Monthly Archives: February 2010

A national obsession

Lynne Shallcross February 15, 2010

If you think elementary school students are only learning their ABCs and 123s, think again. Some are also absorbing societal messages that place importance on counting calories and dropping dress sizes.

Anna Viviani, a counselor in private practice in Peoria, Ill., who works with eating disorder clients, remembers a conversation she had recently. A school counselor told her that children as young as first and second grade are talking about dieting and body dissatisfaction. Indeed, research has shown that 42 percent of first- through third-grade girls want to be thinner. Studies have also found that 81 percent of 10-year-olds are afraid of being fat, while 50 percent of fourth-grade girls are on a diet.

Those children may eventually join the nearly 10 million American women and 1 million American men who, according to the National Eating Disorders Association, battle an eating disorder such as anorexia or bulimia. Millions more struggle with binge eating disorder and other eating disorders. “Problems with eating disorders and body image are not just a phase,” says Viviani, a member of the American Counseling Association who is earning her doctorate at the University of Iowa. “This intense preoccupation with weight, food, exercise and body image has become a national obsession, and as counselors, we need to be ready to address it.”

In light of the increase in eating disorders, Viviani advocates the topic being taught more widely at the master’s level for counseling students. “While I recognize that not every counselor will go on to specialize in the diagnosis and treatment of eating disorders, having a thorough understanding of the disease is vital, given the staggering numbers of new cases appearing each year,” she says. “As a professional counselor be it school, mental health, community, rehabilitation, college, marriage and family it is likely that they will encounter a client with an eating disorder at some point in their career.”

The key to understanding eating disorders, experts say, might come as something of a surprise. Namely, it’s not about the food. “I can’t stress (that) enough,” says Erica Riczu, an ACA member who owns a private practice in Toms River N.J., that focuses in part on eating disorders. “You can’t just place these clients on a food diary and expect them to eat properly. The food is a cover-up, a mask for deeper issues.”

Viviani likewise emphasizes that the issues at the heart of eating disorders go much deeper than food. “When one feels

that everything in life is out of control or at least not in their control food, weight, exercise is one thing that many eating disorder patients feel they can control, at least in the beginning,” says Viviani, who spent five years working in a partial hospitalization program specializing in the treatment of eating disorders. “As we work with these clients to help them feel a general sense of control in their lives, many times, the eating disorder behaviors begin to come back under control.”

Although anorexia and bulimia are the most commonly thought of eating disorders, the “eating disorders not otherwise specified” (EDNOS) category is an “extremely common diagnosis,” says Sara Hofmeier, a counselor who has worked at the inpatient, day-treatment and outpatient levels with clients battling eating disorders. EDNOS includes binge eating disorder, which Hofmeier says may soon have its own diagnosis in the Diagnostic and Statistical Manual of Mental Disorders. “The tricky part about eating disorder diagnoses is that many people who present with anorexia or bulimia may not actually meet the diagnostic criteria for those disorders because of some of the stringent requirements,” Hofmeier says. “Many clients ultimately, at some point, receive the EDNOS diagnosis.”

Familiarity with the diagnostic criteria for eating disorders is important, Hofmeier says, but it’s perhaps more critical to understand that not all eating disorders will show up perfectly in line with the criteria. “It is important for counselors to keep an open mind,” says Hofmeier, an ACA member earning her doctorate at the University of North Carolina at Greensboro. “For each client, the eating disorder will look different, will have different symptoms, will have different features, will have different concerns and will bring about different treatment needs.”

Aside from the extreme weight loss seen in clients with advanced anorexia nervosa, there are many more subtle signs to watch for, according to Viviani, including excuses for missing meals, food rituals, avoidance of specific foods, excessive exercise, dressing in layers (especially when the weather is warm), isolation from peers and family and constant chatter about food and weight. Hofmeier adds other signs to that list: undue concern with body shape or weight, perfectionism, rigidity related to food or body image, ritualistic behaviors and cognitive impairment with low weight.

Anxiety, anxiety, anxiety

Some people actively seek out a counselor because they’re tired of struggling with eating or body image issues and want help. But for others who are struggling, realization of an eating disorder doesn’t come until much later. “The biggest thing that gets them through my door is anxiety, anxiety, anxiety,” Riczu says, adding that these clients tend to exhibit an inability to identify how they feel in their bodies. “They will say they feel anxious, but if you ask them how do they know they are anxious where do they feel it in their body many struggle to answer.” Many people with eating disorders lack obvious outward signs and can appear to be at a normal weight, Riczu says. They may also go to great lengths to hide their disorder. “I would say the best approach of all is for a therapist to ask questions,” she says. “I bet many clients don’t even know they are struggling with an eating disorder until you ask the questions.” She says this might include asking clients if they find themselves eating to cope with stress, if they count calories, how they feel when their belly is full, whether they’ve ever felt guilty after eating something or if they have a favorite comfort food.

“The most important way that a counselor can identify an eating disorder is by being aware of what constitutes an eating disorder and appropriately assessing for eating disorder symptoms with new clients,” Hofmeier says. But, she continues, because the signs and symptoms can vary so widely, it’s important that clinicians not jump to conclusions about the presence or absence of a problem. “The best way that a counselor can identify what is going on is by being present to listen to all of the client’s story and being able to ask the right questions to probe for underlying or disguised eating disorders.” Those questions relate to self-esteem and attitudes toward food, she says. For instance, does a client feel good about herself because her pants fit or because she has a sharp wit and is a good friend? When it comes to food, are lots of rules and rigid thinking involved? The answers to these and similar questions can offer insight into where the client is coming from, she says.

As for the question of what actually causes a person to have an eating disorder, no single answer will apply to every client, Hofmeier says. “Many background factors have been associated with eating disorders abuse history, certain athletic involvements, traumatic experiences, difficult periods of adjustment but these are by no means givens and should not be assumed,” she says. “Counselors should screen for experiences like these and others that may be associated with the client’s eating disorder, but the assumption should not be made that there is a single cause for any eating disorder.”

Eating disorders often develop as a result of several experiences and factors combining, says Hofmeier, adding that it’s nearly impossible to pinpoint exact causes. “It is more helpful to think of contributing factors, such as the emphasis that the family placed on weight or appearance, the media that the client was exposed to, the peer relationships the client had, any athletic involvement that placed a high degree of emphasis on body shape, general client tendencies toward perfectionism or traumatic experiences that were not fully resolved or processed in a healthy manner.” Common underlying concerns include low self-esteem or self-worth, limited ability to manage distress or emotions, the desire to achieve and the yearning for perfection, she says.

Another factor sometimes in the mix is past abuse, Viviani says. “In my private practice, I work specifically with survivors of childhood abuses and, many times, even if I have screened for an eating disorder in the initial evaluation, it is months later that the client will openly disclose their eating disorder behaviors. Unfortunately, there is shame attached to having an eating disorder that makes it very difficult for individuals to disclose their suffering.”

Many eating disorder clients have a history of not feeling heard or acknowledged, Riczu says. “I found there is usually some history of a dominant parent who shows conditional love and is very critical,” she says. “It’s like the eating disorder is ‘starving’ for something, ‘purging’ what it wants to yell or ‘filling’ the emptiness. These clients have spent their entire life hearing the messages ‘What you say isn’t important,’ ‘What you feel is wrong,’ ‘You can’t make decisions for yourself,’ ‘I’ll only love you if …’ or ‘I have to control you because you can’t handle it.'”

“At the most basic form, an eating disorder client says, ‘Well, if you won’t listen and you won’t let me have any say, I can choose to not eat,'” Riczu continues. “The anxiety that builds from having the self-concept of being unimportant, not smart enough, unqualified or a failure becomes numbed by hunger or large quantities of food. You can’t feel anxious if your belly is empty. You can’t feel anxious if you are consumed with thoughts about food. You can’t be anxious if you are planning on where you are going to purge.”

Media and societal pressures also play a role in shaping perceptions and expectations, Viviani says. “Prior to World War II, a fuller figure was preferred,” she says. “But after WWII and the rise in television, the drive for thinness became a national obsession and continues to grow. We think about all the other ‘isms’ in society, such as racism, ageism and so on, but we really need to think about weightism and how we treat people based on their weight or physical appearance. Our children watch how we as adults treat each other and model our behaviors. Then peer pressure moves in, and tolerance for different body shapes and sizes can be lost.”

Beyond administering all the assessments and understanding all the presenting issues and common causes, Hofmeier says the best thing counselors can do is simply to listen. “The most important part of identifying the ’cause’ is to focus on what is going on underneath the behavioral level of the eating disorder, and this will only come from getting the client’s story. The client will usually be able to tell you what they remember as being a part of the development of the eating disorder, so it is important to allow the client to tell you this story and listen to whatever they have to say.” Path to recovery

“Why do you want me to be ugly and unpopular again?” one of Viviani’s clients once asked her. The woman was very pretty and had many friends prior to her eating disorder, Viviani says, but those truths weren’t part of the client’s reality. “Difficulty in acknowledging an eating disorder varies depending on the level of investment and reward the client has experienced,” Viviani says. “If a client has received positive feedback on her appearance and peer relationships have improved, it can be very difficult. The perceptual distortions can be very intense in this situation. Changing the perspective of our clients takes time and patience, in addition to training.”

Due to her specialization in eating disorders, Viviani tends to see a higher percentage of clients who have already recognized that a problem exists and want her help in solving it. But other times, clients come to her because someone has told them they have a problem and they want Viviani to assure them that’s not really the case. Initially, those clients can be much harder to work with, she says. “One of the things I remind them is that I have no vested interest in lying to them about their size, weight or condition. I am very forthright with my clients and believe that level of honesty is important to them beginning to trust the therapeutic relationship.”

Riczu also sees a higher percentage of clients who have already acknowledged their problem and want help. For those who haven’t yet come to grips with the idea of having an eating disorder, that acknowledgement can be difficult. “I find that getting some concrete evidence can help, meaning getting them to have some blood work done,” she says. The results normally don’t come back as “healthy” for someone with an eating disorder, she adds.

When a counselor is able to move forward with a client in treating the eating disorder, several types of treatment are available that usually vary by diagnosis, Hofmeier says. The most common approaches include cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT) and interpersonal therapy (IPT). “CBT is useful because it gets at the underlying cognitive structure that an individual with an eating disorder may be struggling with,” she says. “It helps the individual recognize negative beliefs they may hold that fuel the eating disorder and also impact other areas of their life.”

DBT, Hofmeier says, is based on the components of mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance. “While DBT was developed for a different client population, it has been shown to be effective with many individuals with eating disorders. DBT is effective in the way that it facilitates skill building with clients that can ultimately help them move away from eating disordered coping to healthier coping.” IPT, she continues, is geared toward helping clients understand their interpersonal relationships and how their symptoms or difficulties might be linked to interpersonal or relational difficulties.

One additional therapy that’s shown effectiveness with adolescents struggling with anorexia when it’s caught early on is the Maudsley model, Hofmeier says. “Maudsley family therapy works by helping parents and caregivers gain control over the recovery and refeeding process in order to facilitate healthier understanding on behalf of their young person. The Maudsley model aims to help create a new relationship between the young person and food, thereby helping the young person to not see food as a means of control. It also can help to reinforce the idea that the sense of control felt through restricting is not actual control and can therefore help to weaken the eating disorder. Part of how Maudsley works is by helping realign family relationships for the young person, both with siblings and with parents, to help them have healthy relationships both interpersonally and with food.”

In Riczu’s office, mindfulness training is front and center. “I call my eating disorder clients ‘floating heads’ meaning they are so disconnected with their own bodies, they don’t even recognize body sensations, and if they do recognize body sensations, they automatically interpret them as ‘something is wrong,'” she says. “I start here with many of them. We focus on mindfulness techniques to get them back into their bodies, so they can notice hunger and satiation. Symptoms of eating disorders are often a way of coping with intense feelings and running away from body sensations. Teaching mindfulness techniques helps clients to learn a sense of control over their own sensations as well as makes them more mindful of their eating habits. A client can learn to say, ‘Hey, am I eating because I’m hungry or because I’m angry?’ because they have learned to recognize hunger and satiation.”

Riczu also works with her clients on resource building, using not only mindfulness training but also eye movement desensitization and reprocessing therapy to help them build internal resources, such as “safe place” imagery, to cope with stress. Symbolism is also helpful, she says. “Many of my clients can’t quite put words to their suffering, and I have found through the use of symbols, we can retell their stories in a positive light. I do this through sand play therapy, where we can battle out the eating disorder, literally, in the sand.”

Using symbolism helps clients to retell their life stories without the negative messages they have been carrying around in their “invisible backpacks,” Riczu says. “Retelling the stories must go beyond talk therapy, where clients can get stuck in defense mechanisms and left brain or black-and-white thinking. I help my clients retell their stories through symbolism and play. We create my clients’ worlds in a sandbox of miniatures where we can explore and manipulate the symbolism of food, self, family, friends, etc. This allows a whole body approach at a nonverbal level, where, often, the negative self-concepts began when language was still being developed.”

These counselors agree that effective treatment of eating disorders and body image issues consists of many components. “Psychotherapy, group therapy, family counseling, nutrition counseling and medical management are typically required to ensure recovery,” Viviani says. “A team approach to treatment with the client as part of the team is essential to success.”

Hofmeier agrees that a counselor working alone with the client isn’t optimal. “Good eating disorders treatment will occur when the counselor is working with a team of professionals that can tend to all of the client’s needs.”

Listening to the story

Sometimes, honesty really is the best policy. “I was once accused of being ‘relentlessly caring’ by a patient,” Viviani says. “She regularly lied to me to protect the eating disorder, and I called her on it every time. I named excuses as I saw them and held her accountable at every turn. Because I knew she wanted recovery and because she knew I cared, the approach worked. There were many tears and much anger along the way, but through it all, she knew that her recovery was my primary concern, which allowed her to stay in treatment and find full recovery.”

Requiring accountability shows the client that the counselor cares, Viviani says. “When I press clients for what a binge or restriction episode was about, while it can be very difficult, it helps them to dig deeper than the surface excuses of the behavior to why it really happened. It is then that the client can begin to address those underlying issues and begin to create change in their life.”

Riczu says counselors should also feel comfortable being honest with their clients about how long they will attempt to work with them on an outpatient basis. “I usually tell my clients that we will start out with a month. As long as we are stable and moving toward progress, we can continue,” she says. “But if the client is declining or is not showing much motivation, I will refer to residential treatment. I found being upfront with this from the get-go makes my clients a bit more open to residential help.”

It’s important for counselors never to assume the eating disorder is a choice clients have made, Hofmeier says. “Most clients do not see their eating disorder as something they chose and, therefore, recovery is not as simple as choosing to stop. The eating disorder can be seen as serving some function for the client, regardless of how healthy that function is, but being able to see how the eating disorder has served a purpose can potentially help the client understand it more fully. The counselor and client can then work to find new ways to have the same functions served for the client in a more adaptive manner. It is important that the counselor not convey to the client that the eating disorder is something they are choosing to do to themselves. This is likely not how the client sees it and would likely leave the client feeling as though they or the eating disorder are not understood.”

Be open to the client’s story, Hofmeier adds. “Making an assumption from the start about whether a client is struggling or not will hinder the process for both parties. When directly working with a client who is struggling, a counselor can help by accepting the client’s story for what it is. Whatever the client is struggling with is what they will need support from their counselor for.”

Also important, Hofmeier says, is counselors modeling healthy attitudes toward their clients. “Avoiding ‘fat talk’ with clients not talking negatively about their own bodies while in session or with clients sets an example of acceptance as well as downplaying the importance of physical appearance,” she says.

By looking beyond their own offices, counselors can also help fight eating disorders communitywide. “By active engagement in prevention activities, with communities or schools, counselors can make a huge difference for individuals who may be at risk for eating disorder development,” Hofmeier says. Ideas include offering media education workshops at schools and providing information and education to people regularly in contact with susceptible young people, such as pediatricians, coaches and Girl Scout leaders.

Tips from the pros

On the basis of their many years of combined experience in treating eating disorders, Viviani, Hofmeier and Riczu shared a few of their top tips. Following are 12 do’s and don’ts for other counselors working with eating disorders and body image issues.

“Do listen without judgment,” Viviani says.
“Do acknowledge your limitations,” Hofmeier says. “You are not expected to be the weight expert, food expert, etc., so seeking input from other professionals who are experts in those areas is incredibly important to giving your client the best care possible.”
“Don’t rush,” Riczu says. “This is a slow process of rebuilding resources, coping and identity.”
“Do involve the family or other support systems for the client,” Hofmeier says. “If you are working with a child or adolescent, involving the family is crucial. If you are not comfortable providing family-based services, involve a fellow counselor who is.”
“Don’t automatically go hunting for sexual abuse,” Riczu says. “It might be there, but you can scare away your client (by assuming that).”
“Do work on your own issues first,” Hofmeier says. “There are many individuals who struggle with an eating disorder and eventually go on to work with others who are suffering. These individuals can become great therapists or doctors or dieticians, but it is important that they have worked through their recovery first. As a counselor working with eating disorders, it is essential that you have worked through any of your own eating disorder history. In general, it is also important that a counselor is aware of their own feelings about their body.”
“Don’t make a list of what they have to eat or how many calories,” Riczu says. “Leave that to the nutritionist.”
“Do recognize that eating disorders can be life threatening and deserve to be taken seriously,” Viviani says.
“Don’t use food and weight as the only measures of health and recovery for your client, but don’t ignore their physical health either,” Hofmeier says.
“Do be present in the sessions,” Riczu says. “You might be the first person who really listens to (this individual).”
“Don’t get discouraged. Relapses may happen, but it doesn’t mean the treatment didn’t work,” Viviani says.
“Don’t downplay the expertise that your client has,” Hofmeier says. “While the client is coming to you because they don’t know how to recover on their own, they are the only one who knows where they have been thus far. Allow your client to tell you their story, their history and their struggle. Their eating disorder is unlike anyone else’s, and it is important to understand their whole experience so that you can help them in the best way possible.”

Reaching out

Working with local schools, physicians and nutritionists is often the best way for counselors to reach those battling eating disorders and body image issues. “Having an educated medical community that can make appropriate referrals is important, as the physical signs may often be the most noticeable in some cases,” Hofmeier says. “Also, working with school systems to help instructors and staff appropriately recognize symptoms in students and provide the appropriate support and referrals is a helpful way to ensure that kids and teens are receiving timely and appropriate services.” For those interested in helping this population, education is key, counselors say, including attending conferences sponsored by eating disorder associations, learning about therapy techniques and keeping up with literature on the topic. Viviani points to the International Association of Eating Disorders Professionals, which, she says, offers certification in the treatment of eating disorders after the counselor completes a rigorous training program. The National Eating Disorders Association, the Something Fishy Website on Eating Disorders (something-fishy.org) and the Renfrew Center are other resources that Riczu has found particularly helpful.

Although attending conferences and workshops and networking with other professionals is important, supervision is vital to making everything “fully connect,” Hofmeier says. “A supervisor who has experience in this area can help you define your treatment plan and can share with you their own clinical experience.”

As counselors build their knowledge base, one of the most critical lessons is remembering never to trivialize a client’s condition, Viviani says. “A father said in a session once, ‘If she would just go have a hamburger…’ If as counselors, or as family members or friends, we trivialize the eating disorder, we reinforce the shame and make it even harder for the person to talk,” Viviani says. “These clients are trying as hard as they can to keep up daily, so when they are told, ‘Just have a hamburger,’ it tells them that the other person doesn’t understand and that they are not supported. I have witnessed so many tears over ‘the hamburger.’ If trivialized, this client may never seek help again, or not until even more physical damage has been done to their body and spirit.”

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org. Letters to the editor: ct@counseling.org.

Eating disorders among gay men

From a young age, Kristin Meany-Walen was involved in sporting activities that emphasized physical appearance, weight and athleticism. Growing up, the sister of one of her friends suffered from anorexia and later died of complications from the disorder. But it was a remark from a gay friend in his early 20s who suffered from body dissatisfaction that pushed Meany-Walen, a counselor earning her doctorate at the University of North Texas, to delve into the topic of eating disorders further. The friend told her that being thin was part of gay culture.

Meany-Walen, a member of the American Counseling Association and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling, began researching gay men’s experiences with body dissatisfaction and disordered eating as her thesis project before graduating with a master’s from the University of Northern Iowa. Using a sample of three participants, she found a complicated combination of experiences and expectations can make gay men particularly susceptible to developing an eating disorder.

“Males, straight or gay, are raised from childhood as if they are straight,” Meany-Walen says. “They are typically groomed to find a female partner who is attractive. The attractiveness of one’s partner can be a measure of one’s self-worth, success, etc. Gay men experience these expectations from an early age.”

When they begin to pursue other men, she explains, gay men are aware that other men are looking for an attractive partner. “Because of their keen understanding of the pressures men have of finding an attractive partner, these men believe it’s all the more important to be attractive in order to be sought after by another man,” she says. She adds that her research participants also described a power structure in which the more someone is sought after, the more power he possesses.

Meany-Walen discovered the desire to find a partner was a major presenting issue with these men. “They did not want to be alone, and each believed if he were more physically attractive, he would be able to secure a partner and guarantee (he would) never be alone.” The participants’ body image issues stemmed from a fear of loneliness, she says. “In a lot of ways, this group has been oppressed and discriminated against. They want to find a way to belong and to be valued. … The focus on appearance is more about creating relationships and avoiding loneliness.”

Meany-Walen says the most significant insight she gained was that the focus on physical appearance wasn’t cumbersome to her study participants. “They felt purposeful and productive in their efforts and don’t have a desire to change,” she says. “Two of the three men interviewed were overweight and then lost weight when they decided to come out. As they did this, they felt an increased acceptance from others as they became thinner. The attention and acceptance from others encouraged and promoted them to continue with their weight loss and workout efforts. They found this as a way to belong.” However, Meany-Walen says this group represents only one section of the gay community. “Through presentations and conversations with other gay men after I conducted this research, I became aware of other subgroups within the gay community which do not value thinness, muscularity and this type of attractiveness.”

Through her research, Meany-Walen says she also learned a significant amount about being an effective counselor. “This was just another way to confirm for me that my job as a counselor is to respect my clients’ experiences and try to understand them through their lens,” she says. “As a Caucasian straight woman who identifies as a feminist, I initially wanted all people to value themselves as human beings of value and capable of being loved. Although I believe this to be true of all people, I also value others’ understanding of what they need to do, think or feel in order to feel connected to others.
— Lynne Shallcross

Eating disorders among African American women

Regine Talleyrand, associate professor and coordinator of the counseling and development program at George Mason University, has been researching the topic of eating disorders among African American women for more than a decade. A major obstacle in helping this population, she says, is that people with eating disorders are stereotypically thought to be White, adolescent or young adult, middle- or upper-class females who are obsessed with the desire to be thin or perfect and develop anorexia or bulimia in the process.

“This current stereotype of who, how and what defines eating disorders is what causes many African American women to go undiagnosed,” says Talleyrand, a member of the American Counseling Association. “For example, four out of five African American women are considered overweight and/or obese and experience high rates of heart disease and diabetes, yet we tend not to discuss binge eating disorder, which occurs frequently in obese populations, when we talk about eating disorders.”

Talleyrand points to research showing obesity rates to be higher among African American women than all other racial and ethnic groups. She adds that while dieting and restrained eating appear to be more common among White women, binge eating and purging appear to occur as frequently among women of color. Although the prevalence of anorexia among African American women is fairly low, research shows the age of onset is earlier than with the general population. According to research done last year at the University of Southern California, African American girls are 50 percent more likely than White girls to be bulimic.

Like other populations, African American women with eating disorders may come to counseling presenting with stress-related issues, Talleyrand says. “Stress can cause people to overeat or undereat. For African American women specifically, stress may come in the form of racial stressors, gender-related stressors, classism, acculturative stressors and/or racial identity.”

Research has shown that racial stressors may negatively affect physical, mental and spiritual well-being, Talleyrand says, and eating problems may be one way some women attempt to cope with various traumas, including racism, sexism, classism, poverty and heterosexism. “There is empirical support for the notion that societal or systemic influences can be viewed as stressors in the lives of Black women, and response to these stressors can be in the forms of compulsive or binge eating.”

Talleyrand cautions counselors against minimizing the experience or buying into the myth that Black women do not have eating disorders. Being open to discussing eating disorders beyond anorexia and bulimia and exploring symptoms related to binge eating disorder and obesity is important, she says. “Finally, realize that African American women may not present with the typical disordered eating attitudes and behaviors (and) may or may not engage in compensatory behaviors after their binge eating. External factors outside of the individual may have significant influence.”

Counselors working with African American female clients should use assessments with culturally sensitive measures, be familiar with stereotypes related to African American women and people with eating disorders and incorporate cultural considerations in treatment, prevention and training activities, Talleyrand emphasizes.

— Lynne Shallcross

Managing resistant clients

By Lynne Shallcross February 14, 2010

You can’t change anyone else; you can only change yourself. Many counselors have used this common bit of wisdom to help clients overcome problems, but it’s crucial that counselors internalize that idea themselves, says Clifton Mitchell, a professor and coordinator of the community agency concentration in the counseling program at East Tennessee State University.

“We tell our clients things like, ’You can’t change other people; you can only change yourself.’ Then we go into a session trying to change our clients. This is hypocritical,” says Mitchell, the author of Effective Techniques for Dealing With Highly Resistant Clients, which is in its second edition. “I teach, ’You can’t change your clients. You can only change how you interact with your clients and hope that change results. That’s all you get.’”

The concept of counselors focusing exclusively on their interactions with clients and letting change happen on its own is key to the successful management of resistance and the pivotal point of effective therapy, says Mitchell. For 10 years, the American Counseling Association member has studied and presented seminars on dealing with resistance in therapy. “Although most therapists have been trained extensively in theoretical approaches, few have had extensive training in dealing with resistance,” he says.

Conventional thought defines resistance as something that comes from within the client. In other words, says Mitchell, “If you’re not buying what I’m selling, you’re resistant. Those definitions have existed for years in the mental health literature. The problem with that is it makes it difficult to do something about it.”

But times and definitions of resistance have changed, he says, removing the blame for resistance from the client and putting the responsibility squarely on the shoulders of counselors. Modern definitions come from social interaction theory, Mitchell says, and indicate that resistance doesn’t exist until a counselor and client have a conversation; resistance is borne out of the interaction style. “This says if what you’re doing with the client is not working, then do something else because your interaction is creating resistance,” he says. “The beauty of viewing resistance from a social interaction theory is we’re empowering ourselves to do something about it.” Mitchell defines resistance as something “created when the method of influence is mismatched with the client’s current propensity to accept the manner in which the influence is delivered.”

When counselors label a client’s behavior as resistant, typically, one of two things has occurred, Mitchell says. “Either we do not have a technique to manage what is going on in the interaction at the moment, or we do not understand enough about the client’s world to understand why they are responding the way they are. So, we label them as resistant as a result of our inability and lack of therapeutic skills. There is always a reason the client is responding the way they are. Our job is to understand the client’s world to the degree that we see their behavior for what it is and not as resistance.”

Another shift in thinking that can benefit counselors? Accept that resistance isn’t always inappropriate, says Robert Wubbolding, director of training for the William Glasser Institute and director of the Center for Reality Therapy in Cincinnati. “It is a client’s best attempt to meet their needs, especially their need for power or accomplishment,” says Wubbolding, an ACA member and professor emeritus at Xavier University. “Resistance is a universal behavior chosen by most people at various times. Sales resistance is helpful for the purpose of practicing thrift and saving money.”

Clients are sometimes resistant because the counselor is asking them to deal with an undesired agenda, Wubbolding says. “Resistance means we’re working on the wrong problem a problem that the client doesn’t care to work on. Counselors need to connect with the client in order to find the right problem. I suggest connecting on the basis of clients’ perceived locus of control. Many clients resist because counselors focus too quickly on the clients’ feelings, behaviors or sense of responsibility. If a client resists because they feel everyone else has the problem, then focusing on the client presents a miscommunication.”

A dose of reality

Wubbolding uses a reality therapy approach to reduce resistance. “The counselor needs to help (clients) see that their resistance is not to their advantage,” he says. “As a teacher and practitioner of reality therapy, I suggest that the counselor begin by asking clients what other people in their environment are doing to them, how they oppress them, reject them, make unreasonable demands on them and control them. It is important for counselors to connect with clients on the basis of the client’s reality rather than putting emphasis on the counselor’s agenda. In other words, the counselor may want the client to make better choices, but without connecting with the client’s perceptions in the beginning of the counseling process, the counselor might facilitate more resistance rather than less.”

“Then,” Wubbolding continues, “the counselor can help clients explore what they’ve done to get people off their back and to do what they want them to do. The key here is questions focusing on self-evaluation such as, ’Have your efforts been successful?’ Clearly, they have not been successful, so when clients decide that what they’ve been doing is not working for them, they are more inclined to make alternative choices. Thus, self-evaluation is key in dealing with resistance.” Wubbolding offers the example of a teenager who is flunking out of school, taking drugs and being rebellious toward school personnel and his parents. “Connecting with this individual on the basis of perceived victimhood and external control is often effective and serves as a basis for asking crucial questions: Have you tried to tell these people to leave you alone? How have you tried? Is what you’re doing to get them off your back working? Is there any chance that telling them one more time is going to do the trick?”

“It seems to me,” Wubbolding might tell this resistant client, “that you have two choices” to continue down your current path or to choose a different path. “You can continue to do what’s not working, or you could try something different. One road maintains the misery you (currently) have and will probably make it worse. The other road will more than likely help you if you’re willing to give it a try.”

“After connecting with the clients’ perceptions, their sense of external control or sense of being controlled,” Wubbolding says, “the counselor can proceed to inquire as to whose behavior the client can control, what choices are available and whether making a change is either possible or desirous.”

A two-way street

Newer definitions of resistance empower counselors to exert more control and influence over the situation, Mitchell says, but these definitions also place great responsibility on practitioners to keep things moving forward. “If you feel your client is resisting you, you also must be resisting your client,” Mitchell says. “Resistance goes two ways. The challenge is having to find more creative and different ways to interact.”

It’s a task worth tackling, Mitchell contends, because the degree to which a counselor effectively manages resistance can determine whether therapy is successful. “Therapeutic outcomes are determined by how well we manage the places in therapy where ’stuckness’ appears to occur,” he says.

The counselor-client relationship is key to helping the client move forward, Wubbolding says. “Clients are less resistant if they feel connected with the counselor. If counseling is to be successful, the client must be willing to discuss the issue, examine it and make plans. If clients will not disclose their inner wants, actions, feelings and thinking, change is very difficult. But in the context of a safe, trusting relationship, they are more likely to disclose such information. After clients lower their defenses, they can then more freely discuss their inner thoughts and feelings. After this occurs, the counselor can help them conduct a more fearless self-evaluation.”

Also important, Mitchell says, is having a mutually agreed-upon goal. It’s all too easy for counselors to put themselves in situations where they have a goal in mind for the client, but the client either isn’t aware of or doesn’t agree with that goal. If the client-counselor relationship is key to good outcomes, Mitchell says, a mutually agreed-upon goal is the key to a good client-counselor relationship.

Mitchell admits that receiving “I don’t know” answers from clients can be frustrating and make counselors feel as though they aren’t getting anywhere in session. But he advises counselors not to grow discouraged or to waste time fighting the client’s response.

Responding, “Oh, yes, you know the answer,” will only create resistance and force the client into a defensive position, Mitchell says. “The safest way to respond to an ’I don’t know’ response is to accept it, embrace it and empathize with it,” he says. “If you do that, you will decrease the defensiveness that comes with fighting it.”

If a counselor empathizes with the client and agrees that the problem is difficult to figure out, the counselor is indicating that he or she is joining the client in the attempt to find a solution, Mitchell says. Too often, he adds, counselors make the mistake of treating an “I don’t know” answer as a barrier rather than an opportunity to work with the client. “Use it as a doorway into the struggle,” he says. “Most people don’t realize it’s a great place to get to.” Assuming the role of “expert” can also get counselors into trouble with resistant clients, Mitchell says. When a counselor gives ideas or suggestions related to a client’s problems and starts hearing “Yes, but …” answers, it’s time for the counselor to vacate the expert seat, he says. “You need to stay in a naïve, puzzled, unknowing, curious position. You need to not have knowledge; you need the client explaining to you. We want them talking, not us talking. If you’re not buying what I’m selling, I need to quit selling.” Encouraging clients to analyze their situation and explain it to the counselor is important, Mitchell says, because in the process, they might discover insight for improving the situation.

Mitchell also exhorts counselors to do the unexpected. “Typical responses beget typical answers, and typical reactions keep clients stuck in their situation,” he says. “Resistance is fueled by the commonplace. The client is likely expecting the same type of response from you and already has a rebuttal waiting. If socially typical responses were effective, we would not need therapists. Why do the unexpected? It disrupts patterns of thinking and responding a key to creating change.”

Perhaps the best way for counselors to avoid resistance with clients is to allow change to happen on its own, Mitchell says. If a counselor enters the therapeutic relationship and pushes the client to change before that person is ready, resistance will be the likely result, he says. Instead, he advises counselors to simply listen to the client and focus on not creating resistance and not fostering defensiveness. Then, step back and let change happen, he says. “If you go in there and make not creating resistance your first priority and let the change come as a second priority, with highly resistant clients, you’re more likely to get change.”

Quick tips

Counseling Today asked Mitchell and Wubbolding to weigh in with their best recommendations for managing resistance in the counseling relationship.

“Stay out of the ’expert’ position,” Mitchell says. “The more resistant the client, the less knowledge you should profess to know. The more motivated the client, the more knowledge you can express.”
“Don’t collude with clients’ excuses,” Wubbolding says. “Don’t buy into and encourage feelings of victimhood and powerlessness. Discussion of these perceptions are useful in the beginning of the counseling session, but the counselor needs to move beyond them and lead the client beyond them. There is a French saying, Qui s’excuse s’accuse. Whoever excuses, accuses. Facilitating feelings of powerlessness only communicates to clients that they are powerless. This is a disservice to them.” Empathize, but don’t sympathize, he says. “Try to see the client’s point of view without communicating a sense of victimhood.”
“When you encounter resistance, slow the pace,” Mitchell says. “Trying to go too fast is a perfect way to increase resistance. Only take baby steps with resistant clients.”
“Don’t argue,” Wubbolding says. “This creates more resistance.”
“Focus on details. The devil is in the details, and so are all solutions,” Mitchell says. “Details create options. If you do not have enough options, you do not have enough details about what is occurring in the client’s situation. All therapeutic breakthroughs come from addressing and processing a detail in the client’s life that no one has ever discussed and processed before.”
Leave blame out of it, Wubbolding says. “Don’t blame the client, and don’t blame the people they think are creating their problems.”
“Always treat the resistance with respect,” Mitchell says. “The client has a reason for what they just said, (so) respect it.”
“Seek emotionally compelling reasons for change,” Mitchell says. “Do not waste time trying to create change through logic. If people changed because of logic, nobody would smoke or drink and everyone would have an exercise program and get eight hours of sleep. When people make major changes in their life, they don’t do it because of logic. They do it because they have an emotionally compelling reason.”
“Stay out of an excessive questioning mode of responding with resistant clients,” Mitchell says. “Questions are micro-confrontations with resistant clients that invite unproductive answers. Excessive questioning is the primary means by which therapists get sucked into the client’s ’stuckness.’ Learn to dialogue without questions.”

Ultimately, all therapy comes down to the successful management of resistance, Mitchell says. “Most therapists approach clients from the perspective of creating change. They would benefit themselves greatly if they would approach clients from the perspective of not creating resistance and let change occur as a natural result of the client exploring his or her own world.”

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Letters to the editor: ct@counseling.org.

Remembering play

Stacy Notaras Murphy

Sometimes, cohesion is an open therapy group’s biggest challenge. Although the open-door approach provides ongoing support as people find themselves in need, building connection may feel nearly impossible as members trickle in and out each week.

“Our open groups never close. I may have 13 women one week and three more the next. Our purpose really is to provide insight about what’s happening then and there,” explains Chris Johnson, an American Counseling Association member and licensed professional counselor intern who works with battered women and their children at Sistercare Inc. in Columbia, S.C.

Faced with the challenge of leading a group that is in an almost constant state of flux, Johnson uses balloons to help build bridges. “The balloons always get a reaction,” she says. “It’s one of the most successful ways I’ve found to build cohesion. I bring in different colors. They get to choose, blow them up and tie them up.” She then directs the women to balance their balloons in the air without letting them touch the ground.

“Then they pair off, and the two of them have to work as a team, which is something they’ve not been allowed to do (in their abusive relationships) have meaningful relationships and partnerships with other women,” Johnson says. “About 10 seconds in, you start to hear them laugh. They’re not as intent as they were before. Some laugh so hard they cry. Some have not laughed in so long they don’t remember what it’s like. Later I ask, ’What did you see?’ And I say, ’I saw a room of happy women.’ We talk about the last time they were a part of that kind of thing, and you hear stories about how they weren’t allowed to laugh at home. That’s when the support group becomes therapeutic for them.”

While the balloons in this instance serve as a simple ice-breaking exercise to accelerate the bonding process, they also demonstrate how play therapy techniques can enhance counseling work with adult clients. “Every program I’ve worked in has been about empowering the client to move forward with her own agenda,” Johnson says. “I’m very person-centered and eclectic and found myself asking, ’What can work in short order?’ If I have someone who has not been able to communicate a woman, a child, an adolescent boy how do I get them to a point of building rapport quickly and building trust? That’s where I came to play (techniques).”

Fun (and therapeutic) for all ages

“Although play therapy is frequently conceptualized as a treatment approach for children, there is growing support for the use of play therapy across the life span,” says Sueann Kenney-Noziska, president of Play Therapy Corner in La Mesa, N.M. “Play therapy provides some of the same benefits to adults. If incorporated into a solid, clinically grounded treatment approach, play therapy can provide an adult with an appropriate avenue to safely examine their thoughts, feelings and issues.”

Kenney-Noziska notes the Association for Play Therapy, a professional organization for play therapists headquartered in Clovis, Calif., recommends that university programs address the application of play therapy with adults and the elderly. The 2009 APT conference featured a workshop titled “Play Therapy Across the Life Span.” Counselors who want to incorporate these techniques into their work should pursue educational opportunities to develop this expertise. “Since play therapy is an area of specialization, training is imperative. Without adequate and appropriate training, a therapist should not utilize play therapy with adults,” Kenney-Noziska says.

Play therapy techniques may be appropriate for treatment of grief and loss, mood disorders, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder and attention-deficit/hyperactivity disorder. Some say play techniques that involve metaphor and other imagination-based approaches are not recommended for those suffering from delusions or hallucinations.

Distancing, mastery and projection are examples of the benefits adults may derive from play therapy, according to Kenney-Noziska. “Play therapy approaches often create a sense of safety from which some adults may be more comfortable approaching threatening issues or topics,” she says.

Johnson describes a drawing exercise called “The House That Is Me” that helps domestic violence survivors in her groups pinpoint their feelings at an exact moment in time. “I ask them to draw what the world would see if they each were a house what color it would be, are there trees in the yard, what is happening on the inside. Many of the houses have a plain outside look. Many of my women have dealt with isolation, power and control. They don’t have their own things, (so) they draw boring, plain-looking little houses. But when you open the doors, there is more to the story. One woman who is not very verbal in the group drew a bunch of little black circles inside her house. She said that she feels empty and has nothing inside. This was a breakthrough for her.”

Creative play techniques often cut through the more “adult” characteristics of guardedness and rationalization, helping the counselor understand the client’s issues at a deeper level. “Play therapy allows the adult to return to a slower, unrushed pace that is more conducive to the opening of the psyche to a greater arena of options for the client,” notes Pamela Coleman, an ACA member in Yuma, Ariz. “People talk when they are relaxed, and I pose that their subconscious self may ’peek out’ in play … allowing for a better knowing of one’s self and, thus, having a greater range from which to draw in meeting their treatment goals.”

Coleman was trained in play therapy at Arizona’s Children Association and learned to use play during family sessions to help parents “join” with their children. Following a 12-week model for brief strategic family therapy, she found that most families benefited from play activities as part of the treatment plan. “In many cases, the counselor/therapist has the ability to model positive interaction skills for the adults with their children during play,” she adds. “All involved child, adolescent and parent seem to relax and are able to come further in therapy, as all become more open when having fun and learning about one another.”

At play in supervision

Just as play therapy techniques offer alternative paths to deeper meaning in counseling sessions, they also can be used to enhance counselor supervision experiences. Kenneth McCurdy, an ACA member and associate professor of community counseling at Gannon University in Erie, Pa., finds that play techniques such as drawing or puppets help his supervisees explore how their own styles of life are reflected in their counseling work.

For example, McCurdy has asked supervisees to re-create a client case using a sand tray. “The supervisee is asked to identify all of the contributing factors to the client’s case people, places, things, feelings, issues, etc. and re-create the whole conceptualization of the case in the sand. Next, the supervisee selects miniatures that best represent each of the contributing factors,” he says, noting that the first miniature placed in the sand is the client and the last is the supervisee. “We then process the whole sand world re-creation. I share observations about the creation, the miniatures and my feedback about the process of the supervisee selecting the miniatures and creating the sand world. This process often results in the supervisee seeing perspectives of the case and issues with the client that were previously unknown or not as easily identified.”

While using sand tray in his supervision of counseling students, McCurdy is also training supervisees to utilize the technique in their own counseling practices. “Not many other supervisory techniques can be applied as easily in both sides both in supervision and in clinical practice,” he says. Meanwhile, McCurdy is researching the actual impact of play techniques in clinical supervision. “I have found that some supervisors establish a stronger supervisory working alliance when they use the sand tray as compared to when the same supervisor uses traditional didactic supervision,” he says.

McCurdy admits the biggest challenge may be convincing supervisees to “buy into” the use of toys in supervision. “Often, I use the toys from the first supervisory session as we are getting to know each other,” he says. “I usually give them a toy during the first session to show my appreciation for their willingness to participate in supervision a Matchbox car, a figurine, a finger puppet, etc. Very often, that spurs them to explore using toys in their counseling practice if they do not already use them.”

Facing the resistance

Understandably, some adults may feel embarrassed if asked to use a puppet or play a game during a therapy session. Here, a strong counseling alliance built on trust can be the key to reaching that next level of therapeutic insight. “I try to just be open and honest when I’m doing these things with my (battered women’s) groups,” Johnson says. “I ask them to trust me. You are always going to have some resistant adults who are not going to want to participate but, hopefully, like any other play therapy session, the potential to enjoy themselves can draw the client in. Even participate yourself if that’s what gets them engaged.”

Coleman notes the counselor must consider the client’s personality and interests before applying a play technique. “I realize that play therapy does not lend itself well to adults who do not prefer a creative approach … due to their logical, dominant side of the brain,” she says.

McCurdy agrees: “I find that drawing and sand tray seem to be the two play media that adult clients readily respond to. I think it is because these two media do not initially come off as ’childish.’ Most of the adult clients I counsel have lost touch with their child side, and those who are most successful in counseling are the ones who come back in touch with the joyful/playful experience of childhood.”

Some adults who have experienced trauma may be numb to their feelings or block them out entirely. Reminding these clients of the childhood experience of joyful play can help make feelings safe again, allowing for deeper understanding between the client and counselor.

“I had the privilege of working with a grieving mother whose 4-year-old daughter was killed by a drunk driver. Mom struggled to directly discuss her thoughts and feelings related to her profound loss,” Kenney-Noziska recalls. “Using a cognitive behavioral framework, I began to incorporate play therapy interventions into our clinical work to create a less threatening and more indirect way for the mom to process her thoughts, feelings and issues. Once play therapy was incorporated into her treatment, the mom displayed an improved ability to share and process things on a very deep level. My clinical impression was that incorporating play therapy into the mom’s treatment tapped into mom’s ability to really explore her loss.”

As with any new method, counselors who add play therapy techniques to their work are advised to make room for case consultation and review. “Like any other treatment technique, counselors need to make sure that the play technique is a valid and reliable approach to use with the given client for the given treatment goal,” McCurdy advises. “It is imperative that the treatment goal is reliable and measurable. The counselor must be able to show how the objectives of the goal have been impacted in a verifiable way by the play technique.

“The most important thing is to treat play techniques like any other treatment modality empty chair, medication, etc. It must fit the client (and) the goal/objective, be assessed in relation to the intended outcome and be reliable and valid as supported in the professional literature.”

Stacy Notaras Murphy is a licensed professional counselor practicing in Washington, D.C. Contact her at snmurphy@verizon.net. Letters to the editor: ct@counseling.org.

An opportunity designed for you

Richard Yep February 1, 2010

Richard Yep

Next month, thousands of professional counselors, counselor educators and graduate students will convene in Pittsburgh for the ACA Annual Conference & Exposition, cosponsored by the Pennsylvania Counseling Association (PCA). We will be joined by hundreds of exhibitors, publishers and employers. Many roads lead to Pittsburgh (literally), so I am aware that a number of counselor education departments and others will be caravanning to the event.

In addition, US Airways uses Pittsburgh as one of its main hubs in the United States for both domestic and international flights.

I really do hope you will be part of the year’s largest gathering of the counseling profession. Each year, we strive to make sure this “big event” includes components of community and networking so attendees will feel both welcomed and comfortable as they decide which of the more than 400 Education Sessions and Learning Institutes to attend. This year, the conference will also feature major keynotes by world-renowned counselor educator Gerald Corey and internationally acclaimed author Patti Digh.

Not to sound like an infomercial, but if you haven’t been to Pittsburgh in a long time (or ever), you will discover a very vibrant, robust city full of great restaurants and galleries, plus some of the nicest people on Earth. Pittsburgh has great theater and music venues, the Andy Warhol Museum, a world-class science museum for kids of all ages and eateries featuring various cuisines.

Because we want to do our part for the environment, ACA and PCA are pleased to present this year’s conference in the world’s “greenest” convention center. We will be meeting in the “Gold LEED-certified” David L. Lawrence Convention Center located on the banks of the Allegheny River in downtown Pittsburgh. This is a very walkable city, but we will also have a shuttle that runs at scheduled times between our conference hotels and the convention center.

Because we know that you value social time, we have built in gatherings that will allow you to dance, eat and mingle with friends both old and new. For those who need that digital tether to their friends and loved ones who will not be in Pittsburgh, the Expo Hall will have computers hooked up to the Internet so you can check your e-mail.

As you may have guessed, ACA and PCA have really tried to respond to your suggestions and input. We have also gone the extra step and will be introducing services, benefits and conveniences designed to enhance your attendance at the conference.

The only remaining special ingredient we need is you. I know many of you are facing various economic challenges, so we have tried to be sensitive about the costs involved in attending our event. I think you will find there is great “bang for the buck” when you compare our conference with others. In fact, by attending sessions, keynotes and other learning events at the ACA Annual Conference & Exposition, you can actually leave with 38 continuing education credits!

So, if you haven’t registered for the Annual Conference just yet, I hope you will go to www.counseling.org/conference and do so right away. If you have already signed up, I hope you will be successful in bringing at least one additional colleague with you.

The staff, volunteers and leadership of ACA and PCA have worked very hard to make this the premier event of the year for professional counselors, counselor educators and graduate students. Our guiding vision was to provide all that you need to be the best at what you do.

The ACA Annual Conference & Exposition is a labor of love for many of you. It really is a unique event in regard to the speakers, education sessions, presenters and resources you will find. But in my 20-plus ACA Annual Conferences, I have always found that one of the most special things about the event really is the attendees! Having thousands of counselors in one place for a number of days always results in some very positive dialogue, networking and information exchange.

I look forward to seeing many of you in Pittsburgh next month at the Annual Conference. Please contact me with any comments, questions or suggestions that you might have via e-mail at ryep@counseling.org or by phone at 800.347.6647 ext. 231.

Thanks and be well.