Tag Archives: women

Is it OK to have it all?

By Kathleen Smith December 21, 2016

As Lindsey Mitchell approached the end of her doctoral program in counseling at George Washington University, she wasn’t quite sure what was next. After a decade of intense focus on her education, she found her career options in the field both exciting and intimidating. When Mitchell began talking to other women in her program about career choices, she realized that questions about ambition, leadership and family were common among female counselors.

Energized by these discussions with her colleagues, Mitchell decided to take the conversation to the American Counseling Association’s 2016 Conference & Expo in Montréal. Her idea took shape as a panel session called “To Lean In or Not to Lean In: The Diverse Experiences of Women in the Counseling Field.” The title alone was enough to catch the attention of many women at the conference and set the stage for an engaging talk between four ambitious and thoughtful counselors.

The phrase “lean in,” made famous by Facebook Chief Operating Officer Sheryl Sandberg’s 2013 book, Lean In: Women, Work and the Will to Lead, is rife with connotations and criticisms. Sandberg encouraged women to take risks, not make sacrifices based on hypotheticals, and to pursue leadership by taking a seat at the table. A former chief of staff for the U.S. Treasury secretary and a leader in the tech industry, Sandberg draws from her years of experience in male-dominated fields.

But when Mitchell and others considered this philosophy of leaning in, they faced an important question: What does “sitting at the table” mean in the counseling profession when the majority of counselors and ACA members are already female? Weren’t they already at the table?

A colleague of Mitchell’s recommended that she recruit Desa Daniel, a doctoral counseling student at Kansas State University, as a compelling voice for the ACA Conference panel discussion. Daniel thinks that numbers alone aren’t enough to change leadership dynamics. Although ACA and the counseling profession as a whole may be filled with women, she notes that leadership positions within the profession don’t always mirror those numbers. “We still have a long way to go until women hold positions in universities and governance that reflect their presence,” says Daniel, adding that she’d like to serve as president of ACA in the future. She currently serves as the student representative for Counselors for Social Justice, a division of ACA, and as student liaison for Division 45 (the Society for the Psychological Study of Culture, Ethnicity and Race) of the American Psychological Association.

Jessica Jackson, a licensed mental health counselor and a doctoral candidate in counseling psychology at New Mexico State University, also joined the discussion. She points to the male-dominated foundational and theoretical influence in the field as a real challenge. “When you look in the texts, our foundational knowledge is coming from men of European descent, and the structure of the training is based on that,” she says. “No one deviates from the blueprint, so to me, that doesn’t feel like a field dominated by women.”

Jackson also points out that texts such as Sandberg’s, as well as feminist psychology and various waves of the feminist movement, typically failed to include black women in the conversation. Part of her role on the panel, she says, was to help remind counselors that women of color can still be forgotten or excluded in a space that is predominantly female.

Having it all

Comedian Tina Fey wrote that the rudest question someone can ask a woman is, “How do you juggle it all?” Fey suggested the question operates on the assumption that, for women at least, success in one arena of life (e.g., the workplace) implies failure in another (e.g., family life). The question is rarely posed to men. Members of the conference panel set out to consider what “having it all” looks like in the counseling profession and whether balance between multiple arenas of life is possible.

“Can women have it all? I think yes, but we may have to package what that looks like in a different and creative way,” Mitchell says. Currently serving as an Americans with Disabilities Act counselor at Houston Community College, Mitchell points to the male-dominated workplace models that create impediments to women who desire balance between work and family life. For instance, she observes, when their children are ill, some mothers in the workforce will hide that fact and instead claim a sick day for themselves because they don’t want their parenting responsibilities to hurt how they are perceived at work.

“You would think that in a female-dominated field like counseling, it would be better,” Mitchell says. “But we’re still using these male business models instead of thinking about how we can be greater leaders to women that maybe we didn’t have. Sometimes we don’t have a model for what that looks like, so we have to start creating our own.”

These sentiments reflect a common critique of Sandberg’s idea — namely that Lean In ignores systemic obstacles that are present and remain unchanged in the workplace, regardless of whether women make it to the top playing by the current rules. So what rules do counselors need to change to make the workplace and the classroom more flexible and empowering places for women?

Mitchell asked Megan Doughty Shaine, an assistant professor of psychology and counseling at Hood College in Maryland, to bring her voice to the panel as a professor and parent. Shaine shared how her desire to have a multifaceted career and also be a mother affected her path. “It does change the way you move through your education, from the internships you accept, to the jobs you consider, to how you prioritize things,” she says. For example, Shaine limited her search for doctoral programs to the East Coast because she wanted to be close to her family when she started one of her own.

Shaine recommends that women in counseling leadership model how conversations about “having it all” are OK and even encouraged at work. “You’re more likely to have a female supervisor than a male supervisor, at least in the clinical world,” she says. “We have to really evaluate how open we are with these issues of work-life balance.”

Jackson agrees, pointing out that real pressure still exists to choose between focusing primarily on career or family in academia. “People don’t feel comfortable choosing a middle ground because that looks like you don’t know what you want,” she says. “But I don’t think it’s impossible to integrate and have both. My idea of success is being able to acknowledge and appreciate the many roles that I have as a black professional woman without having to sacrifice what means the most to me.”

Finding balance

Members of the panel also considered how to model what good mental health looks like for women trying to balance multiple roles in life. “So many of the conversations that we have about self-care feel fake,” acknowledges Daniel, who does CrossFit every day as a self-care measure. “We have to show tangible examples of what it looks like and how people manage it over the course of their careers. We need to lead by example but also help people set objectives and deadlines for self-care.”

Mitchell suggests that establishing and maintaining boundaries is an important piece of achieving balance. “I feel the pressure to be everything to everyone, and I know that is not a realistic expectation,” she says. “There will be stages in my life where my professional career has to take priority and other times when it will take a step down in importance. I know I entered this profession because I care about people and want to help, so there can be a conflict when I have to put myself first and inadvertently disappoint somebody in another area of my life. So it is a bit of a Catch-22. But this conflict will have to be resolved by continuing to reevaluate my values, my stage of life and what my goals are at the time. It’s an ever-changing process.”

Rather than a detour from success, Jackson sees the pursuit of balance as integral to achieving her goals. “I’m a happier and better person when I can feed the many different parts of who I am,” she says. “By engaging in prayer, checking in and being honest with myself, and being present in the moment, I am better prepared to achieve my idea of success. Potential conflicts may arise due to this expectation that to be successful in your career, you must dedicate your entire life to your career. But I don’t believe in that. I don’t believe that I have to achieve burnout in order to be successful.”

An intersectional approach 

Another critique of the philosophy behind the “lean in” movement and second-wave feminism is the relative lack of examination of women’s intersecting identities. At the ACA Conference, panel members wanted a significant amount of the conversation to focus on the diverse roles and identities of women in the counseling field and the impact this reality has on what it means to lean in.

Jackson points out how traditional advice given in books such as Sandberg’s, including the call to be assertive, may not work for every woman. “As a black woman, being assertive comes across as being the angry black woman. So how do I navigate the need to be assertive without also coming across as angry, even when I’m not angry? Because as soon as I’m assertive, that’s what everyone assumes,” Jackson explains. “When people give you advice, it’s coming from their social identity: their privilege, their background, etc. So you have to figure out what you can take from that and what you can leave.”

Jackson also recommends that female counselors gather both mentors who share their identities and those who do not to help them better navigate the field. When her interest in pursuing a research career led her to apply to the National Research Mentoring Network, she decided to choose a white male as one of her mentors to give her a different perspective. “He gave some insight on how to approach challenges rather than simply focusing on why people don’t understand things the way I do,” Jackson says.

For Jackson, who aspires to improve pipelines for people of color into academia and the mental health field, leaning in also includes starting conversations about the changing landscape of counseling and the reality that counselors don’t provide services to just one population. “We have to expand our ability to provide therapy to people with multiple identities and make room for them at the table as well,” she says. “If the path to leadership was really so linear, there would be a more diverse group of people stepping into those roles.”

Shaine asserts that counseling programs also have to address intersecting identities for their students, particularly those who are considered nontraditional. She points to the young women in her classroom who also work full time and the middle-aged mothers who are returning to school after a long hiatus or a career change. “We have to support them and try to be creative in helping students navigate a program,” she says. “Otherwise, we’re going to lose their voice and we’re going to end up with this monolithic student body, which I don’t think any of us want. That feels very antithetical to the counseling profession, where we want a diversity of perspectives.”

Counseling education programs could also use creativity and a focus on intersectionality to prepare women for a variety of roles in the field. Daniel points out that these programs rarely focus on issues such as licensure, starting a business or management roles. “Counselor ed programs need to step up their game and talk to people about what’s possible on the ground,” she says. “It’s socially unjust to send women out into the field without the full resources of what it really means to have a clinical practice.”

Advice from the panel

When asked what advice they would give to women entering a counseling education program or their first job as a counselor, panel members provided a variety of suggestions.

Mitchell, who aspires to a major leadership role in university student services, says that surrounding herself with the type of women who prompted these conversations in the first place was her best resource. “Sometimes we’re afraid to do that because we don’t want to feel like the least intelligent person in the room,” she says. “But you have to put your insecurities aside and see what you can learn from these women because, someday, you’ll be the person in the room somebody else is looking up to.”

Jackson says that advocating for your interests can go a long way. “If other people have that interest, then maybe you have enough people to request a class on that subject,” she says. “To me, that’s how change starts — being vocal and advocating for yourself.”

Shaine says women in the counseling profession shouldn’t lose sight of the flexibility they possess. “You can make a choice and change your mind later. We have an incredibly flexible field that gives us many different options. Be gentle with yourself,” she advises, “and know that the choices you make now can always be adjusted if they don’t suit you in the future.”

Daniel, who aspires to be a faculty member in a counselor education program, says that supporting other women can be empowering in itself. “We need to be better about supporting all women in their journeys, even if it doesn’t look like [our] own,” she counsels. “At the end of the day, we are creating pipelines for little girls to be what they want to be.”

 

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Kathleen Smith is a licensed professional counselor and writer in Washington, D.C. Her book, The Fangirl Life: A Guide to All the Feels and Learning How to Deal, was published earlier this year. Contact her at ak_smith@gwmail.gwu.edu.

Letters to the editor: ct@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.

Girls feeling pressure to be ‘sexy, famous and perfect’

By Laurie Meyers April 5, 2016

In our culture, women receive many messages that can eat away at their self-esteem. For example, self-worth equals youth and beauty. Perfection in all areas of life — professional and personal — is not only achievable, but expected. Women begin to learn these “lessons” as girls, say counseling experts.

American Counseling Association member Laura Hensley Choate says girls are taught that their value is connected solely to what she calls the “three A’s” — appearance, attention and Vgu1RUfKT3WN1ZYxSWaR_14672519443_13d8873062_kaccomplishments. The expectation they take away is that not only must they look their best, but they must also be noticed and popular, all while achieving high grades and earning recognition and awards in sports or other extracurricular activities, Choate explains. In addition, these messages are trickling down to girls at younger and younger ages, so that now even the youngest girls feel the pressure to be, as Choate puts it, “sexy, famous and perfect.”

This pressure has harmful effects on girls’ social and academic development, says Michelle Bruno, a counseling professor at Indiana University of Pennsylvania whose research interests include trauma and resiliency in adolescent girls. Bruno had the opportunity to work with girls on these issues through her involvement in an empowerment program designed by the nonprofit organization Ruling Our eXperiences (ROX), which began as a research study by counselor educator Lisa Hinkelman at Ohio State University.

ROX programs are designed for elementary, middle and high school girls. The programs target areas such as confidence, self-esteem and body image, healthy relationships, effective communication, social media, cyberbullying, sexual violence prevention, stress and coping, academic and career development, and leadership. Bruno, an ACA member, helped bring ROX to several schools in western Pennsylvania, coordinating with school counselors and serving as one of the onsite supervisors.

“Girls [as young as 9] are navigating peer relationships and beginning to be able to choose more independently their participation in classes and activities in school,” she says. “How they perceive and feel about themselves plays an important role in such tasks. Younger children often display higher levels of confidence than what we see in adolescents. We see younger children believing they can do anything, believing that they are the best at whatever fun activity they are trying out. During the preteen and teen years, many girls experience comprised levels of optimism and decreased healthy risk taking. They value acceptance by others and work hard to achieve it among their peer groups. Girls may not want to try new things for fear of failure or standing out.”

Bruno, like Choate, decries the tremendous pressure placed on girls regarding appearance. “The prominent messages about female beauty depict unrealistic and even unhealthy images,” Bruno explains. “Body image struggles are exacerbated by the sexualization of girls in the media, which teaches girls that their value stems from sexual appeal, to the exclusion of other traits. Young girls may end up engaging in self-objectification to achieve attention from others. How one looks becomes a significant focus for young girls, who of course are also in the midst of physical changes.”

Girls are also constrained by what they learn about “acceptable” female behavior, Bruno continues.

“Girls may be oversocialized with regard to expectations around relationships, with a need to please others being paramount over other behaviors,” she says. “This may lead to a perceived need to regulate emotions such as anger, which can result in relational aggression. This is often a result of when girls experience anger or other difficult emotions but mask it because of negative consequences seen as ‘unladylike.’ This creates incongruence and the message that being authentic is not always OK. Taken together, girls in their preteen years are forming all of these ideas around self-worth, how to define it and how to be worthy.”

ROX is a 20-week program that aims to help girls “unlearn” — or not learn in the first place — these “lessons,” Bruno notes. During the course, school counselors or other facilitators work with small groups of girls in what Bruno describes as “interactive psychoeducation” that focuses on building skills such as communication through practice and role-play. The girls also receive homework to work on in between sessions.

Bruno’s involvement with ROX was brief — her role was simply to help introduce the program into Pennsylvania schools — but she remains a big proponent.

“I saw the ROX program as unique and empowering because it is built upon a framework that examines the interrelatedness of all of these factors [appearance, appropriate behavior, etc.] and creates a safe space for girls to examine these topics while building concrete skills,” she says. “The program is highly successful because it addresses the very issues that many women can continue to struggle with throughout their adult lives. Learning these skills at 11 or 12 years old provides opportunities to support girls in defining themselves by internal standards, to help them exercise the ability to communicate feelings in an appropriate manner and to recognize the impact that outside factors can have on them.”

One of the predominant outside factors influencing today’s girls is social media, and Choate is very concerned about its effect. Although she does not view social media as the root of all negative messaging, she is concerned about certain aspects of it.

“Social media is … a new and constant pressure for girls as they feel they must be ‘on’ and perform at all times in order to get noticed and not to miss out on anything,” says Choate, whose book on cultural influences and young girls, Swimming Upstream: Parenting Girls for Resilience in a Toxic Culture, was recently published by Oxford University Press. “They tend to measure their worth on their numbers — their number of friends, followers and likes for each picture. This leads to the development of an inauthentic self that is focused on pleasing others instead of what is authentic to her.”

“We have not yet seen the long-term effects of these pressures on girls because they are so new,” she continues. “It will be interesting to see today’s young girls, who have grown up on social media and who experience a lack of face-to-face communication, in terms of their mental health. What we do know is that rates of depression, anxiety, substance use problems, eating disorders and self-injury are all on the rise for adolescent girls and young women. So I am concerned about these trends and how they will affect girls’ future development and mental health.”

Because of these concerns, Choate, a professor of counselor education at Louisiana State University, also wrote a book for mental health professionals, Adolescent Girls in Distress: A Guide for Mental Health Treatment and Prevention, in 2013. In it, she recommends that counselors focus on the following areas when helping adolescent girls navigate cultural pressures:

  • Parenting: Working with parents to improve communication and family support.
  • Authenticity and self-awareness: Encouraging girls to take time for self-reflection to gain a strong understanding of who they are and what they value. Possessing this level of self-awareness can encourage adolescent girls to stand up for who they are and what they believe in rather than giving in to the pressure of meeting cultural expectations.
  • Wellness, spirituality and gratitude: Encouraging girls to maintain balance in all life dimensions, not just the ones valued by culture (such as the physical). In addition, recognizing meaning and purpose in their lives and being grateful for what they have rather than focusing on what they do not have.
  • Problem-solving and decision-making skills: Promoting problem solving versus ruminating about problems and learning to have the confidence that they can take action to solve their own problems.
  • Coping skills for emotional resolution: Teaching girls how to manage intense emotions without harming themselves or others.
  • Social skills for communication, assertiveness and conflict resolution: Teaching girls how to develop healthy relationships first with peers and then with romantic partners.
  • Cognitive skills for cognitive restructuring and self-regulation: Helping adolescent girls learn to delay gratification and think through the consequences of actions.
  • Body acceptance and positive physical self-concept: Teaching girls to love the changes in their developing bodies and to appreciate their bodies for what they can do, not just for how they look.
  • Media literacy skills: Teaching girls how to critique the cultural messages they receive through the media and to recognize and resist the intent of the messages.
  • Goal-setting skills and perseverance: Encouraging girls to develop goals and a positive outlook for the future.

 

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Related reading: For more on women, body issues and societal pressure, see “Falling short of perfect” in the April issue of Counseling Today

 

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Laurie Meyers is senior writer at Counseling Today. Contact her at LMeyers@counseling.org

Falling short of perfect

By Laurie Meyers March 28, 2016

This past December, a major pop culture event occurred for which millions of people had been waiting longer than three decades: Star Wars: Episode VII was released. Finally, the story from 1983’s Return of the Jedi was continuing. Many fans reserved tickets two months in advance, while others camped out in line overnight to be part of the audience for the first of the film’s showings. Individuals active on social media reasoned that it was essential to see this latest installment of the Star Wars series as soon as possible to avoid tripping over spoilers.

As with any work of art, people held widely divergent views of the film. In print and online — particularly on social media — passionate discussions were held on virtually every facet of the new movie, but one of the most frequently broached topics involved actress Carrie Fisher. People weren’t usually talking about how Fisher’s character, Princess Leia, was now a general or how great it was to see one of the original characters in the newest film or even the quality of Fisher’s performance though. Instead, the comments most frequently referred to her graying hair and extra weight. The overall sentiment was that Fisher was not aging “well.”

At the same time, no significant accompanying discussion took place about Harrison Ford’s (Han Solo’s) graying hair or Mark Hamill’s (Luke Skywalker’s) prodigiously grizzly beard. Instead, the refrain heard throughout social media was: What happened to the princess in the gold bikini?! (For those who have somehow managed to resist the force of the original Star Wars trilogy, Fisher — as Princess Leia — had two scenes in Return of the Jedi in which she was held prisoner while dressed in a gold-colored leather and metal bikini. The image of Fisher in the costume has become iconic.)

As Fisher herself said in a 2011 blog post discussing her decision to become a spokesperson for the weight loss company Jenny Craig: “You know, I swear when I was shooting those films, I never realized I was signing an invisible contract to stay looking the exact same way for the rest of my existence.”

Fisher’s “invisible contract” is representative of the expectations that women face in American society today: to remain young and beautiful forever, to work harder to be considered equal to men (and yet be paid less) and to be a perfect daughter, mother and wife or partner — all while doing the majority of the housework, child rearing and caregiving. Despite the significant strides women continue to make toward equality, societal expectations still lead many women to think that they can (and should) “have it all.” But that picture is acutely unrealistic, say counselors.

“Having it all means being able to fulfill multiple expectations simultaneously — the perfect appearance, perfect relationships, perfect mother and perfect career,” says Laura Hensley Choate, a licensed professional counselor (LPC) who has written extensively about women’s and girls’ issues. “It means being perfect according to societal standards for each of these roles, but even if this were possible, it also means achieving them all simultaneously.”

The problem, counselors say, is that these standards are perniciously presented to women not just as goals that can be achieved but as expectations that must be met. And when women fall short of these standards, they often view their unsuccessful attempts as personal failures rather than as an understandable inability to meet unreasonable expectations. This perspective can cause feelings of frustration, inadequacy and shame and, in some cases, lead to more serious problems.

“These expectations are so unreasonable and unattainable, and much of it is out of an individual’s control,” comments Vanessa McLean, an LPC from Richmond, Virginia, whose specialties include women’s issues. “It is easy to see how women become plagued with anxiety, self-doubt and negative cognitions that can easily spiral into anxiety disorders or depression.”

By identifying and countering these harmful societal influences, counselors want to help women separate self-image from societal expectations — and perhaps even start changing and setting the expectations themselves.

Chasing eternal youth and beauty 

Throughout much of history, women were valued only for their beauty and fertility, says Choate, a member of the American Counseling Association. Although these qualities are no longer the sole sources of a woman’s worth, youth and beauty are still the most valued, she continues, and once a woman ages and those qualities are diminished, she loses value. In contrast, Choate says, research has shown that the characteristics most prized in men — wealth, power and status — increase with age, meaning that men generally gain value as they age. This disparity is evident in popular culture, particularly in films, which frequently pair young women with much older men, but not vice versa, she notes.

In society at large, this translates into an internalized mandate for women to fight against aging by any means necessary: products, diets, surgery and so on, says Choate, a professor of counseling education at Louisiana State University. Although we live in a youth-obsessed society, the pressure Branding-Images_Falling-Shortis mostly one-sided, she notes. “Men do not feel this same pressure. Certainly not to the same extent that women do,” Choate says.

The youthful ideal that women are supposed to maintain is in itself unrealistic, McLean says. “It isn’t just attractiveness that is the ideal but an obsession with physical perfection,” she explains. “Perfect hair, perfect skin, perfect body, perfect teeth. … And the message is not only geared to young single women but to all women.”

“Women now have equal rights and opportunities to pursue education and careers,” McLean continues, “but if you consider the message that mainstream media send, both overtly and covertly, the message is still that women’s primary value is sex, [which equals] physical attractiveness.”

Working more for less

Women have largely seized the opportunity to pursue advanced education and careers, but on a societal level, their contributions in the workplace are not as highly valued as those of men — not just symbolically but also literally, experts contend.

According to a 2014 study by the U.S. Census Bureau, the median annual salary for women is 79 percent that of the median annual salary for men. That’s 79 cents for every dollar a man makes. A 2015 comparison by the U.S. Department of Labor measuring weekly salaries found that women make 81 cents for every dollar that men make. “Women often feel more pressure in the workplace to perform, simply to get equitable recognition and pay,” McLean says.

Many women’s wages are affected by factors such as maternity leave and child care, as are their career trajectories, which are often linked to making better wages, says Nadine Hartig, an associate professor and chair of the Department of Counselor Education at Radford University in Virginia. Beyond the physical demands of pregnancy, giving birth and raising children, women are often confronted with choices related to balancing their work and life roles. These are choices that men generally do not have to make, Hartig points out. Even if a woman’s husband or partner assumes some of the child-rearing and household responsibilities, the bulk of those responsibilities will typically still fall on the woman, says Hartig, a member of ACA.

Hartig notes that she made a career choice herself because of the demands of motherhood. “I chose not to go into a tenure track right away mostly because I thought it would kill me to do that at the same time as raising children,” she says.

Many women wrestle with the challenge of how or if to try balancing motherhood and work, knowing that the decisions they make could mean delaying or even derailing a career. Women are sometimes judged negatively for taking time away from work, even for maternity leave, but they are also susceptible to being judged for returning to work as quickly as possible and continuing to pursue their careers, note Hartig and Choate.

When a woman who is a mother seeks a promotion, her dedication to her children may be questioned, along with her ability to get the work done, says Hartig, an LPC who also maintains a small private practice. “This can be done in really insidious ways, with comments such as, ‘I’m concerned you won’t have enough time for your family [if given the promotion].’ Generally, men do not face this same kind of judgment. No one questions a man’s commitment as a father if he takes a promotion.”

McLean says that when parenting and household duties are factored in, research has shown that women perform 50 percent more daily work than men.

“The reality is that working mothers still tend to serve as ‘managers’ of the home,” agrees Choate. “They are the ones who keep up with the schedules, the tasks that keep the household running, the doctor’s appointments, the school needs. And while research shows that fathers do help out, it is the mothers who tend to assign the tasks to keep everything on schedule.”

“So, the mothers have to manage the home tasks — which of course take a great deal of mental energy for planning and can lead to worrying — while fathers tend not to carry this burden with them,” Choate continues. “And the societal expectation is that a good mother will keep the family’s schedule flowing seamlessly. If things don’t run well in the home, the expectation is that the mother is not doing her part well. And for single mothers, this pressure is even greater because they are not only the managers of the home, but they also have to carry out all of the tasks with very little help or support.”

Sadly, for many women, the harshest critics they face are themselves, Choate says. They try to have it all and then feel like failures when they can’t achieve the impossible. In essence, she says, “having it all” boils down to “figuring out a way to look young, thin and beautiful, be home with the kids as much as possible, be a superstar at work, have lots of successful friendships, have a blissful romantic relationship, have a perfectly decorated, always clean home [and] cook fresh, organic meals daily.”

Breaking free of the mold 

Choate says counselors can help their female clients uncover the unrealistic expectations they are operating under. “What are the actual standards they hold up for themselves in order to feel they are a success? Actually putting these expectations into words is the first step in helping to change them,” she says. “Where did they learn these expectations? How did they come to internalize these expectations? Did they learn them from parents? Teachers? Coaches? Popular media? Whose approval are they seeking?”

Once a client realizes she is responding to outside forces rather than considering options that might be right for her, the counselor can help her identify ways of creating a healthy balance that fits her life, Choate says. The counselor should have the client ask herself what makes sense for her given her personal strengths and resources.

“This will look different for everyone,” Choate says. “What are realistic and meaningful goals that respect self-care and balance versus living up to a never-ending treadmill of others’ expectations? Helping our clients separate the difference between societal ‘shoulds’ versus what each client actually wants for herself will be very freeing for her.”

In Choate’s book Girls’ and Women’s Wellness: Contemporary Counseling Issues and Interventions, published by ACA, she talks about strategies couples can use to strike a balance in household duties. Rather than trying to decide how to divide tasks exactly 50-50, she suggests that couples talk about particular duties that each partner prefers. For instance, one might prefer folding laundry to vacuuming, or washing dishes rather than taking the trash out. Couples should also talk about who will keep track of items such as bill paying, appointments and other deadlines. The most important goal is for both partners to be satisfied with the division of labor, Choate says. It is also important for partners to be flexible enough to temporarily take on more or less responsibility when needed, she adds, such as one partner tackling extra household tasks when the other partner has a project that requires extra hours.

Hartig also helps her clients re-examine the stereotypes they have been taught, particularly as they relate to body image. “I believe the first step is assessing where clients’ narratives about their bodies began,” she explains. “For example, was the client told she was fat by a parent, or did the client gain a significant amount of weight and feel differently about his or her body? Identifying the struggles a client has about his or her body is important to begin working toward self-acceptance. Often, a negative body image is indicative of feelings of inadequacy and shame. Working on these feelings can lead clients to finding peace with their bodies.”

“Some of the ways that we work with clients on self-acceptance is to explore the negative self-talk they experience and where this self-talk originated,” Hartig continues. “Coaches, parents, teachers and friends all can have an immense impact on self-talk. Counteracting this self-talk with CBT [cognitive behavior therapy] can be very helpful. Creating a new narrative about the client’s self and body is also helpful. For example, a client who can say ‘My body is strong and my body helped me escape some pretty hard situations’ is on the road to appreciating her body.”

Hartig also notes the importance of counselors being aware that negative societal messages about appearance and body image are even greater for women who are not white or heterosexual. “Women of color face even greater assaults on a positive body image [because] our culture has an ideal that is rarely inclusive of all women — or people,” she says. “Women who identify as lesbian or bisexual are also often marginalized and misunderstood with regard to body image.”

“Internalized self-loathing is a natural consequence of media and other outlets that do not embrace the beauty of diversity and realness of people,” Hartig says. “Understanding these issues specific to different cultural groups is key to helping clients with body image issues.”

McLean uses brain-based psychoeducation to help women understand why they feel they need to meet society’s unrealistic expectations. For instance, she explains that humans are hard-wired to seek social approval, so it is normal for people to want to conform. McLean then helps clients to understand their own expectations and fears and to recognize and reframe cognitive distortion. She encourages women to explore how to balance their lives around their personal values rather than around social expectations.

Hartig likes to use narrative therapy to examine her clients’ struggles with the expectations they feel they need to meet. As she listens to clients’ stories, she finds it particularly important to note losses — for example, dreams or plans a woman may have had to let go of in one part of her life, such as her career, to attend to an aspect in another domain, such as family.

For instance, Hartig had a client who had decided not to have a second baby because she wanted to pursue tenure. However, after achieving tenure, she didn’t find it particularly satisfying and felt that she had given up the chance to have another child for nothing. It was important for the woman to grieve this loss, Hartig says.

Hartig encourages clients to grieve such losses by helping them develop rituals for letting go. This might involve a client writing a letter to herself and then burning or shredding it, releasing balloons, journaling or even holding a “funeral” for what was lost. The funeral ritual might include gathering pictures or symbols of what the woman lost, putting them in a box and burying them.

Once the client is ready, Hartig helps her to “reimagine and recreate,” building a narrative around what she wants her life to be going forward and how she can make that happen.

“For some, writing this plan down makes sense and is helpful,” Hartig says. “This can take the form of a ‘letter from your future self’ or free writing/journaling about hopes for the future. This process can also be done in the therapy session, as some clients do not respond well to written homework. I think the crucial element is to gently invite the client to envision a life that looks different than what … she originally planned, once the grief has dissipated.”

Until society rejects the picture of perfection that is “having it all,” counselors can play an important role in helping women strike a balance that allows them to have what they need.

 

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To contact the individuals interviewed for this article, email:

 

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Related reading:

See Laurie Meyers’ companion article to this piece, “Girls feeling pressure to be ‘sexy, famous and perfect’,” for more on how counselors can help young girls defy societal stereotypes and pressures.

 

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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

 

A counselor’s view of advanced breast cancer

By Cheryl Fisher February 29, 2016

Breast cancer touches all of our lives, and I am no exception. In February 1996, I went for my first mammogram. I was only 33 at the time, but I had read about the importance of having a baseline mammogram for early detection of breast cancer. Early detection meant cure, right? As a single mother of two young daughters, I was all about early detection and cures.

So, I went for a mammogram, astonished at how my 34B’s were able to squish like a schnitzel on the chilled mammography plate. The technician greeted me with a smile and warm hands, and for both I was grateful. The procedure, while uncomfortable, was not unbearable. I mean, I had given birth to Branding-Images_Canceran 8-pound baby without so much as an episiotomy. This was a simple walk in the park. The technician informed me that no news was good news, and I left feeling initiated (once again) into the sisterhood of womankind.

You can imagine my shock when I received a call mid-March that something unusual had been detected in my mammogram and that I needed to return for an amplification. The previously chipper technician met me with a solemn face and greeted me in almost a whisper. She did not make eye contact. The amplification was done in silence. Again I was told that I would be contacted if something was detected.

A week later, I was scheduled for a needle biopsy. As I lay facedown, my left breast dangling through the hole in the hospital table, thoughts raced through my head: “What if it is cancer? I can’t stop working. How will I take care of the girls?”

“No,” I told myself. “This is not cancer. I’m only 33 after all, and who gets cancer this young? I am a vegetarian. I am an aerobics instructor, for heaven’s sake! I don’t feel sick!”

I was provided with a bag of ice to place over the area of my breast that had been biopsied. They had found three suspicious areas and removed them, leaving a marker just in case … In case of what? I wondered. I left with my bag of ice and a fearful heart.

I started noticing articles in newspapers and magazines about young women with breast cancer. Had these always been there? Was I just now seeing them? I went home, hugged my daughters and cried. I cried the entire weekend as I waited for Monday’s pathology report.

I went alone to the hospital. I didn’t want to feel like I had to take care of another human being if my news was grim. I wasn’t sure I could take care of myself, let alone another person.

I went to the desk and announced my arrival. Again, the quiet whispered reception. I was immediately whisked away to a back office. Alone. Alone with a running video titled Living With Breast Cancer. Oh, my God! It’s true! I must have breast cancer. They’re preparing me by showing this video.

I began rehearsing how I would tell my family … my parents … my brothers … my daughters. The pathologist arrived and sat in a chair across from me. I took a deep breath. I don’t think I exhaled until I had been home for several days.

The pathologist began. “Well, we found three suspicious nodules and we removed them.” OK, buddy, so what are they?

“I’m curious,” he continued. “Have you ever experienced a trauma to the left breast?”

A trauma? You mean other than the needle biopsy that occurred the previous week? “No,” I replied in a small voice while still holding my breath. “Not that I am aware of. Why?”

“These are calcifications that appear to be from a traumatic blow to the breast,” he answered.

Let me get this right. I have been poked, prodded and petrified because of benign calcifications that possibly occurred during a Thanksgiving round of family football?

“So, I do not have cancer?” I whispered.

He shook his head and finally made eye contact. I was flooded with relief. I would live. I would raise my daughters. I would endure their teenage antics, their graduations, their weddings perhaps. I might even experience grandchildren!

What I wasn’t prepared for was the second wave of emotion that I experienced — anger. Anger at the time wasted, waiting and worrying for four excruciating days before I had to return to the hospital, find parking and sit in a room for 20 minutes watching a video about breast cancer. Anger at waiting for a doctor to hand over my fate. To me, this seemed so insensitive and cruel. What is wrong with health care that we treat the disease without treating the person?

However, I was 33 years old, a single mother, and I had just been told that I did not have cancer. I left that hospital, lived my young life and put breast cancer aside — until recently.

The call

I am a licensed clinical professional counselor. I had been in private practice for a few years when I received an email from METAvivor (metavivor.org), a local nonprofit group whose mission includes providing emotional support to individuals living with stage 4 metastatic breast cancer and promoting funding for research projects. The organization was looking for a therapist to facilitate a support group focused on meaning construction and stage 4 metastatic breast cancer.

Author and psychiatrist Viktor Frankl provided us with a foundational understanding of the importance of meaning construction in his classic book Man’s Search for Meaning. He proposed that the search for meaning was universal to the human experience and that it was a prerequisite for mental and physical well-being. Furthermore, an inability to make sense of our situation has been found to be associated with poor health. Therefore, a cancer support group that promoted meaning-making could provide patients with the necessary tools to experience a sense of well-being, even in light of their diagnoses.

My clinical practice had included counseling for bereavement and hospice care, but I had been spending more time working with survivors of trauma and had focused my advanced training in the area of trauma and spirituality. So, I wasn’t certain that I was going to be the best person to facilitate a support group for stage 4 metastatic breast cancer. Regardless, I agreed to co-facilitate
the pilot group with a colleague from a local hospice.

The pilot group lasted eight weeks. During that time, I became acutely aware that the youngest member of the group was experiencing her diagnosis in a much different way than her older counterparts were. She was a 30-year-old married woman who had been diagnosed with stage 4 metastatic breast cancer eight months prior to the launch of the group. She had a beautiful 6-month-old baby boy who provided all of us such joy when he visited our group. Her disease appeared to be relentless, however, resulting in a complete bilateral mastectomy and oophorectomy and causing her days of nausea and fatigue. She would come to group pale and weak, convinced that the last round of treatment had to be curative because of its great potency. She died two months after our group ended.

According to the Metastatic Breast Cancer Network, approximately 162,000 women in the United States are living with stage 4 metastatic breast cancer, and only 27 percent will survive as long as five years. This translates to one death from metastatic breast cancer every 14 minutes. Of this population, 5 percent are women younger than 45. Metastatic breast cancer is more aggressive the younger the person is at onset; only 2 percent of premenopausal women with metastatic breast cancer survive longer than five years following their diagnosis of advanced cancer. Most women living with breast cancer may share similar experiences regarding self-image, relationships and support issues, but unique needs appear to exist among young women living with advanced breast cancer.

As a result of meeting the young woman in our pilot support group, I conducted my dissertation research on spirituality and meaning-making in premenopausal women diagnosed with stage 4 metastatic breast cancer. I dedicated my dissertation to her and to all of the young women living with advanced breast cancer, and I committed my work to serve as the voice of those who can no longer speak. What follows is some of the wisdom provided to me by the women in my pilot group and research study.

I am woman?

The treatment for advanced breast cancer involves invasive surgeries that remove not only what many women described as their femininity (breast tissue and nipples) but also their fertility (ovaries and uterus). As a result of treatment, women were catapulted into early menopause and became subject to the physical and psychological manifestations of estrogen depletion.  These manifestations included weight gain related to decreased metabolism, hot sweats, dry skin, decrease in vaginal lubrication and decline in libido.

According to the women in my study, the experience of metastatic breast cancer had stripped them of their bodies, their fertility, their youth and their sexuality. Extensive research demonstrates that physical alterations of the body related to the treatment of breast cancer may have negative effects on identity, confidence, mood, esteem, sexuality, self-satisfaction and quality of life. Treatment may involve not only the removal of breast tissue and nipples, surrounding lymph nodes and ovaries, but also the insertion of an external port to receive chemotherapy. This may be followed by radiation therapy. The body is left scarred and burned with an existing portal that emerges from the upper trunk.

Many of the women in my study described feeling like a “freak,” a “mess” or a “patchwork quilt.” All of the women described feeling detached from their bodies following their treatments. The body that remained was described as lifeless and clinical, almost corpselike.

BFFs and other strangers

The struggle to cultivate authentic relationships was a common theme in this study. The women spoke of their desire to be able to discuss the genuinely harsh reality of their diagnoses with family members and friends. However, the women felt that a substantial portion of their circles of support were unable (or unwilling) to assimilate adequately and comprehend the grave world of living with advanced cancer. The women were asked (directly and indirectly) by family and friends to compartmentalize their experience with cancer and to act as if they were not ill. Such requests led at times to feelings of anger, resentment and, eventually, rejection and isolation.

Sexuality

In addition, there appears to be an absence of sensuality as it relates to the body that remains. This, combined with decreased libido, proved to be a common issue for all the participants in my study. The women expressed a desire to resume an active, healthy sex life with their partners, but they struggled with experiencing a lack of sex drive and feeling unattractive.

Research indicates that women younger than 45 who are diagnosed with breast cancer have more difficulty adjusting than do older women. These younger women have lowered overall quality-of-life ratings linked to concerns about body image, partner relationships and sexual functioning, and they also exhibit less adaptive coping styles.

It also appears that having casual sexual encounters becomes less attractive when living with advanced cancer. One of the women described the need to feel emotionally safe before allowing a stranger into the scarred world of breast cancer. She noted, “I will need to trust the person to tell my whole story.”

Legendary living

Engaging in honest dialogue regarding the fears experienced by a person living with a life-threatening illness seems to provide some degree of anxiety relief for the person. This appears to be the result of directly identifying and addressing that which concerns the individual.

For example, many of the women in this study spoke of their fear of being forgotten and not having a part in the rearing of their children. This discussion provided opportunities to identify ways that might allow their values and beliefs to continue to exist even after their lives ceased. Among the ways these women attempted to provide continuity of their presence in the lives of their families was through writing letters, keeping journals and signing cards for future events.

In addition to memory-making projects, all of the women in the study were involved in using their stories to promote education and awareness of the specific needs of young women living with stage 4 metastatic breast cancer.

Pink isn’t my color

In addition to feeling isolated from family and friends, these young women living with advanced breast cancer described feeling alienated from the breast cancer community as a whole. The “pink” model of breast cancer awareness strives to inspire hope of survival and a cure. However, these women live with a diagnosis that mandates that they are not in remission and that the cancer has spread to other organs. For them, there is no cure at this time. One woman in the study described the pink ribbon as “a noose that is killing me.”

Faith and peace

Psychiatrist and author Irvin Yalom proposed, “If we must die, if we constitute our own world, if each is ultimately alone in an indifferent universe, then what meaning does life have?”

As one of the study participants said, life-threatening illness can “suck the meaning out of life, making the person feel already lifeless.” In facing death, we are faced with making sense of life, and it would appear that we make choices about how to live our lives until death. Therefore, anything that affirms life force, meaning and importance to others can counter the sense that death has made its claim.

Frankl reminds us that we have the ability to choose how we respond regardless of our circumstance. This can be empowering even when facing death. The women in my study discussed the role of choice. One woman described using humor to help her cope with the chemotherapy. Another described an attitude of gratitude: “I show gratitude more often. … It is liberating to know I can choose happiness.”

The women spoke of feeling a sense of being part of a bigger, universal plan. In particular, they described feeling that a divine presence was actively participating in their illness. Some women in the study felt that their diagnosis was a wake-up call to be more present in their lives and to be closer to the transcendent. Each described a restoration process of reclaiming and redefining her life.

Other women in the study believed that their spiritual faith gave them the strength to endure the changes brought about by their illness and its subsequent treatment. Interestingly, all of the women described experiencing a richer, more authentic life that a “loving presence” had transformed from the ashes of advanced cancer.

Conclusion

As counselors, we have an incredible opportunity to help support young women living with advanced breast cancer in the following ways.

Body talk: We can help these women (and their partners) reconnect with their bodies in a healthy and empowering manner. We can talk about sexuality and recognize the role that it plays in our emotional, spiritual and physical well-being. To support premenopausal women who are living with advanced breast cancer, we need a greater understanding of their fears around rejection and increased recognition of the role that sexual intimacy plays in their lives. This is a focus of my current research.

Bittersweet friendships: We can validate the changes that occur in these women’s friendships and offer grief work around these losses. We can help clients establish healthy boundaries in relationships that feel authentic and protective. In addition, we can promote the strengthening of those relationships that are nurturing and empowering.

Legacy work: We can help clients cultivate strategies for legacy. Lillie Shockney, administrative director of the Johns Hopkins Breast Center, has written an exceptional book titled 100 Questions & Answers About Advanced and Metastatic Breast Cancer that helps clients and families navigate the challenges of advanced breast cancer. It also provides excellent ideas for being present and remembered beyond the cancer. In addition to her book, Shockney hosts exceptional retreats for families living with advanced breast cancer and provides a forum for discussion, connection and community to these patients and families.

Beyond the pink ribbon: We can connect young women who have advanced breast cancer to communities that are validating and supportive. Wonderful online communities include Young Survivors Coalition (youngsurvival.org) and the Pink Daisy Project (pinkdaisyproject.com).

Faith and justice: Facing death directly can be strangely comforting and empowering. However, counselors may be uncomfortable facilitating a candid dialogue that might be painful for their clients. Furthermore, counselors need to be open to their own discomfort in discussing death and dying. Counselors are encouraged to work from a conviction that they are helping rather than hurting clients by asking them to lean into the discomfort that comes from confronting one’s death. These clients are faced with family members and friends who are reluctant or unable to join them on this journey of facing death. Counselors have the opportunity to embody the existential experience and join the client on this difficult journey. The essence of relational, embodied theology is not captured simply by the empathic presence of the counselor, nor the rites and rituals that inspire spiritual and psychological nourishment. The essence of embodying suffering is to give voice to marginalized persons and to tell their stories. Better still, counselors can be instrumental in nurturing the intrinsic divine wisdom that is present in all of us and empowering clients to tell their own stories.

 

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. Additionally, she is a visiting full-time faculty member in the pastoral counseling program at Loyola University Maryland. Her current research is titled “Sex, spirituality and stage 3 breast cancer.” Contact her at cy.fisher@verizon.net.

Letters to the editor: ct@counseling.org

Empty crib, broken heart

By Bethany Bray September 22, 2015

This past summer, Facebook CEO Mark Zuckerberg and his wife, pediatrician Priscilla Chan, announced that they are expecting a baby. This celebrity baby news grabbed headlines for a different reason than most, however. The couple’s announcement included a candid acknowledgment that they had been trying to have a baby for several years and had suffered three miscarriages along the way.

“It’s a lonely experience,” Zuckerberg wrote in a July Facebook post. “Most people don’t discuss miscarriages because you worry your problems will distance you or reflect upon you — as if you’re defective or did something to cause this. So you struggle on your own. … We hope that sharing our Empty-crib-broken-heartexperience will give more people the same hope we felt and will help more people feel comfortable sharing their stories as well.”

Zuckerberg and Chan’s post resonated with millions of people (witness the post’s 1.7 million “likes,” nearly 112,000 comments and 49,000-plus shares as of the end of August) and helped raise the curtain on some painful yet common issues that are rarely talked about openly.

Although many people who face miscarriage and infertility feel alone or isolated, statistics show the circumstances are much more common than people may think. Miscarriage, defined as the loss of a pregnancy before 20 weeks, occurs in 15 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists. The U.S. Centers for Disease Control and Prevention reports that about 12 percent of women ages 15 to 44 have “difficulty getting pregnant or carrying a pregnancy to term,” while an estimated 7.4 million women in that same age bracket have used fertility services.

“Trying to make sense of it all is really, really challenging. The depth of the pain and the challenges you go through are hard to put into words,” says Kristin Douglas, a licensed professional clinical counselor and American Counseling Association member in Kentucky who has personal experience with infertility and multiple miscarriage losses. “You don’t ‘get over’ these kinds of losses. You work through them, but you don’t get over them.”

Mourning what might have been

A person or couple can’t help but think about the future, even if cautiously, after a fertility treatment or positive pregnancy test. Considerations from possible baby names to how the mother might be “showing” by a certain month naturally spring to mind.

“When that is taken away” — either through miscarriage or an unsuccessful fertility treatment — “you’re not grieving the past, you’re grieving what was going to be. You’re grieving the future,” says Valorie Thomas, a licensed marriage and family therapist and licensed mental health counselor in Florida. “With pregnancy loss and infertility, each time it doesn’t happen, you’re grieving … for all the ways you were thinking it was going to be. Helping the client to see that can be eye-opening — acknowledging that it’s real, it’s a loss [and] it’s gut-wrenchingly painful.”

Thomas knows this pain firsthand. She has been pregnant 10 times, but only one — her sixth pregnancy, a now 16-year-old son — was carried full term. Thomas and her husband also have a 7-year-old daughter whom they adopted.

Unlike when other family members, friends or acquaintances die, miscarriage and infertility can leave clients without memories to grieve. Often, people don’t even realize that they have the right to grieve, says Thomas, an ACA member who has a small private practice and is an adjunct professor at Rollins College in Winter Park, Florida. It’s the type of loss “that’s hard to understand,” she says. “You [typically] think of a loss as something that was already here, and you’re grieving it [no longer being here].”

With fertility treatment, she says, “You get the call from the doctors saying, ‘The pregnancy test was negative, we’ll see you next month,’ and they hang up,” leaving the individual or couple reeling with a flood of emotions, from anger and frustration to sadness and embarrassment.

Clients who are struggling with infertility or grieving a miscarriage can present with a range of issues in a counselor’s office. Depression, anxiety and intense stress are very common, Douglas says, as are feelings of guilt, anger, disappointment, frustration and fear. It is also possible for these clients to wrestle with trauma symptoms associated with their loss, she says.

It is not uncommon for couples or individuals to have experienced both infertility and miscarriage. Miscarriage, or “the inability to carry a pregnancy to term,” may be part of the infertility experience, Thomas says. But even when there is no overlap, couples who experience a miscarriage may share some of the same emotional responses as those who are having difficulty conceiving, she says, including a sense of helplessness, desperation and loss of control.

Because miscarriage and infertility can be taboo subjects, clients may not realize that they can — and should — acknowledge a pregnancy loss. For example, Thomas says, perhaps a client feels “down” every autumn but doesn’t know why. It could be that she experienced a miscarriage years or even decades ago during the fall that she never processed.

Professional counselors can provide help and support in a variety of ways to those who have experienced infertility or miscarriage. This might include helping clients work through the pain and stress of disappointment, self-doubt and even family or cultural expectations. It might also encompass encouraging these clients to practice self-care and teaching them coping mechanisms to help them get through the bad days.

Above all, counselors must familiarize themselves with infertility and reproductive issues if they are going to be sensitive and effective helpers for these clients, says Ebru Buluc-Halper, a mental health counseling graduate student at Pace University who runs a support group for couples and individuals going through infertility.

“If [a counselor] doesn’t know what they’re talking about, it’s a huge turnoff,” says Buluc-Halper, an ACA member who led a poster session on multicultural considerations in infertility counseling at ACA’s 2015 Conference & Expo in Orlando, Florida. She has friends “who were very frustrated by [a therapist’s] lack of knowledge and were turned off from therapy because they wanted to be understood. It doesn’t happen to everyone, but it does happen.”

“People want to be heard and want someone to talk to,” says Buluc-Halper, who has personal experience with miscarriage and fertility treatment. “They are deeply in need of empathy and understanding, which they’re not getting from the people around them, sometimes even from their partners.”

Counselors who don’t understand miscarriage and infertility — at the very least possessing a basic knowledge of the processes, terminology and biological factors surrounding these issues — risk reinjuring and alienating clients, agrees Douglas, an assistant professor of counselor education and coordinator of the counseling clinic at Murray State University in Kentucky. People who disclose their miscarriage or infertility struggles are often subject to the well-meaning but hurtful comments and assumptions of others, she says. Among the statements that are common: “If you just relax and de-stress, you’ll get pregnant”; “Just give it time, it will happen”; “At least you weren’t that far along to get attached”; “Maybe you should just adopt”; and “Maybe it’s not in your cards.” Comments such as these are often completely untrue and very upsetting to the receiver, says Douglas, who wrote her doctoral dissertation on miscarriage at the University of Wyoming.

“The last thing a person wants is to talk to a counselor who is going to say some insensitive and hurtful things in response to what that person experienced,” Douglas says. “There is a fear of what a counselor might say. Are they going to say the insensitive things that everyone else says? Things that are so hurtful or that minimize the loss?”

Handle with care

One of the most important things counselors can keep in mind is that no two clients’ experiences are the same, says Courtney Armstrong, an ACA member with a private practice in Chattanooga, Tennessee. Each client will attach a different meaning to what she or he is going through.

“Everyone’s experience with infertility is different. You can’t just make assumptions,” says Armstrong, a licensed professional counselor who accepts client referrals from a fertility clinic in her area. “You have to respect that it’s a process for people to come to terms with their infertility. It’s not something you can help them reason their way out of. You have to treat each person individually because every person is going to respond in a different way.”

Counseling and therapy must also be individualized in cases of miscarriage. Douglas says she finds it much easier to talk about her first miscarriage, which involved triplets, than her second, which was a single baby. “People would never compare the death of a sibling or a parent to that of an uncle or other relative,” Douglas says, “but somehow, [people] just lump all the miscarriages together. Each failed fertility treatment is not the same either.”

There is no one-size-fits-all way to address a client’s infertility or miscarriage in counseling, agrees Thomas. “It’s important that the counselor be aware [of] spirituality and traditions and culture. Your clients are bringing all of that to you,” she says. “You can’t just [use] a cookie-cutter approach.”

Thomas terms miscarriage a “silent sorrow,” saying that the loss typically goes unacknowledged by society. Too often, she says, the message that women who have experienced miscarriage receive is: “Get over it. You’ll be fine. Don’t worry about it.”

“But depending on your spiritual beliefs, depending on what that meant to you at the time, what it signified, what does family mean to you, what does creating a family [mean to you], how bad you wanted it — all those things play into your reaction,” Thomas says.

Paying careful attention to the language the client uses can provide counselors clues about how the person is processing the loss, she says. For example, does the client say, “I was 10 weeks pregnant, and I lost the baby,” or does she use another word? If the client or couple isn’t ready to use the word “baby,” the counselor shouldn’t refer to the pregnancy that way either, Thomas advises.

After going through pregnancy loss and several rounds of in vitro fertilization, Armstrong and her husband made the choice to be child free. Making that conscious decision was empowering, she says. “The choice piece is the really important part — deciding if this is the best and right thing for me,” she explains.

Likewise, Armstrong says, in counseling it can be empowering for clients to find meaning and realize they still have the ability to make choices in an unwanted situation. Wanting to be a parent and wanting to be pregnant are two different things, and helping clients to uncouple those two concepts in their mind can be helpful, she says.

“If they’re going to explore infertility treatment, adoption or other options, is this about having a child or having a child that’s biologically connected to you? The most important thing is that they feel they have the freedom to make a choice,” she says.

Thomas’ experience with infertility caused her to rethink the assumptions she’d held growing up in a Catholic family with nine brothers and sisters. “In my family, it was just assumed we’d all have large families,” she says. “When that didn’t happen for me, I had to revisit [that] and ask myself if I’d be OK if that didn’t happen. Then I came to grips [with the realization] that you can create family in different ways. It was OK that I had other parts of myself to be a whole person. I realized that it may be different for me.”

How to help

Heartbreak can accompany miscarriage and infertility. But so can hope and healing. Here are a few ways counselors can help clients who are processing these experiences.

Storytelling and narrative therapy: Two of the most important things counselors can provide to these clients are a listening ear and empathy. “It’s just so important to listen to their story, really listen to their story,” Thomas says. “Every one of them is so different. Each one has a different journey. Listen compassionately and really be present.”

Douglas recommends inviting clients, but not pressuring them, to talk about their loss experiences, such as where they were and how they felt when they learned they were pregnant, what it was like to be pregnant, what happened during their miscarriage and what feelings they had when they learned their pregnancy was over.

“Just like with other types of trauma, you want to be sensitive to not retraumatize clients by having them share their story over and over again,” she says. “But at the same time, if clients feel it would be healing to share their story, invite them to share it and process it as many times as they feel they need to. It can be healing to remember, to talk it through, to process these things with other people, especially if clients did not feel their loss was acknowledged or if they did not have the opportunity to share their story in full with anyone.”

This hit home for Douglas as she wrote the narrative of her first miscarriage for her doctoral dissertation. It was the first time she had written out the entire story, start to finish, she says. Afterward, she read the four-page narrative aloud to her own counselor in a therapy session. “It was such a powerful moment. I just sobbed and sobbed as I read it,” Douglas says. “It was then that I realized I had shared my story with lots of different people but never the whole thing beginning to end — only parts. That was huge for me. I had a further glimpse into the power of story, the power of vulnerability, the power of giving voice to nebulous experiences and the power of validation. Sharing my story beginning to end was emotional but very healing.”

The empty chair approach: This Gestalt technique can be helpful for processing “unfinished business” — something all too common for those who have had a miscarriage, according to Douglas. Counselors might ask clients to speak to an empty chair as if their child who was miscarried were sitting there. Or use the empty chair to have clients speak to whomever they need to — perhaps a co-worker who made an insensitive comment or a doctor who came across as callous, sterile or impersonal. The empty chair can also provide a means for clients to speak to their deity, even venting frustration or another emotion.

“This can be a way to give the client a voice or provide a degree of closure,” Douglas says. “It not only helps clients work through complex feelings as they process lost hopes, dreams and frustrations, but also helps them have an important, needed voice.”

Journaling and letter writing: Writing a letter can provide clients an outlet to tell their miscarried baby that they miss and love the child. Similarly, clients can write themselves a letter from the baby, Thomas says.

“At some point when they’re ready, have the client write a letter from the baby to the parents. They can say, ‘I’m still here. I love you.’ That’s very healing, but it shouldn’t be done right away,” Thomas warns. “It takes time. [The parents] have to be ready for that.”

Creating a journal can also help clients process a pregnancy loss by encouraging them to explore the loss and what it meant to them, Thomas says. Each experience will be different, whether it is the client’s first miscarriage or third, whether the client already has children at home, whether it was an unplanned pregnancy and so on.

Expressive arts and other creative therapies: Douglas displayed copies of some of the pastel chalk drawings she created as part of her own way of coping with her miscarriage loss when she co-presented a session at the ACA Conference in Charlotte, North Carolina, in 2009.

She advises counselors to pay attention to their clients’ creative interests and incorporate those interests into the therapeutic process, if appropriate. For example, if the client likes to garden, planting a tree in honor of a child who was miscarried might be healing for the client. If the client has a flair for design, perhaps she could design a bracelet with charms that represent the pregnancy. Douglas finds that expressive arts or other creative therapies not only help clients work through challenges associated with their loss, but also assist in making the intangible tangible.

Douglas had one client who enjoyed scrapbooking. Creating scrapbook pages became her version of a journal and helped her find meaning in the miscarriage she had suffered. Scrapbooks or other creative projects can include ultrasound images, hospital bracelets, photos of baby gifts that were received or a narrative written by the client about what it felt like to find out she was pregnant.

“One of the challenges of miscarriage is the intangibility,” Douglas says. “When you have such few items, those ‘artifacts’ such as an ultrasound photo become very important in validating your experience and your loss. You cling to those things.”

Mind-body and wellness approaches: Thomas says mind-body approaches such as yoga, relaxation techniques, meditation, deep breathing, guided imagery and repeated prayer can be helpful to clients who have experienced miscarriage or infertility. In one case, Thomas used guided imagery with a client before her fertility treatment, instructing her to envision that her grandfather, who had passed away, would be with her to support her throughout the procedure.

In addition, encouraging clients to pursue a wellness lifestyle, including eating healthy food, exercising regularly and getting enough sleep, can be helpful, both because of the health benefits provided and because it gives clients a new area of focus. Spending time on healthy cooking, for example, can divert a client’s energy and focus away from frustrated or anxious thoughts. Assure clients that they are working to be “in the best place they can be to ride this roller coaster,” Thomas says. The thought becomes: “I am doing the best I can to make my body healthy so I have a chance of conceiving.”

Encouraging clients in the practice of self-nurturance, such as taking 30 minutes each day to do something they really enjoy, can also help refocus their energy away from the stress of fertility treatments. Thomas instructs clients to think of 10 things that they enjoy doing and that make them happy. Then she asks clients, “How many of these things are you doing? You’re allowed to enjoy things during this time. Look for ways to enjoy yourself.”

Developing signals: Sometimes social situations can be overwhelming for individuals who are going through infertility or who have experienced a miscarriage. Buluc-Halper and Douglas both suggest that counselors have these clients develop a signal to let their partners or trusted friends know when they need to change the subject or take a break during social gatherings.

But clients also need to be realistic about what they can and cannot handle, Buluc-Halper says. “Going through this experience is a good time in your life to put yourself first,” she says. “[When] you’re expected to show up at a dinner or a baby shower and you emotionally, truly, cannot handle it, it’s OK to put yourself first and say, ‘It’s not a good day for me.’ Put yourself in touch with what you’re feeling. You’re in such a fragile state. There are days when you wake up and you know that you can’t go, and others when you are strong enough.”

Externalize the problem: Buluc-Halper suggests that counselors help clients remove the word infertile from their vocabulary. Infertility is not their identity, she explains. “We don’t say, ‘I’m cancer.’ We say, ‘I have cancer,’” she says. “Infertility doesn’t define them. It’s just part of their journey. Finding a way to externalize that does make it easier to go to the dinner, the family gathering, the baby shower, [knowing] this is just part of my journey. Everybody will go through something in their lives, and this [infertility] is one of the things that we just happen to be going through. … Everybody will find some sort of resolution, whatever that may be. As in every experience, there will be a resolution. It might not be the resolution you envision, but you will find some kind of closure.”

The trusted friend: When clients are hesitant to tell family and friends about what they are going through, Buluc-Halper suggests that they pick one person, such as their mother or a favorite sister or cousin, to confide in. Ideally that person should be able to serve as a buffer when awkward or painful subjects or questions are raised at family or social gatherings. In Douglas’ case, she had a trusted friend who would intercept baby shower invitations for her, knowing she wasn’t ready to face such a baby-focused event.

A cultural perspective: A client’s cultural background can play a huge role in how that person views and deals with miscarriage or infertility. At the same time, counselors should never assume that individual clients will experience these issues within the cultural norms of their respective backgrounds, Buluc-Halper says. Doing a cultural genogram with clients can help counselors get a better idea of the role that cultural background plays in a person’s life, she says.

Thomas agrees, noting that she asks clients about their spirituality and family of origin at intake.

“The very, very important part for all counselors to remember when working with infertility clients from a cultural perspective is to be very aware of their own cultural biases,” Buluc-Halper says. “Be cognizant not to distort the couple’s experience based on how you assume that culture perceives infertility in terms of its ideologies, in terms of its experiences or in terms of the resolution. … They might not be experiencing infertility the same way you might expect them to based on their cultural background.”

Taking a break: For clients who are going through fertility treatments, each stage brings a series of decisions and procedures that can be exhausting, Armstrong says. Counselors can offer their clients reassurance that if they decide to take a break from treatments, it doesn’t mean they are giving up,Empty-crib-broken-heart-small she says. “Maybe take a month off, regroup and then go on to the next stage [of fertility treatment]. Tell them, ‘You’re not giving up. You’re just backing off for a minute to get some perspective and come back,’” Armstrong says.

Internet forums: Numerous websites and online forums are available for people going through infertility and reproductive issues. Although these sites provide helpful information and a way to connect with and find support from other people facing similar issues, the sites can also cause clients to spend more time focusing on issues that cause them anxiety, stress or sadness.

In Armstrong’s case, she stopped visiting online forums while she was undergoing in vitro fertilization because they were provoking her anxiety. Although such forums can offer support in many situations, Armstrong found they could also act as a platform to swap “horror stories” or misinformation. “Some people find them very helpful, while others find it makes them feel worse,” she says. “It helps them know that they’re not alone, but there can also be a risk because it can make them more worried.”

If online forums don’t appear to be serving clients’ best interests, counselors can suggest that they take a break and attend in-person support groups instead. Support groups, whether online or in person, can play an integral role in breaking through the isolation that often accompanies experiences of miscarriage and infertility, Buluc-Halper adds.

Grief: Douglas theorizes that women grieve miscarriage loss developmentally. “This is a life that would have been,” she explains, “and you will most likely grieve in different ways and different stages for what that child would have been like [as it aged]” — such as when the child would have started walking and talking or when the child would have started kindergarten. Missed milestones may be extra emotional as time passes. As a result, grief may resurface over and over again, but in different ways, complicating the healing process, Douglas says.

Anniversaries: In cases of miscarriage, multiple dates can be painful, such as the day the couple found out they were expecting, the baby’s due date, the date they lost the pregnancy and so on. Counselors might suggest that clients engage in extra self-care on those anniversaries or commemorate the dates with rituals such as playing a meaningful song, lighting a candle or sending up a helium balloon with a letter inside to their miscarried child, Douglas says.

Control: One of the most difficult aspects of dealing with infertility or miscarriage for clients is accepting that what has happened or is happening is largely out of their control. “A lot of people blame themselves and think, ‘I’m not doing enough or could be doing things differently,’” Armstrong says.

In cases of infertility, some clients will do things to try to take control of the situation, such as cutting gluten out of their diets or taking their temperature daily. Counselors need to be sensitive to the fact that these clients may have devoted a lot of time and energy to finding different methods that might increase their chances of conception, Armstrong says. If the methods are giving them more confidence or security about their situation, that can be good, Armstrong says, but if the methods are only serving to make clients blame themselves further, that can be harmful. “Be mindful and aware of helping clients find what makes sense and what may not be influencing whether or not they get pregnant,” she says.

In cases of miscarriage, Armstrong says she most often points to biology with clients. The human body is designed to abort a pregnancy that could be harmful, she says. “I really try and bring it back [to the fact] that we don’t understand all the reasons why [women miscarry], but it’s purely biological,” she says.

Offering hope: Individuals receive very straightforward — and sometimes upsetting — information from medical doctors about their infertility, including the slim percentage they may have of getting pregnant or the complications that could happen as a result, Thomas says.

On the other side of that coin, a counselor’s focus on the positive can provide clients an antidote to discouragement, she says. “Hope is such a big factor. … Put [clients] back in charge of their life,” she advises. “Offer hope that there are some coping strategies [available and that the client is] a normal person responding to the struggles of creating a family. [Tell them], ‘You need to give yourself permission to be angry and cry. … Keep the faith. If you want a family, it will happen. It may just not be the way you envisioned.’”

Couples: It takes two

Spouses or significant others will naturally deal with miscarriage or infertility in different ways and process things at different rates. In fact, it is common for a counselor to see relationship partners who are in two very different states emotionally, Armstrong says. One partner may have already accepted what has happened, while the other is still in a bargaining stage, thinking, “Surely there is something we can do” to change the situation, Armstrong says.

Counselors can help by educating couples that the grief that accompanies a miscarriage or infertility will come in waves and that each partner is likely to be at a different point along the grief spectrum. Once couples understand that it is natural to feel differently about what they are experiencing, they often express a sense of solace, Armstrong says.

“They’re relieved [because] they don’t see themselves in conflict, just at different stages in the process. Then they can understand and be more patient with each other,” she says. “Help them understand that they’re in different stages and how to communicate and best support each other” wherever they are in the process.

Differences in spirituality level or religious background can threaten to divide a couple during a miscarriage, notes Thomas. For example, one partner may consider a miscarried baby to have a soul, while the other does not.

“Spirituality can be very healing or create a lot of conflict if they’re coming from different perspectives,” Thomas says. “One may feel it’s ridiculous to grieve, while the other feels it’s necessary. Work with them to be respectful of each [other’s perspective].”

It can be helpful for counselors to suggest that a female client bring her partner to medical and therapy appointments when possible, Buluc-Halper says. It is important that the client learn to rely on her partner for support throughout the entire process, not just during times of extreme anxiety, she points out.

“Partners don’t always understand how all-consuming this [infertility] experience is,” Buluc-Halper says. “You’re the one that is doing blood work, and your arm is purple from all the injections. It’s not to diminish the male experience of this, but they don’t always understand why the female can’t really detach herself from the issue.”

As important as empathy is for counselors, it is equally important to teach that skill to couples, Thomas says. She often has couples hold hands as they tell each other what the miscarriage journey has been like for them. The counselor is there to assure both partners that whatever they are feeling is valid, real and quite possibly intense, Thomas says.

“Give them a safe place to explore what this has been like for them — sometimes for the first time,” Thomas says. “What does that loss mean to them? [They are] really seeing each other describe what happened and how they’re feeling right now. Because they grieve differently, it’s important to validate their experience and [explain] that it may trigger some previous losses and intensity that might scare them.”

“With infertility, they can get stuck and not want to move on if they’ve had a pregnancy loss and not really grieved it,” she says. “They need to slow down and experience what they need to experience before they go on to the next step.”

Breaking the silence

By inviting conversations about miscarriage and infertility, counselors can play an important role in removing the stigma and isolation that surround these issues. Douglas cites the example of breast cancer, a once-taboo subject that is now openly talked about and advocated for with well-publicized campaigns and fundraisers.

“Invite the conversation and break the silence,” Douglas says. “Help give women and men permission to grieve miscarriage losses and give voice to those losses. Give them a safe, nonjudgmental place to share their stories. Invite those stories. Take time to listen to those stories over and over again, as many times as people need.”

 

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For more information

  • Valorie Thomas will be presenting two sessions on these topics at the 2016 ACA Conference & Expo in Montréal. Thomas’ sessions are titled “Creating Rituals for Couples Experiencing Early Pregnancy Loss” and “A Mind/Body Approach for Struggling With Infertility.” See counseling.org/conference for session and registration information.
  • Oct. 15 is Pregnancy and Infant Loss Remembrance Day. Visit october15th.com for information and events, such as remembrance walks, listed by state.
  • The National Infertility Association (resolve.org) offers a wealth of information and resources, including online support communities and a hotline, 1-866-NOTALONE.
  • The American Pregnancy Association has resources on infertility and pregnancy loss at its website: americanpregnancy.org
  • An ACA Practice Brief titled “Counseling People Experiencing Infertility,” by Donna M. Gibson and Jennifer M. Gerlach, is available to ACA members on counseling.org. (Practice Briefs are listed at the Center for Counseling Practice, Policy and Research page, which is under the “Knowledge Center” tab on the homepage.)

 

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Bibliotherapy resources for clients and practitioners

  • Jaffe, Janet and Diamond, Martha (2011). Reproductive Trauma: Psychotherapy with Infertility and Pregnancy Loss Clients
  • Kohn, I. and Moffit, P. L. (2000). A silent sorrow: Pregnancy loss: Guidance and support for you and your family. New York: Routledge. Doubleday Dell Publishing Group, Inc.
  • Kushner, H. (1981). When bad things happen to good people. New York: Avon Books.
  • Domar, A. D. and Kelly, A. L. (2004). Conquering infertility: Dr. Alice Domar’s mind/body guide to enhancing fertility and coping with infertility. New York: Penguin Books.
  • Jones, C. F. (2009). Hopeful heart, Peaceful mind: Managing Fertility. Fraser Davis Press.

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org