking clients to imagine what they would say or want to hear if they could talk to their deceased loved ones. But certain types of death, such as suicides, horrific accidents, murders or even sudden and unexpected losses, can be traumatizing to clients. In such cases, Sheehan-Zeidler has found that the use of eye movement desensitization and reprocessing can be helpful.

All losses can be complicated

A loved one’s death is not the only type of loss that can result in complicated grief. Mustaine once counseled a woman who had been divorced for five years yet still fully expected her ex-husband to return, even though he had remarried and had children with his second wife.

In cases such as these, clients may not even have begun to grieve because they have not identified (or cannot identify) the loss and associated feelings that it engenders. Mustaine doesn’t dive into grief work right away with clients who are experiencing complicated grief. Instead, she focuses on establishing the therapeutic bond and giving the client time to accept the counseling office as a safe space. Later, she asks these clients — such as the woman who couldn’t accept her divorce — how they feel about their loss and starts to tease out any underlying feelings. For instance, “I hear you saying that you have not experienced any anger over your divorce, but a lot of people would feel angry.”

Mustaine waits to see if the client takes her statement as a cue to express anger. If the client doesn’t, Mustaine will circle back and say something such as, “You really don’t feel anger?”

In these instances, it is not uncommon for clients to respond that they don’t feel anything because they are numb, Mustaine says. So she sometimes asks them to imagine what they might feel if they weren’t numb. She then explores the reasons behind their inability to truly express their emotions. “What were you taught about having feelings?” Mustaine asks. “Maybe that it’s not OK to express your feelings?”

“You give them permission to have their defenses,” Mustaine continues, “but broach the idea of emotion: ‘What’s so scary about thinking about even having a feeling?’”

Some clients grew up in environments in which it wasn’t safe to express emotions, Mustaine says, such as having a father who would say, “You don’t have anything to cry about. I’ll give you something to cry about!” In such cases, Mustaine says there might be a need to switch from grief work to traditional psychotherapy.

 

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All of the sources Counseling Today spoke to for this article cautioned that in order for counselors to avoid their own complications, they should engage in their own grief work before working with clients on grief and loss issues.

 

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Additional resources

To learn more about the topics addressed in this article, take advantage of the following resources offered by the American Counseling Association:

Books, etc. (counseling.org/bookstore)

Podcasts (counseling.org/continuing-education/podcasts)

  • “When Grief Becomes Complicated” with Antonietta Corvasce
  • “Remembering Lives: Conversations With the Dying and Bereaved” with John Winslade and Lorraine Hedtke

VISTAS Online articles (counseling.org/continuing-education/vistas)

  • “A Shift in the Conceptual Understanding of Grief: Using Meaning-Oriented Therapies With Bereaved Clients” by Jodi M. Flesner
  • “Current Trends in Grief Counseling” by Elizabeth A. Doughty, Adriana Wissel and Cyndia Glorfield
  • “Frequency and Importance of Grief Counselor Activities” by Darlene Daneker
  • “The Anniversary of the Death of a Loved One” by Rebecca M. Dedmond, Annie K. Smith and Sania Frei-Harper
  • “Understanding Grief and Loss in Children” by Jody J. Fiorini and Jodi A. Mullen

Practice Briefs (counseling.org/knowledge-center/practice-briefs)

  • “Death and Dying Issues” by Kathryn Layman & Jessica Swenson

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The value of contemporary psychoanalysis in conceptualizing clients

By Whitney Keefner, Hilary Burt and Nicholas Grudev October 5, 2016

branding-_sigmundAs students in the University of Vermont’s graduate counseling program, our professors have stressed both the benefits and critiques of Sigmund Freud’s psychoanalytic theory. We grew curious about how Freud’s pioneering ideas have evolved over time and how they can be applied to clients today. We think that contemporary psychoanalytic theory provides a great foundation for understanding human development, and this article allowed us to explore its progression.

Freud’s psychoanalytic theory has received widespread criticism since its establishment in the late 19th century. However, Freud’s original theories have undergone numerous evolutions, resulting in the de-emphasis of antiquated ideas pertaining to psychosexual fixation and a modern emphasis on the influence of early life family dynamics on later life relational patterns. This shift from examining repressed libidinal urges to the intrapersonal/interpersonal etiology of relational patterns allows counselors to place problems into an addressable context — namely, the bolstering of intrapersonal resources (i.e., ego strength) and the formation and maintenance of quality attachment relationships. These two branches of psychoanalytic thought are known respectively as ego psychology and object relations.

Ego psychology

From a contemporary psychoanalytic perspective, an individual’s mental health is dependent on the regulatory abilities of the ego. The ego is the contemporary psychoanalytic term for the psychological mechanism that governs the processing of reality and the regulation of instinctual urges and moral rigidity. The ego has many significant roles, including perceiving and adapting to reality, maintaining behavioral control over the id and defending the individual from undue anxiety. The undeveloped (or overstressed) ego can lead to a wide span of threats to a person’s wellness.

Mental health issues arise when the ego has not developed properly and its regulatory functions are either immature or absent. The Psychodynamic Diagnostic Manual (a psychoanalytic “companion” to the Diagnostic and Statistical Manual of Mental Disorders that is used by many practitioners of contemporary psychoanalytic theory) outlines several functions of ego health. These functions (collectively referred to in the Psychodynamic Diagnostic Manual as the Personality Axis, or P Axis) include:

  • The maintenance of a realistic and stable view of self and others
  • The ability to maintain stable relationships
  • The ability to experience and regulate a full range of emotions
  • The ability to integrate a regulated sense of morality into day-to-day life

Counselors might use these functions collectively as a guide to conceptualize the health of a client’s ego, while simultaneously considering specific aspects of ego function as possible starting points for counseling interventions. It is also worth considering how clients may defend their sense of self through the use of defense mechanisms.

Considering ego and relationships: Object relations

Whereas ego psychology represents contemporary psychoanalytic views on the development and regulation of the self, a separate yet related branch of contemporary psychoanalysis focuses on the self in relationship with others. Many theorists within the psychoanalytic school of thought place significant emphasis on the association between intrapersonal and interpersonal wellness.

From an object relations perspective, counselors may view barriers to client wellness as stemming from the quality of early interactions between the client and his or her caregivers and how the client internalized these early relational experiences. When an infant is first born, it is undifferentiated from the mother. Thus, the self has not yet formed. The self is composed of the ego, the internal objects (i.e., structures formed due to early experiences with a caretaker) and the affect that binds the ego and internal objects together.

The development of internal objects and ego is crucial to one’s functioning in later life because impaired object relations may result in the development of abnormal behaviors, cognitions or emotions. To elaborate, when an individual experiences negative relational experiences in the caretaker-child dyad, healthy object relations fail to formulate. These relational blunders occur after ego-relatedness (i.e., the phase of absolute dependence on the mother). When the child is not provided with an ego-supportive environment, growth of the ego is inhibited.

Fragmented ego strength during childhood may contribute to later issues in adulthood. Object relations bears a strong theoretical resemblance to attachment theory in that the relational experience between a caretaker and an infant carries implications for functioning across the life span. For example, the relationships that individuals hold with others (caregivers, friends, romantic partners, etc.) shape the development and regulatory ability of the ego. Individuals with fragmented ego strength are therefore at a disadvantage because they developed a faulty foundation for both self-regulatory abilities and social interactions later in life.

Defense mechanisms

In her book Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2011), Nancy McWilliams conceptualizes a person’s capacity to acknowledge reality — even when that reality is unpleasant — in terms of ego strength. Ego strength, like other aspects of wellness, is constantly in flux and can be eroded temporarily by the stresses of day-to-day life. When ego strength is compromised by anxiety-provoking circumstances, or even by mental fatigue (we note, for example, that our egos begin to feel considerably less sturdy by the end of the semester), ego defense mechanisms serve as a kind of respite from perceived threats. When sensitive topics are broached in the context of counseling, client defense mechanisms may present themselves. Because these same defenses likely arise in other contexts that are interpersonally challenging for clients, acknowledging and discussing these defensive processes may prove to be a generative pathway to change.

According to McWilliams, when clients use a defense mechanism, they are generally trying unconsciously to avoid the management of some powerful, threatening feeling (e.g., anxiety, grief, shame, envy). In the same way that fabled knights used shields to deflect the fiery breath of a dragon, clients may use defense mechanisms to ward off potential threats while attempting to maintain safety and stability in their stances.

It is important to note that the use of defense mechanisms is a common, if not daily, occurrence in the lives of most people. Indeed, the use of defense mechanisms is considered by most mental health professionals to be adaptive and necessary for sound mental health. George Vaillant (1994) described how defense mechanisms help people to regulate internal and external reality, and decrease conflict and cognitive dissonance. However, it is also important to note that defense mechanisms can be used in ways that are more adaptive or less adaptive. The degree to which an architecture of defenses might be considered adaptive pertains to the frequency and rigidity with which the defenses are used and the types of defenses employed.

In broad terms, defense mechanisms might be defined as primary or secondary defensive processes. McWilliams considers primary defenses to be less adaptive because they contain a greater degree of distortion in the boundary between the self and the outer world relative to secondary defenses. Primary defense mechanisms are characterized by the avoidance or radical distortion of disturbing facts of life.

For example, McWilliams explains how the primary defense mechanism of introjection involves substituting the perceived qualities, values, behaviors or beliefs of another person for one’s own identity. In effect, these individuals are uncritically adopting the attitudes, values or feelings that they perceive a valued other wants them to have. McWilliams suggests that such global distortions of self and reality likely have their origins in early developmental stress and the lack of developmental opportunities to cultivate a coherent and stable ego or a differentiated sense of self.

McWilliams considers secondary defenses to be “more mature” because they allow an uncompromised sense of self to remain relatively intact, even as an uncomfortable reality is held at bay. Secondary defenses allow for greater accommodation of reality and a stable sense of self. For example, counseling students may occasionally employ “gallows humor” (humor is one of numerous secondary defenses that McWilliams describes) before taking tests such as the National Counselor Examination. Humor in such cases helps to ease the tension by distracting from the reality of the situation without engaging in significant denial or distortion of the situation itself.

The degree to which developmental opportunities have allowed for the establishment of the aforementioned ego domains and the type of defensive architecture generally used (i.e., primary vs. secondary) contribute significantly to how clients perceive difficulties in their lives.

Ego dystonic vs. ego syntonic

An essential aspect of understanding an individual’s mental health is the presence or absence of an observing ego. According to McWilliams, an observing ego enables clients to see their problems as inconsistent with the other parts of their personalities. Such problems are termed ego dystonic. In terms of counseling individuals with ego dystonic problems, the client’s and the therapist’s understanding of the problems are likely to align because both parties recognize the problems to be undesirable. Thus, the observing ego allows for identification of unwanted problems and helps the client bring his or her personality back to a desirable level of functioning.

Problems that are unrecognizable by an individual are termed ego syntonic. According to McWilliams, such problems are likely to be rooted deep in the individual’s personality and often develop during early childhood. Because ego syntonic problems are intertwined in the person’s character, addressing these problems can be perceived to be a direct assault on the individual’s personality.

Taking away an adult representation of an adaptation from childhood could compromise an individual’s entire way of being. It is therefore important for counselors to handle ego syntonic problems slowly and delicately. For example, counselors could validate and empathize with a client’s ego syntonic experience while subsequently offering an alternative perspective. Establishing rapport and trust in the counseling relationship is perhaps the strongest tool when working with individuals whose maladaptive behaviors are intertwined in their personalities.

Substantial time is required for ego syntonic problems to become ego dystonic, and treatment is not possible until an individual can recognize his or her problems as such. The presence or absence of an observing ego determines whether an individual’s problems are neurotic or entwined in his or her character. Ego syntonic problems are telling of a dysregulated ego because the ego lacks the ability to acknowledge, understand and accept reality. Individuals who are capable of recognizing their problems likely have a better sense of self and a more developed ego.

Summary

Contemporary psychoanalytic thought emphasizes the impact of the ego on an individual’s well-being. Whether development is viewed from an object relations lens or an ego psychological lens, the ego is at the core of healthy development. The ego’s ability to balance the id and the superego, and process reality and emotions, can be learned only if an individual’s social relationships throughout his or her lifetime foster healthy ego development. Unhealthy development or underdevelopment of the ego can cause psychopathological problems because an individual’s abilities to process reality and emotions are likely to be impaired.

According to McWilliams, all of us have powerful childhood fears and yearnings. We handle them with the best defense strategies available to us at the time and maintain these methods of coping as other demands replace the early scenarios of our lives. Thus, defense mechanisms are useful in protecting the ego, but when used in excess, they may cause psychopathological problems. In this way, ego defense mechanisms are like sugar. When needed, sugar provides valuable energy that prevents the body’s systems from malfunctioning. But when consumed in excess, sugar can cause disease and negatively affect an individual’s well-being.

Conceptualizing clients through a contemporary psychoanalytic lens can provide counselors with a deep understanding of the past and present factors that are shaping clients’ lives. This approach illuminates how adaptations formed during childhood can present as maladaptive behaviors or cognitions in adulthood. Unlike classic psychoanalysis, contemporary psychoanalytic theory considers the social factors that contribute to ego health, therefore giving counselors a more comprehensive and applicable understanding of the client.

 

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The authors would like to extend a special thank you to Aaron Kindsvatter for his contributions and supervision.

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Whitney Keefner is a second-year student pursuing a dual master’s degree in clinical mental health counseling and school counseling at the University of Vermont. She is currently interning at Spectrum Youth and Family Services in Burlington, providing integrated co-occurring treatment for mental health and substance abuse issues. Upon completing her degree, she hopes to continue working with individuals struggling with substance abuse in a community mental health setting. Contact her at wkeefner@uvm.edu.

Hilary Burt is a second-year graduate student in clinical mental health counseling at the University of Vermont. She is interning at UVM Counseling and Psychiatry Services. After she completes her degree, she hopes to work with children and adolescents in a community mental health setting. Contact her at hburt@uvm.edu.

Nicholas Grudev is a second-year graduate student interning at the MindBody Clinic at the University of Vermont Medical Center. Upon completing his master’s degree, he plans to enroll in a doctoral program to study counseling psychology. Contact him at ngrudev@uvm.edu.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for getting published in Counseling Today, go to ct.counseling.org/feedback.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

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The Counseling Connoisseur: Zen and the Art of Home Improvement: Learning to ACT

By Cheryl Fisher July 24, 2016

“When you catch yourself slipping into a pool of negativity, notice how it derives from nothing other than resistance to the current situation.”

Donna Quesada, Buddha in the Classroom: Zen Wisdom to Inspire Teachers

 

I recently took on several home improvement projects. With a contractor hired, my home became a construction site for two weeks. I had pined over the built-in bookshelves, cabinets and window seat for so long that the books I had selected to place on the shelves were now in their second editions. Sawdust, spackle, paint and trips to the local hardware store became my new normal, but the inconvenience and chaos would all be worth it in the end. I had even thrown in a bathroom update project for my guest bathroom that had lain dormant since the 1980s. A new sink, faucet set, medicine cabinet and light fixture updated the look, especially after the dated tile backsplash was removed, spackled and painted. What a tremendous difference a light facelift can provide to the appearance and feel of a room. The final day arrived when I paid my contractor and began the arduous cleanup from two weeks’ worth of construction.

With everything clean, I stood back and admired my new built-ins. I imagined what the custom pillow that was being sewn would look like when put in the window seat. I longed to place the books on the shelves and board games in the cabinets. However, the paint needed to cure (according to our contractor), photo-1418754356805-b89082b6965eso there would be no decorating for at least two weeks lest we put dents in the freshly painted built-ins.

With a sigh (both of satisfaction and impatience), I took my admiration to the guest bathroom. It was so crisp with its new white marble sink and designer brushed nickel faucet against the blue walls. The large framed mirror (also brushed nickel) boasted ample storage in the cabinet. The three-sconce light tilted upward, shining new LED lights against the clean white ceiling. So classic and fresh: Blue and white, brushed nickel … and chrome? The glare from the chrome towel bars was blinding. I adjusted the towels a bit to cover the shiny finish. Unsuccessful, I turned the lights off, and then on again, to see if it had been just a momentary glare. Much to my frustration, however, the brash incongruence from all of the chrome accessories now looked painfully hideous.

OK, no worries. I would simply buy new towel bars and a toilet paper holder in a brushed nickel finish. My contractor was already on to a project for another client, but how hard could it be to replace these items myself? I would buy the same exact sizes, remove the old bars and slap the shiny new brushed nickel bars over top. Simple!

Those of you who have engaged in home improvements of any type know there are fundamental rules that govern this process:

1) Rarely are things as simple as they look.

2) It usually takes longer than planned.

3) It typically costs more than planned.

My simple project was no exception. As I removed the surface mounts, I noted huge holes left in the wall from previously removed toggle anchors. No worries. I would just put the new mounts over top and cover up the blemishes. No such luck. The positioning of the new towel rods exceeded the length of the previous mounts. Therefore, the mounts needed to be moved roughly 1.5 inches out from the original point. This resulted in the need to spackle the old sites and sand, measure, level and drill new holes for the new mounts.

Really? All I wanted to do was craft a quick little facelift for my guest bathroom. Now I was going to have to set aside time to plan the project, identify and collect the needed tools, and actually do the work! Furthermore, I would need to find the leftover paint or attempt to match the color. Frustrated, I went down to the basement where the tools hibernate. I collected my power drill, level, Allen wrench set, Phillips and straight-head screwdrivers, spackle paste and applicator, sandpaper and (low and behold) a can of matching blue paint for the touch-ups.

Armed with the tools, I went back up to the bathroom, laid out my tools and unfolded the instructions. Taking a deep breath, I accepted the situation, committed to the project and started the work.

Acceptance and commitment

Acceptance and commitment therapy (ACT), developed largely by Steven Hayes in the 1980s, is a mindfulness-based behavior therapy that assumes the normal human experience includes destructive patterns that results in psychological suffering. ACT, based on empirical study, emphasizes values, forgiveness, acceptance, compassion, living in the present moment and accessing a transcendent sense of self.

According to Russell Harris in his article “Embracing Your Demons: An Overview of Acceptance and Commitment Therapy,” the goal of ACT is to “create a rich and meaningful life while accepting the pain that inevitably goes with it.” Suffering and symptoms are not labeled and targeted for reduction. Often, it is our pathologizing of thoughts, behaviors and experiences that leads to attempts at symptom reduction or elimination. This pattern often results in disordered behavior — and the cycle continues.

The aim of ACT is to transform our relationship with our difficult thoughts, feelings and experiences in a way that normalizes the experience. The byproduct of acceptance appears to be — wait for it — symptom reduction.

For example, I recall working with a young client who had been experiencing some discontent in her relatively new marriage. She described her husband as “immature and a hermit.” She then went on to discuss how excited she was about a new work project that was challenging, social … and attached to a handsome, charismatic project leader who “commanded the attention of everyone in the room.”

The client initially denied her attraction to this co-worker and the role it played when viewing her less-than-perfect spouse. Once she was able to lean in to her feelings for the co-worker and assess the deeper meaning around her attraction, she recognized that she resented her younger husband who had always relinquished his power to her. He liked being taken care of, and she resented not having an equal partner. Armed with this revelation, the client was able to focus on her marital dissatisfaction in couples counseling rather than avoid it with the studly distraction at work.

Do the work

ACT interventions emphasize two main processes. The first is to develop acceptance of situations that are out of our control. Devoting energy and time to that which we have no control over is futile. The second is to commit to engaging in activities that cultivate living a valued and meaningful life. Again, there is emphasis on identifying that which is worthy of our efforts and energy.

Furthermore, there are six core principles that guide the processes.

  1. Cognitive defusion: The ability to view thoughts, images and memories as simply bits of language, words and pictures. This is different than perceiving them as threatening events, rules that must be obeyed or objective truths and facts. For example, my thoughts around the bathroom project rested in the “I don’t have time” category. I have struggled often with this myth that there is never enough time. When I stopped obsessing over these thoughts, I was able to actually take action.
  1. Acceptance: The process of making room for uncomfortable feelings, sensations, urges and experiences, and allowing those things to come and go without struggling with them, avoiding them or giving them undue attention. Once I accepted the feelings of inconvenience and discomfort that originally paralyzed me, I was better able to begin the steps toward completing the bathroom project.
  1. Contact with the present moment: Focus on and engage fully in whatever you are doing. Being able to watch my progress from holes in the bathroom wall to finished product was satisfying. Each step provided me with a new sense of accomplishment.
  1. The Observing self: From this perspective, it is possible to note that you are not your thoughts, feelings, memories, urges, sensations, images, roles or physical body. Although these are aspects of you, they are not the essence of you. I knew this was a project that would stretch me out of my professor-clinician-author comfort zone, and it was possible I would not succeed. However, the project (regardless of the end result) would not define me or my worth. I realized that I am part of something bigger that transcends my spackling abilities.
  1. Values: Clarify what is most important, significant and meaningful to you. I like to think of myself as open and always ready for a new challenge. My “can do” attitude has taken me to (and through) some amazing and challenging experiences. Completing this project would validate my belief that I am capable of any endeavor with a little effort.
  1. Committed action: Set goals that are guided by your values, and take effective action to achieve them. Breaking down my bathroom project into smaller, more manageable steps proved effective. Step by step, I completed each task and experienced success in a way that propelled me to the next step. Ultimately, I experienced the sense of accomplishment in tackling this small but meaningful project.

Conclusion

Clients often present an earnest desire to be pain free. We can assist them in reframing their understanding that the discomfort they are experiencing (which may be paralyzing) is a participant in their journey. It is the fear of this discomfort (anger, sadness and depression) and the desire to avoid it that creates greater angst. When we lean in to the situation, accept that it may be difficult and, during some parts, even unpleasant, we allow emotional space to engage in getting the work done! In other words, one can feel uncomfortable and still survive — even thrive and accomplish goals.

Therefore, taking a bit of my own advice, I rolled up my sleeves, grabbed a drill and proceeded to hang my new towel bars. Once I was able to accept the temporary discomfort of engaging in this project, I was able to commit the effort required to complete it. The mess, previously underneath the shiny new mounts, had been carefully and completely tended to, allowing my new towel racks to hang solidly and sturdily, ready to take on their purpose: to hang my new bath towels.

 

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Cheryl Fisher

Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland, and a visiting full-time faculty member in the Pastoral Counseling Department at Loyola University Maryland. Her current research examines sexuality and spirituality in young women with advanced breast cancer. She is currently working on a book titled Homegrown Psychotherapy: Scientifically-Based Organic Practices, of which this article is an excerpt. Contact her at cy.fisher@verizon.net.

 

Embracing intuition

By Lynne Shallcross

One meaning of intuition is “something that is known or understood without proof or evidence.” Given that definition, it’s not surprising that objectively studying and measuring a counselor’s intuition can be challenging. But that hasn’t stopped Jesse Fox from trying.

In 2013, as part of research Fox was doing for his dissertation, he set out to observe and track counselor intuition, a concept that he defines as rapid, nonconscious insight into what is going on in a client’s mind or behavior. Fox, an assistant professor in the Department of Pastoral Counseling at Loyola University Maryland, says counselor intuition is a little like breathing — more automatic than it is controlled.

Fox believes counselor intuition can be quantified and observed, and in his research, he aimed to accomplish that by looking at how 44 counseling experts responded to a variety of two-Branding-Images_intuitionminute client video segments. Four of those counselor experts viewed nearly 40 client video segments, identifying six to 10 directions a counselor could take with each individual client based on what had happened in the corresponding brief video. Then the remaining 40 counselor experts viewed those video segments and rated the possible next steps on a 5-point scale ranging from “strongly agree” to “strongly disagree.”

The result? Fox says intuition was apparent in the way that the counselors leaned collectively toward certain directions to take with each client. “The best way that I could say [it] is that there was substantial common perspective that [the counselors] brought to those sessions,” says Fox, a member of the American Counseling Association who presented a poster session on his research at the 2015 ACA Conference & Expo in Orlando, Florida.

‘Substantial commonality’

Fox, who is in the process of submitting his research for publication, believes his study is the first of its kind to go beyond counselor self-reports in an attempt to look at intuition in a more scientific manner. By looking at the study results and the like-minded way that the counselors responded to the clients in the videos, Fox believes it is possible to “see” counselor intuition taking place. Additionally, he wanted to contribute to the study of intuition a standardized set of scenarios that could be given to any counselor to study his or her intuitive reaction.

In the setting Fox created, the expert counselors had nothing more than the individualized two-minute video segments to go on when making their decisions about what direction a counselor should take with each client. Fox says that setup required the counselors to draw from information they had accumulated across the course of their careers. “They don’t have all the information [about each client],” Fox says. “They just have a two-minute segment, so they have to rely on information they’ve stored long term that they have to access very quickly.”

Ideally, counselors want to have a full session, at minimum, with each client before making any decisions, Fox says. “But in this case, it was a challenging task, and what elicits an expert’s ability is that you give [him or her] something with high challenge and see what happens.”

Despite the standardized nature of the client video segments and the resulting similarity in the counselors’ reactions in Fox’s study, he is careful to point out that he isn’t claiming that no variation exists between counselors after they reach a certain level of experience. “What I am saying is that there certainly does seem to be some substantial commonality that people develop over time that helps to guide them toward good and bad directions to take,” Fox says.

Recognizing patterns

Some of the original research on intuition was done with chess players half a century ago, Fox says. What researchers found was that chess masters “see the board differently,” he says. Whereas novice players might need to think through a decision tree of outcomes, master players instinctively know the right move based on the information they have stored up over past years.

“It takes you time to develop expertise, and what you’re doing during that time is you’re beginning to recognize certain patterns that come up,” Fox says. “So if you took those findings and you applied them to counseling, what’s happening probably is that as people practice therapy, they begin to recognize certain patterns of clients that come to them.” Master counselors, just like master chess players, can identify those similar patterns and make decisions based on what they instinctively see, Fox says.

“Counselor intuition is that little itch at the back of your head, that small voice prompting you to take a risk and to speak [to] a client’s situation that may seem like it’s coming out of left field,” says ACA member W. Bryce Hagedorn, the director of the counselor education program at the University of Central Florida who served as the chair of Fox’s dissertation study on counselor intuition. “Clinically, intuition is born out of experience in the profession, experience with the client and experience with the client’s presenting concerns. It is a way of subconsciously tapping into these realms and making conclusions that may not be directly observed but rather ‘felt.’”

Some counselors report relying on intuition extensively, Hagedorn says, “oftentimes forgoing specific theoretical orientation for the sake of a clinically sound intuitive moment.”

Still, Fox and Hagedorn acknowledge that the use of intuition in counseling is not without controversy. Some critics question intuition’s very existence on the basis of its subjective, self-reported nature. Others maintain that counselors should not rely on intuition because human judgment is flawed and people make mistakes, Fox says.

On the other side, proponents of intuition might argue that in therapy, there is no way of fully removing the human element, Fox says. “In other words, we’re kind of stuck with humans, with human judgment,” he says. “If you can find a way of identifying what makes people experts or intuitive, why not go find out what makes them that way and then try to teach other people how to do it?”

Regarding the use of theory versus intuition in therapy sessions, Fox thinks counselors should strive for a combination of both. Theory gives practitioners a guiding framework from which to work, but counselors should simultaneously seek information that comes from assessments and the counselor’s experience or intuition, he says.

Counselors interested in developing their intuition can work toward greater awareness of their “gut moments,” Fox says. When counselors feel their intuition kick in, they should become conscious, skilled observers and take the time to “unpack” those situations, he suggests. “When you experience intuition, investigate it,” Fox says.

Unfortunately, no shortcut to honing intuition is available, Hagedorn says. “Outside of gaining more experience, interacting with seasoned clinicians, journaling, recording their sessions and seeking supervision, it can be quite challenging to create intuition in the short game,” he says.

Fox offers two book suggestions for counselors looking to develop their intuition: Educating Intuition by Robin M. Hogarth and Intuition: Its Powers and Perils by David G. Myers.

Counselors should avoid going to either extreme on the intuition spectrum, instead shooting for somewhere in the middle, Fox says. If the intuitive, human element is removed entirely, then it’s no longer therapy, he emphasizes. But on the other hand, it wouldn’t be wise for counselors to rely solely on their intuition in every situation, he says. Counselors should always strive to pull from more than one source of information, Fox says, whether that second source is supervision, consultation, assessment or something else.

Hagedorn agrees. “Therein lies the main crux of the problem: knowing when to apply intuition,” he says. “I don’t believe it is an either/or but rather a both/and in the sense [that] intuition and clinically proven assessments and interventions both belong in the therapeutic setting.”

 

 

From the trenches

To further explore how and why counselors integrate intuition into their work with clients, Counseling Today asked a handful of leaders in the field to weigh in with their views. Responses have been edited for length and clarity.

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Richard S. Balkin is a professor and assistant chair in the Department of Counseling and Human Development at the University of Louisville and the editor of the Journal of Counseling & Development.

How do you define counselor intuition?

The definition that makes the most sense to me is “knowing without knowing,” and it came from a writer for The New Yorker, Malcolm Gladwell. In other words, you have an understanding about an event, phenomenon or experience without having gone into the reasoning and formal process of learning about the phenomenon, event or experience.

In what ways can intuition help the counseling process?

Intuition is most often aligned with the counseling relationship. When the counselor knows the client, being intuitive may become second nature. With a strong working alliance, the client may feel more comfortable with feedback, even if it is confrontational, due to the trust and the feeling that the counselor understands.

Can counselors hone their intuition?

I view intuition as a function of the relationship. When the client-counselor relationship is strong, the client is apt to take more risks, but so is the counselor. Risk-taking, from the counselor’s perspective, is rarely about trying some new empirically supported treatment, though it can be. Rather, risk-taking from the counselor often involves, “What happens if I say this to the client? Are we at a point where I can be this honest, genuine and even direct?”

How is this developed? I often go back to my nearly 40 years of martial arts training — time on the mat. When you know without knowing, it is often because of the experience in working with clients and trusting yourself as a counselor. [Rhonda] Neswald-Potter, [Shawne] Blackburn and [Jamie] Noel talked about this as professional self-concept [in a 2013 Journal of Humanistic Counseling article], and I think it aptly applies.

Why is the topic of intuition sometimes controversial in counseling?

“Knowing without knowing” flies in the face of the accountability movement and the focus on empirically supported treatments. We know the relationship and intuition are the most important elements in counseling. But these components are difficult to investigate empirically, whereas treatment approaches lend themselves to empirical investigation much more readily. Ultimately, we end up spending more time on elements that affect very little variance in terms of counseling outcomes, as opposed to concepts like intuition, which are tied more closely to the counseling relationship.

How should counselors balance the use of intuition with the use of more objective interventions such as assessments? 

Both are needed. We live in an era of accountability and where our ethical code mandates the use of interventions based on rigorous research methodologies. Intuition alone does not suffice, but of course it is a naturally occurring phenomenon within the counseling relationship. There are times when objective assessments provide important and valuable information that the counselor might otherwise miss. However, such assessments are not error-free, and counselors should utilize their subjective insights to complement or confirm what is identified objectively. Objective assessments are a nice check and balance to counselor intuition, but counselor intuition is also a nice check and balance to objective assessment.

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Jeff L. Cochran is a professor of counseling at the University of Tennessee and president of the Association for Humanistic Counseling, a division of ACA. He is also co-author, with Nancy H. Cochran, of the book The Heart of Counseling: Counseling Skills Through Therapeutic Relationships.

How do you define counselor intuition?

I think of counselor intuition as the counselor’s ability to make informed responses in the moment in therapeutic relationships. This can mean hearing a client’s emerging communication and responding to that, even when the counselor is not sure of [the] correct understanding. A counselor does not often have time [to] evaluate what her client is communicating; rather, she has to respond with her hunches.

With that said, there is also a necessary balance. I encourage students and beginning counselors to learn to wait. A first-hunch intuition might not be right. It’s best to have the hunch, realize it and set it aside. Then see if it persists [and] continues to feel right.

Does intuition take time to develop?

Beginning counselors often understandably hold back, at times too much, in [the] therapeutic relationship, which can make one hard to connect with. I work with beginning students to listen to recordings of sessions. I ask them to state their first impressions of how they might have responded, then evaluate how that in-the-moment response might have worked.

Can counselors hone their intuition?

Counselor intuition comes from within and from without. I think each counselor works from her own “n of 1” example for understanding the world. I’m OK with that as long as the counselor’s view of self and the world is continuing to develop through open self-reflection, through listening well to her or his thought patterns, and attending to and finding meaning in feelings. Self-reflection can inform a counselor’s intuition well if the counselor’s experience is considered through working toward unconditional positive self-regard, allowing her to see her experience most closely to what it really is, and [self-reflection] can tell her about self, others, the world and persons in relationships.

And, importantly, counselor intuition is developed through study. Through initial graduate study and ongoing life as a scholar, counselors study a range of counseling theories, with each carrying its own view of human nature, how we develop, what drives our problems and how we make significant life changes. Each counselor becomes [an] expert in one to a few theories and knowledgeable of others. And each counselor becomes [an] expert in the populations of persons that they serve and the problems commonly faced by those persons. So, when the counselor has to make decisions of how to respond in sessions, based on her hunches of what is going on with the person of her client, her intuition is informed by the meaning she has made of her own life experiences and by what she is continually learning as a scholar [and through] human nature and change.

Why is the topic of intuition sometimes controversial in counseling?

Counseling is research based, but it is not a science. We can know the factors of [the] therapeutic relationship that predict positive counseling outcomes. But we also want to think of counseling as a definitive science, where the only answers needed are to the question, “What techniques lead to what outcomes for what populations with what problems?” But the work is actually much more subtle than that. It’s all about the relationship, and there are many unknowns that we have to feel our way through with intuition.

Is intuition important for clients too?

Often, what clients get out of counseling is self-awareness, regaining trust in the value [of] listening to one’s own experience, which can be thought of as intuition. Many of the clients I served had given up their view of self in favor of how others see them or how they imagine that others see them. Many of the clients I served had come to doubt their own experience.

But helping them rediscover and respect the intuition of their own experience didn’t usually come from the obvious route of pointing out that need. In hindsight, it was the counseling process — me following what I hear in my client’s self-expression and responding as a person in the moment, informed by years [of] scholarship and careful self-reflection — that led us both to my client’s newfound intuition and trust in self.

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Lori A. Russell-Chapin is a professor of counseling at Bradley University and co-director of the Center for Collaborative Brain Research. She also facilitates ACA’s Neurocounseling
Interest Network.

How do you define counselor intuition?

I believe there are four major factors that allow counselors to have intuition: early personal attachment, counseling experience, the vagus nerve and the default mode network (DMN) in
the brain.

Secure, early attachment will allow the counselor to be safe enough to trust the counseling relationship, and thus easily build therapeutic rapport. Once that is accomplished, psychological resonance will occur more often, and the client and the counselor will together solve problems easier with both “heads” offering solutions.

If a counselor does trust his or her judgment and intuition, the longer counseling is practiced, the stronger this intuition becomes.

The vagus nerve is the 10th cranial nerve and the longest nerve in the body. This nerve begins at the base of the medulla oblongata and ends at the abdomen. The vagus nerve takes in so much information from so many sources and senses, it was named from the word “vagabond,” as it wanders throughout the body. This [nerve] offers the counselor, and the client for that matter, invaluable and rich communication about many possible thoughts, senses and emotions.

The DMN in the brain consists of the posterior cingulate, precuneus, cerebellar tonsils, bilateral temporoparietal junction, medial prefrontal, bilateral superior frontal, inferior temporal and parahippocampus. This network has many functions, but one of the main functions is to allow us to introspect and retrospect. If we are relatively healthy and regulated, the DMN helps us understand the world of self and others. This network helps us to mind-wander and create better understandings about our clients from this wandering and being “offline” for a while.

Can counselors hone their intuition?

Counselors can hone their intuition by understanding there is top-down and bottom-up communication in the body. The brain informs the body — top-down — and the body informs the brain — bottom-up. These electrical and chemical impulses send messages about the world around us. Understanding that our physiology gives us those hunches or intuitive feelings may allow counselors to be more in tune with those emotions and sensations. Counselors have to listen to their brains and bodies.

Can you share an anecdote about intuition in your work as a counselor?

Recently, a student supervisee did not show up for a very important meeting pertaining to his future. The student supervisee was typically very punctual. I waited patiently for over 20 minutes. After I returned back to the university, something just didn’t feel right. I listened to my intuition, my body and years of counseling. I began calling around and could not get in touch with this person. I finally called the campus police and asked them to begin a search. Finally, the person was located and had overdosed. Because of my intuition and working with other available resources, a life was saved.

Why is the topic of intuition sometimes controversial in counseling?

Many helping professionals believe intuition is just a soft science, much like the old days of counseling. Today we know that counseling is not a soft science, as counseling does change the function and structure of the brain. The advances in EEGs (electroencephalograms) and brain scans have demonstrated those changes. Now that we also understand the function of the vagus nerve and the DMN, the implications to social connectedness and our social brain, it may not need to be as controversial.

How should counselors balance the use of intuition with the use of more objective interventions such as assessments? 

Assessment and intuition need not be in competition with one another. Both are necessary to a complete evaluation of the client’s needs. Quantitative and qualitative measures, whether that be in the form of self-reports, standardized tests or physiological impulses, are all essential to successful outcomes and efficacious counseling treatment.

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Jeffrey Kottler is a professor of counseling at California State University, Fullerton, and the author of several books that explore the counselor’s experiences with intuition, including On Being a Therapist, On Being a Master Therapist and The Therapist in the Real World.

How do you define counselor intuition?

One way to think about intuition is that it represents internalized experience. It’s a shortcut to solving problems, selecting courses of action or interpreting the world or one’s own experience based [on] cognitive templates that are developed over time. It is an ethereal or mysterious phenomenon precisely because words can’t really touch what it feels like.

How is intuition important in the counseling process?

Intuition is a felt sense, an inkling, sometimes felt in the body, sometimes in the heart or mind, that represents one possible interpretation of events or experience. As such, it is a hypothesis that is usually subject to testing and confirmation. I sense that a client is uncomfortable with what is transpiring in the moment, but if I stop and try to explain how and why I know this, I feel at a loss. Observable behavior is not yet apparent, except on a preconscious level. Such initial thoughts and feelings, if not supported with some other evidence, can indeed be problematic, or even dangerous. Calibrating one’s intuitive powers comes with systematic experimentation, making the sense more attuned and accurate after processing honest feedback.

In what ways can intuition help the counseling process?

Intuition sometimes leads to breakthroughs in ways nothing else can touch. Our field has traditionally been dominated by older, white, male theorists who worship logic, rationality, empirical verification and objective data. Of course, this is critical for scientific advancement. But in actual practice, we also rely on hunches, inklings, images and internal feelings that sometimes offer clues that would be inaccessible any other way. Likewise, if these feelings are based on personal biases, distortions, exaggerations or one’s own needs, then counseling can become self-indulgent and not in the client’s best interests.

Can counselors hone their intuition?

Intuitive powers are developed over time, with reflective experience, systematic assessment of accuracy and explorations into alternative domains that bypass mere language. The difference between beginners and veterans is that those new to the profession haven’t yet accumulated sufficient experience to know whether their feelings or hunches are targeted or appropriate yet. But with practice and commitment, all of us learn to be more responsive to others without needing to explain or interpret how the process actually happened.

Can you share an anecdote about intuition in your work as a counselor?

I was doing trauma work in Nepal after the series of devastating earthquakes that occurred last year. A man in his 80s wanted to talk to me about something that was bothering him. It was explained to me by a relative that although he wasn’t physically injured as so many others were, he was still very anxious. The challenge was that he was escorted into my “office” — a schoolroom that was one of the rare buildings still standing — and didn’t speak a word of English.

My Nepali language skills are feeble, and my translator left to help treat another patient. So we just sat there and stared at one another for a few minutes until I felt this really strong energy between us. I couldn’t get the idea out of my head that he wanted to hold my hands. Now it’s entirely possible that this was my feeling rather than his, but I nevertheless reached out to hold his gnarled hands in my hands. We just sat like that staring into one another’s eyes and holding hands. He kept talking to me, telling his story, and I kept nodding even though I could only understand a few words he was saying.

When the session was over, we stood up and hugged one another. He wouldn’t let go. I have no idea what actually happened between us, but it felt miraculous. When I have intuitive experiences like this, I deliberately try not to explain what happened. I learned from shamans long ago that sometimes when you make sense of experiences, you destroy their magic.

Why is the topic of intuition sometimes controversial in counseling?

I don’t agree that it is controversial. I just think it is misunderstood. Intuition is simply a thought, feeling, image, sensation or hypothesis that isn’t — yet — supported by more tangible evidence. It is just a starting point that must be checked out. It is ill-advised when people trust their intuition without assessing the accuracy or combining it with standards of care.

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Catharina Chang is a professor at Georgia State University and the president of the Association for Multicultural Counseling and Development, a division of ACA.

How do you define counselor intuition?

Counselor intuition is the counselor’s ability to connect with her client and to understand her client at a level deeper than the spoken words. Counselor intuition guides the counselor to act in a certain direction with her client. Counselor intuition can assist counselors in case conceptualization as well as helping the counselor decide how to move forward with the counseling process.

Can counselors hone their intuition?

I believe you either have intuition or not, but if you do have intuition, you can further develop your intuition. Some have asked whether counseling is a science or an art, and it’s both. Effective counselors understand the science behind good clinical skills, while respecting that the art of counseling is also important. Intuition is a part of the art of counseling. One’s intuition, I believe, comes out of your past experiences and knowledge, so it can be developed and fine-tuned. Counselor intuition allows the counselor to bring herself into the counseling process.

Why is the topic of intuition sometimes controversial in counseling?

From a legal and ethical standpoint, we want to be able to quantify everything, and intuition is something that can’t be quantified — which is why it’s important to follow your hunches/gut/intuition but be able to also back up that hunch with specific details.

How should counselors balance the use of intuition with the use of more objective interventions such as assessments? 

Both are important to be an effective counselor. Intuition helps us know when and where to probe deeper, thus assisting us to gain more concrete information.

 

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To contact the individuals interviewed for this article, email:

 

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Lynne Shallcross, a former associate editor and senior writer at Counseling Today, works for Kaiser Health News as a web producer. Contact her at lshallcross@gmail.com.

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