Monthly Archives: January 2011

It’s a small world

Lynne Shallcross January 17, 2011

The distance around the world remains almost 25,000 miles, but it doesn’t always feel that far today. The Internet, ever-evolving technologies, advances in travel and continuous immigration and emigration are making connections with once far-flung cultures a much more common reality.

Marcheta Evans has embraced that “smaller world” mind-set and is emphasizing a need for the counseling profession to focus on globalization and international collaboration. Midway through her term as president of the American Counseling Association, Evans says she is happy to witness the wheels rolling in that direction.

“In my recent travels, I have seen the wonderful work being done by our international colleagues and their interest in working with ACA collaboratively,” says Evans, associate dean of the College of Education and Human Development at the downtown campus of the University of Texas at San Antonio. “So many have asked to network with us as they are developing their own professional counseling identity in their respective countries. I think we can serve as a great resource, and they can learn from our development by taking the best of what we have done. Also, they can avoid some of the potential problem areas we encountered during our growth. We are receiving requests on a regular basis for various international organizations to affiliate with us through the Alliance of Professional Counseling Organizations, and I am hoping to have a strong number of international attendees at the ACA Conference in March.”

Counseling Today recently spoke with four ACA members who have a passion for bridging counseling work across countries and cultures.

Different ways to wellness

Cirecie West-Olatunji knows introductory counseling textbooks include tips such as sitting squarely, leaning forward toward your clients, looking clients in the eye and asking them to tell you more about a particular problem, challenge or situation. But she also knows important elements those texts don’t include — things such as dancing, singing and storytelling, which are prominent coping mechanisms for certain cultures and communities.

An associate professor and mental health track coordinator in the Counselor Education Program at the University of Florida, West-Olatunji has traveled all over the world to advance the cause of counseling. One message she hears frequently from counselors is that it’s difficult to apply a hard-and-fast Western approach to counseling in other cultures. “There’s a struggle everywhere I’ve been between what people bring as their lived experiences — about what works in life, about how to live well — and the training they receive through the textbooks and the courses.”

Counselors across the globe believe wholeheartedly in the effectiveness of counseling, West-Olatunji says, but sometimes there are discrepancies, such as when holding a session in an office and sitting squarely in a chair opposite your client doesn’t quite mesh with the client’s environment. Part of the message West-Olatunji imparts on her international trips includes embracing a wider definition of effective counseling that incorporates a community’s lived experiences. “Each society has its own ways of defining wellness and psychological health,” says West-Olatunji, the Association for Multicultural Counseling and Development’s representative to the ACA Governing Council. “These approaches to healing are founded upon the historical and sociopolitical contexts of a people.”

For example, she says, the lived experiences of people in Romania are different from those of people in Botswana. “The counselors [she met] in Botswana defined one indigenous intervention as the sharing of stories from their grandmothers and the meaning of ’passing on the blanket’ as a way to stay grounded when stressors cause uncertainty or disruption,” West-Olatunji says. “Within the Botswana culture, a grandmother is associated with the term ’small blanket’ [because] she always wears a blanket on her shoulders. When children play outside and one of them is hurt or is feeling cold, they often run to their grandmother, who is happy to comfort and cover the child with her blanket. Thus, the passing of a grandmother’s blanket is a symbol of solace and healing.”

“In Romania,” she continues, “the counselors defined one of their indigenous interventions as dancing in a circle until there was no more unhappiness. In our Western-oriented perspectives on counseling, we often focus on talk-based therapies and the need for insight in order for clients to move toward transformation and change. Neither of these interventions includes a cognitive component to them, a feature salient in our conventional counseling methods.”

In 2010 alone, West-Olatunji traveled to Singapore, the Philippines, Romania, China and India. The two main themes of her work during these travels were disaster counseling training and school counselor training. As counseling attempts to gain a foothold in many countries, it often finds itself competing with psychology and social work. In these instances, West-Olatunji explains, school counseling frequently offers an opening specific to the field of counseling. “For the most part, counseling is being advanced [internationally] within the track of school counseling,” she says.

West-Olatunji travels to Singapore once or twice per year to meet with school counselors, principals and even parents. Solution-focused school counseling and developing cultural competence are always hot topics, she says, as are many issues familiar to schools in the United States, including bullying, underperformance and interpersonal conflicts. School counselors in Singapore often ask her for help in reaching out to parents, dealing with family issues and addressing psychological symptoms that surface in the school setting.

Parents, on the other hand, often want to know what makes up good parenting, West-Olatunji says. “Many of the parents ask about how to manage mainstream perceptions of good parenting versus the parenting that they’re doing, which stems from their own experiences.” She answers those questions with talk about outcomes. If parents want their children to be autonomous, for example, their parenting style might differ from that of parents who want their children to be interdependent.

West-Olatunji’s most recent travels to Thailand and China were focused on disaster-response training both with school and community mental health counselors. In November, she also led an ACA-sponsored People to People delegation in India with a focus on disaster mental health counseling. The delegation met with senior government disaster response officials, heads of psychiatric hospitals and leaders in community-based agencies, such as UNICEF and Save the Children, in the cities of Delhi and Jaipur.

“Mostly, they want to know what to do when a disaster hits,” she says. “They want to be able to, and are expected to, respond. They want to know what some of the best practices are in responding to disasters.” West-Olatunji distributed literature about crisis and disaster counseling, talked about the skills required to work on interdisciplinary teams and shared the model of culture-centered disaster counseling that she has created.

West-Olatunji says she makes good use of her passport because she believes in the value of counseling and its adherence to the wellness model rather than the medical model. “I believe what we do is meaningful and valuable to people in their everyday lives, so I’m happy to spread that message around the globe.”

Increasing awareness

Yegan Pillay points to the recent mining disaster in Chile as a reason U.S. counselors need to think internationally. In the effort to rescue the 33 miners trapped underground, Chile looked to the United States and other nations for help, he says. In a world that’s constantly getting smaller, that’s a sign to counselors that they should be prepared to offer assistance as well, says Pillay, an assistant professor in the Department of Counseling and Higher Education at Ohio University in Athens.

“It’s important for us in the counseling profession to start thinking more broadly. We will be called upon because the U.S. is seen as the global leader,” says Pillay, who chairs ACA’s International Committee. “We’re not adequately prepared at this stage to make a significant impact globally, nor are we as an organization having discourse about advancing the global counseling agenda.” With that as a motivation, Pillay is hard at work within the International Committee trying to expand the global reach and abilities of ACA and U.S. counselors.

For the past few years, the committee has been working to increase awareness of the counseling discipline internationally, Pillay says, because “counseling is in the shadows of psychology in many parts of the world.” One of the committee’s goals is to enhance collaborations with ACA divisions and other ACA committees that have a global agenda. “The objective is to broaden the scope of the globalization of counseling and then to use as many potential resources within ACA and its affiliates as possible,” he says. Another goal is to better utilize the ACA website, perhaps to develop an online international events calendar in the future.

At the upcoming ACA Annual Conference & Exposition in New Orleans, the International Committee is coordinating a panel of experts to talk about ACA’s global agenda. The panel discussion will be held March 26 at 2 p.m. “We hope that what comes out of that would be a white paper that would guide the ACA leadership with regard to the role ACA can play in the advancement of counseling internationally,” Pillay says.

Also planned for the conference (March 25 at 5 p.m.) is a panel of international students who will speak about counseling in their home countries as well as their counseling experiences in the United States. “The objective is to harness the energy of emerging mental health professionals,” says Pillay, adding that counselor educators and practitioners can learn through this forum how to work with international students and become more knowledgeable about issues pertinent to the international community.

Pillay, who grew up in South Africa before coming to the United States to study counseling, directs the HIV/AIDS in Africa program at Ohio University. Each year, he takes a group of 15 to 20 students for approximately six weeks of service in Africa. Pillay points out that the number of counseling students involved has increased since he’s been involved in the program. The groups have previously traveled to Botswana each year but will be going to South Africa this coming summer.

The students spend the spring quarter at Ohio University in an orientation program researching the nongovernmental organizations (NGOs) with which they’ll be working and the NGOs’ role in the eradication and treatment of HIV/AIDS. On past trips, the students’ first week in Africa was spent role-playing with university faculty and researchers from the University of Botswana. This coming summer, the students will do the same with personnel from Nelson Mandela University in South Africa. The students then spend three to four weeks with one of the NGOs whose work focuses on those affected by or infected with HIV/AIDS, such as a residential facility for orphaned children, hospice-type organizations or crisis counseling centers.

The overall goal is to develop counselors who are multiculturally competent, Pillay says, and these trips go far in showing the students a unique environment, taking them outside of their comfort zones and exposing them to strategies they might use in the future. “It provides a different vantage point than they would otherwise be exposed to,” he says.

On one of the trips, two African American students told Pillay through tear-filled eyes that it marked the first time they truly felt as though they belonged. On the flip side, Pillay says, Caucasian students learn firsthand what it feels like to be in the minority. The students’ counseling skills are unquestionably strengthened through the work they do on the trips, Pillay says, but just as important is the effect the experience has on their empathy. “When they go into the professional world and see clients who might be different for many reasons, I believe they will be more sensitive to understanding that experience,” Pillay says.

When it comes to counselors thinking more globally, Pillay insists there’s no substitute for experience. “The only way you can become aware of individual differences is through contact. It’s through contact that we can challenge some of our stereotypes. Learning transcends the boundaries of the classroom.”

Crossing borders

Fred Bemak has worked as a counselor in 36 countries — emphasis on worked, not simply traveled to or through.

With a passion for international counseling, Bemak, professor and director of the Diversity Research in Action Center at George Mason University, founded Counselors Without Borders in 2005. The catalyst for the organization’s creation, Bemak says, was witnessing the great underserved need for culturally responsive counseling in the Gulf Coast region in the months after Hurricane Katrina.

When an earthquake devastated Haiti this past year, Bemak immediately recognized that same need. With an invitation from Partners of the Americas and funding from the U.S. Agency for International Development, Bemak mobilized a team of counselors who traveled to the country for two and a half weeks in April. The one thing Bemak says counselors must have before working internationally is an invitation. “You should never go and create more chaos,” he says. “You have to have the infrastructure first.”

Once Bemak’s Counselors Without Borders team, composed of himself and two others, arrived in Port-au-Prince, they began intensive training at a school that remained partially standing. They worked with school administrators and staff members from throughout Port-au-Prince, as well as students and even parents. “One hundred percent of the people in Haiti were affected by the earthquake,” Bemak says. “We heard stories hundreds of times about children who watched a parent, sibling or friend die. People just don’t know how to deal with that kind of trauma.”

Bemak helped school staff members work through their own issues, while also teaching them how to effectively assist the traumatized children. “People had an intuitive sense, but they didn’t have the counseling skills,” he says.

“We had Haitian teachers sit in and observe us running counseling groups with children, followed by debriefing and clinical supervision training meetings with staff after the groups,” Bemak continues. “In one of the groups, we had children draw their most powerful memories of the earthquake and then had them share and discuss the drawings within the group context. The drawings and discussions were powerful, and staff learned how to facilitate painful discussions conducive to healing.”

Bemak and his team also traveled to the town of Jacmel, where they trained psychologists and social workers in trauma counseling. “The emphasis is on building capacity in a culturally responsive way and on helping the people there learn the skills to deal with trauma,” he says. “We don’t want people to become dependent on us; we want to transfer the skills.”

Adds Bemak, “The visit was also to assess for continued work in Haiti, which has led to the development and submission of a major grant that would involve significant Counselors Without Borders teams going to Haiti for the next three years if funded.”

For the past two summers, Bemak has also traveled to Uganda to conduct training for staff members of Invisible Children, an organization that aims both to assist children affected by war and to stop the use of child soldiers. With so many children traumatized by civil war, the staff struggles to deal with the children’s issues, he says. Through a combination of classroom and field training, Bemak trains staff members in trauma counseling, both supervising them and modeling techniques for them.

Bemak says the organization chose the most traumatized youths with whom it was working and asked him to help. Many of the youths were former child soldiers, which is “one of the most horrible things people can be subjected to in the world,” Bemak says. Other children he was asked to help were HIV-positive, rape victims, torture victims, child mothers and orphans. “There’s a tremendous breakdown in the community,” he says. “In the past, the community would have taken care of these children, but now their resources are stretched so thin that they don’t have the capacity to continue family and community traditions.”

Invisible Children focuses on helping children succeed in school and eventually become skilled and financially stable individuals. Bemak’s role is training the staff to better understand how to help deeply traumatized children. “We would talk with the students, siblings, parents, caretakers, extended family members, etc., and discuss what was going on in the child’s life,” he says. “The staff would be present and, after each session, we would process the experience and talk about the intervention strategies and how to effectively help traumatized children heal.”

Although Bemak made the past two summer trips alone, he’s pursuing a three-year grant for Counselors Without Borders. “This would involve exchanges by Ugandan staff coming and spending time training with Counselors Without Borders staff here in the U.S. and Counselors Without Borders team members periodically visiting Uganda to provide counseling and training,” he says. “We are now exploring funding to establish an international prototype for psychosocial support and mental health as a major initiative within nongovernmental organizations.”

Even if counselors are working solely within U.S. borders, they still need to expand their worldviews, says Bemak, remarking that one in 10 people living in the United States is foreign-born. “In Haiti, they believe in voodoo. You can’t just say, ’I don’t believe in that.’ You have to weave it into treatment. I think we have to be more attuned not only to cultural diversity within the U.S., including cultural healing practices and beliefs, but also the impact that globalization has on an international population. What’s going on in other countries is now affecting us in multiple ways, and counseling needs to get on board with that.”

A nation in need

Daya Singh Sandhu, distinguished professor of research and former chair of the Department of Educational and Counseling Psychology at the University of Louisville, spent the first five months of 2010 working on mental health issues in India. As a Fulbright-Nehru senior research scholar, Sandhu traveled to the country where he grew up to survey suicide ideations there.

The title of Sandhu’s project was “The Effects of Cross-Cultural Worldviews and Coping Response Styles on Suicidal Ideations: A Comparative Study of Gender and Cultural Correlates of Risk Factors and Reasons for Living Among Americans, Asian Indians and Indian College Students.” In India, suicide rates have increased nearly 60 percent during the past 35 years, reaching 10.8 deaths per 100,000 people. Between 2006 and 2008, Sandhu says more than 16,000 college students ages 19 to 24 died by suicide. He traveled to India, he says, to “find out what’s going on” by talking to college students.

Sandhu, the immediate past president of AMCD, conducted focus groups with roughly eight students at a time. One of the students cried, Sandhu says, because she was haunted by the suicides of two girls involved in a lesbian relationship whose parents wanted them to marry men. Sandhu says his study led to many other stories involving lovesick students, the daunting aspect of forced marriages and intense academic pressure. After meeting with the students, Sandhu says it became obvious that people are experiencing significant multiple stressors in their lives because of rapid economic and social changes in India.

There is a shortage of mental health professionals available in India to those in need, according to Sandhu. He estimates that 95 percent of India’s universities lack counseling centers, and the number of private mental health practitioners is very low. Those actually able to locate a professional must deal with the prevailing stigma against getting help for mental health issues, Sandhu says. “People will think you are crazy,” he explains, adding that if the community finds out the person is seeking counseling, it can severely damage his or her chances of getting married and obtaining a good job.

While conducting research in India, Sandhu also attempted to make inroads in advancing mental health for the nation as a whole. In May, with the help of Guru Nanak Dev University and the U.S.-India Educational Foundation, New Delhi, Sandhu convened a meeting of mental health scholars from various areas of the country, and the group decided to launch the Association of Mental Health Counselors. As the founding executive director, Sandhu’s hope is that the association will prove successful in increasing the availability of counseling centers and mental health professionals, which now stands at one psychiatrist for every 400,000 people in India. The association has already opened its first counseling center in Punjab, and another is set to open at Guru Nanak Dev University in early 2011.

Another accomplishment was the creation of a postgraduate degree program in mental health counseling at Guru Nanak Dev. Thanks in large part to Sandhu’s efforts, the program began its inaugural semester this past July. The program is the first of its kind in India, but according to Sandhu, at least three other universities are planning to begin offering similar degrees this year.

Increasing globalization brings people with a variety of different cultural backgrounds to counselors’ offices, Sandhu says, and a Eurocentric model of counseling won’t work for all of these clients. “We can benefit by learning what is going on in other countries,” he says. Realizing that certain problems and situations are culturally specific and that addressing them effectively takes a culturally unique approach is imperative, Sandhu says. He believes making that realization will lead to a more inclusive, comprehensive approach to mental health counseling. Says Sandhu, “We have a lot to learn from each other when we are at the global level.”

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Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org

Taking care of yourself as a counselor

By Lynne Shallcross

Anyone who has flown on an airplane and listened to the flight attendant before takeoff has been cautioned what to do in the event the oxygen masks fall from the ceiling: Put on your own mask first before trying to help someone else. Counselor wellness experts say that idea has mileage on the ground, too.

Helping yourself first is a principle that applies directly to counseling, says Sandra Rankin, a member of the American Counseling Association who runs a private practice in Austin, Texas. “If you’re gasping for air, you can’t help other people,” says Rankin, who is also earning her doctorate in health psychology from Walden University. “Counselors who neglect their own mental, physical and spiritual self-care eventually run out of ’oxygen’ and cannot effectively help their clients because all of their energy is going out to the clients and nothing is coming back in to replenish the counselors’ energy.”

Although most counselors are familiar with self-care — even preaching the concept religiously to clients — many find it a challenge to put the concept into practice in their own lives. Wellness experts say as life gets busy, counselors may tend to assume that they can, or even should, handle problems and stress on their own. But, these experts caution, counselors who ignore their own needs will find their outlook on the profession going quickly downhill.

“Wellness is one of the critical factors in being a healthy counselor,” says Stephanie Burns, an adjunct professor of counseling at Heidelberg University in Tiffin, Ohio. “We are asked as professionals to provide a tremendous amount of empathy to our clients. We often listen to very tragic and emotionally difficult stories. We are offering this empathy to the client and offering a place to share these stories, yet our profession is not meant to be a two-way street — the client is not there to provide us empathy. So, somehow, when you do that work on a daily basis, you have to have an outlet to receive things back. Otherwise, you end up depleting yourself and you don’t have anything more to give.”

Elizabeth Venart, a private practitioner in Ambler, Pa., who served on the ACA Task Force on Counselor Wellness and Impairment, says offering empathy is imperative in the profession, but this also opens the counselor up to feeling the client’s pain. “While vital, being emotionally attuned and available to clients increases our vulnerability in the work,” she says. “And, yet, we cannot be effective in our work if we are not emotionally attuned and available. Within the counseling relationship and within the moment-by-moment interplay of each session, this is the ultimate balancing act — finding ways to stay attuned to clients while maintaining a strong and deep connection with our own experience.”

The path to finding that balance begins with recognizing warning signs and not feeling ashamed of them, Venart says. “It is important for counselors to understand that there are risk factors inherent in the work and that noticing signs of stress or distress is a sign of health, not impairment. None of us is immune to the effects of the work. When counselors can view their emotional responses to their work as an expected part of empathic engagement rather than something they are doing wrong, they are more likely to seek support, talk about stress with colleagues and engage in self-care practices to support their overall wellness.”

Wellness is especially important because counselors are one of the primary instruments in their own work, says Gerard Lawson, associate professor of counselor education at Virginia Tech. “It’s impossible to separate who I am as a person from the work I do as a counselor,” says Lawson, who chaired the ACA Task Force on Counselor Wellness and Impairment. “If I’m not well, that’s going to get in the way of me being able to tune into the needs of my clients.”

Venart, who is also founder and director of the Resiliency Center, a community of private practitioners offering healing services, community education programs, professional development trainings for helping professionals and other services, echoes Lawson’s sentiment. “Counseling is a profession dependent upon our ability to be authentic and attune empathically because it is through this process of careful attunement that healing and growth occur,” she says. “Research consistently demonstrates that the quality of the therapeutic relationship is more predictive of counseling outcome than any other factor. Since the self of the counselor is an essential component of effective counseling, it is vital that we nourish our own wellness. When we are well, we are better able to connect with our clients, more attentive and creative in our work, and less likely to make clinical errors or violate boundaries.”

Counselors should make it a priority to walk the talk and model wellness for their clients, Lawson says. “It’s not to say we need to be perfect all the time, but we need to be aware. If you’re telling your clients to do it, do it yourself.”

Venart agrees. “We need to be aware of the messages we teach clients when we honor boundaries or neglect to set them, when we take a day off to nurture our health or come into work sick, or when we model joy and curiosity or unintentionally share the flat affect of our unresolved grief or depression.”

It’s important that counselors make a habit of checking in on themselves, Venart adds. “Because counselor wellness and impairment are on a continuum from well to stressed to distressed to impaired, it is critical that we continually monitor where we are on that continuum and address any early signs of stress so we don’t move further down the continuum. We are instruments of healing. If we don’t keep our own instrument tuned, we won’t be useful in promoting wellness in others.”

A self-checkup

Determining how “well” you are as a counselor can start with only a few clicks of the mouse, says Burns, an ACA member who has offered wellness workshops for counselors. She points to resources that came out of the Task Force on Counselor Wellness and Impairment, including handouts on risk factors, assessment tools and more, all available on the ACA website at counseling.org under the “Resources” tab. “It can be hard because of our work schedules and the fast pace of life to know how we’re doing,” Burns says. “All those resources are free, and counselors can download them 24/7. It’s a way for counselors to check in with themselves and figure out where they’re at.”

Leslie Kooyman, an assistant professor in the Counseling and Educational Leadership Department at Montclair State University, says mild feelings of resentment toward certain clients or feeling burdened by certain clients can be a subtle indicator that something isn’t right. Other indicators, Kooyman says, particularly for experienced counselors, are regularly feeling lost in terms of what direction to take with clients and sloppy logistics, such as starting sessions late or allowing sessions to go past their scheduled end time.

Unexpected events can throw a schedule off course, but that should be the exception, not the rule, says Kooyman, a member of ACA. “We all have good days and bad days, good sessions and bad sessions. You’re not always 100 percent, certainly.” But, he cautions, a pattern of such issues might signal the beginning of burnout.

Rankin says other warning signs include feeling irritated about clients, experiencing a low level of energy, having problems develop at home, viewing the world and the people in it as unsafe and losing your sense of humor. Paying attention to the physical and mental symptoms of stress is important, she says, as is taking action to alleviate those symptoms instead of ignoring them and simply hoping the situation will fix itself. “Unfortunately, many counselors use stress as an indicator of the quality of work they are doing, believing they are being ineffective if they experience even a hint of stress,” she says. “What counselors need to remember is that stress and the accompanying symptoms are indicative of how the work is affecting them.”

One of the ways Rankin keeps her wellness in check is by participating in a peer support group with a handful of other counselors. The group meets at someone’s office or goes out for lunch or coffee roughly once every other week, although group members meet more frequently when they feel the need. They are careful to go someplace neutral so whoever is having the worst week can get away from his or her work environment, Rankin says.

In one instance, a counselor in the group was experiencing explosive growth in her practice and was seeing between 40 and 50 clients per week. Some of these clients were outside of the counselor’s specialty and were not as enjoyable for her to work with. The counselor found herself exhausted and with precious little time left over for herself or her family. “When we as a group confronted her, she said it had happened before she knew it and [she] didn’t know how to get out of it,” Rankin says. “Being counselors, we probed into why she was ’suddenly’ overwhelmed with clients she did not want and was constantly working. Like our clients, she used every excuse in the book, including the very real ’If I don’t work, I don’t get paid’ argument.” The group helped her brainstorm options and potential solutions, and after she chose a few, the group gave her deadlines and held her accountable.

“She hired a local company to do her insurance reviews, started referring clients not in her specialty, set boundaries with her existing clients so she was not taking their calls at all hours of the day and night, and went for her own personal counseling to address issues she was using work to avoid,” Rankin says. “It took about a month for all of these changes to be put in place, but by the end of the second month, she was experiencing some relief and returning to her old self. It’s been over a year now, and she actually has more free time than ever.”

Making room for life

When Lawson worked as a counselor in an inpatient setting, he remembers rehashing each day in his mind during the car ride home from work. He would go over the clients he had seen, what he had done well and the things that hadn’t worked. “I was literally taking it home with me,” Lawson recalls.

That winter, Lawson repeatedly found himself getting sick, which previously had been a rare occurrence for him. It took a little while, but he eventually realized stress was taking a toll on him physically, so he determined to make a change. On his drive home, it was necessary for Lawson to cross a river. He decided that crossing the river would signify the end of his work day, at which point he would shut off and leave thoughts of the counseling office behind. “It sounds corny,” he says, “but it was a cleansing moment for me at the end of each day.”

A variety of ways exist to improve self-care, and Venart contends that self-awareness is the first step in creating lasting change. “Create and pay ongoing attention to the balance in your life — balance between work and play, giving and receiving, accomplishing tasks and doing nothing,” she says. “Learn simple strategies to nurture yourself within your day, including nourishing [yourself] with enough water, good nutrition and movement and exercise.”

Among Venart’s other recommendations are venting and problem solving with colleagues, taking a walk, journaling, practicing mindfulness and taking advantage of clinical supervision and peer support groups. Venart keeps herself motivated by maintaining a folder of thank-you notes and success stories from her work with clients. “I refer back to them regularly as a way to remind myself that this work really makes a difference, especially on those difficult days.”

Career-sustaining behaviors are often unrelated to work itself, Lawson points out. Aim for a rich life outside of work, which might include taking vacations or “staycations,” spending time with family or a significant other and making time to meditate or pray. Lawson sometimes asks counselors what they do for leisure outside of work, and he routinely hears responses such as volunteering with the American Red Cross or hospice care. “Those are wonderful things to do but very similar to the rest of their professional lives,” he says. “At some point, you need to do something with another part of your brain, not something where you’re caring for others or putting others’ needs ahead of your own.”

Kooyman advocates integrating relaxing activities such as yoga, deep breathing and listening to music after sessions but says counselors should protect their well-being in session, too. “Wellness is also about being able to take care of yourself in the moment,” he says, “and that’s a little more challenging.” He provides the example of counselors being honest about the days they’re available to be in the office instead of stretching to accommodate a particular client.

Another example is setting limits when negotiating fees with clients. Kooyman, who worked in private practice for 10 years, did pro bono work but was also realistic about having to make a living. At times, he says, counselors can be too client-centered and end up giving more than they should. “If we’re not really comfortable with what we’ve decided, it’s going to eat away at us,” he says.

Maintaining boundaries is a crucial element of self-care, Rankin says. “A lack of professional boundaries can create feelings of being overwhelmed, bitter and angry. Too many counselors have not learned what boundaries are, so they meet with or take calls from clients outside of office hours, do not set office hours or work overtime when there is no real need. Basically, they put clients before their own family, friends and self.”

Setting boundaries means taking vacations and holidays, Rankin adds. That can be a tough decision, especially for private practitioners who aren’t bringing in income if they take a day off, but getting away from work is extremely important, she says. “Long or unusual work hours, large caseloads, caseloads with a high amount of trauma, no vacation or off days and no holidays all contribute to counselors becoming unhealthy in mind, body and spirit and therefore impacts the quality of care provided to clients.”

Keeping up with the literature in the field can also promote wellness, Lawson says. When counselors read the latest research and understand new aspects of a concept or problem, it can remind them to view clients as people rather than the problems they represent. Reading the professional literature can also help counselors guard against taking cookie-cutter approaches with clients, Lawson says. Also a proponent of journaling, Lawson says research has shown that people who journal on a regular basis are less susceptible to illness.

Rankin points to research showing that personal therapy and/or clinical supervision can help counselors stay happy and healthy in their work. However, she says, many supervisors are unaware of the importance of self-care, and many counselors don’t seek supervision beyond their internships. “For example, many counselors I have worked with, as well as counselors I have had as clients, do not understand the difference between emotional attachment and empathy. Learning the difference while in clinical supervision would have decreased their risk of compassion fatigue and burnout. Those that were my clients may not have needed therapy had they learned the difference.” If clinical supervision is not an option, Rankin recommends finding a peer consultation group.

Venart recommends that counselors sort their to-do lists into tasks that are truly essential and those that are not. She recalls a counselor in one of her peer consultation groups who told a story about resenting her husband’s ability to relax and informing him there were no days off in their household. “While believing this assertion wholeheartedly as she was expressing it to him, she had to laugh at herself as she was recounting the story aloud in our group,” Venart says. “She realized it wasn’t OK with her for him to have a ’day off’ because she had never considered the possibility that she, too, might be entitled to regular downtime. We explored the undercurrent of beliefs that drive so many of us to push hard without resting, to put others before ourselves and to deny our basic needs for rest, nourishment and pleasure. Yes, some of the tasks of work and parenting and taking care of a home are essential, but some are not. Counselor wellness is sustained when we take an ongoing inventory of what’s truly important and make sure we’ve made ourselves a high priority on our running list of things requiring care.”

In the process, Venart adds, don’t forget to appreciate the lighter side. “Infuse a sense of play into your life. A sense of play can help you and your clients remember that life need not always be so serious. I have a playful little wire figure of a girl sticking out her tongue that reminds me that humor is healing. Clients love this little figure and have commented that her silly irreverence inspires them to speak their mind and see the humor in situations.”

Not second nature

If wellness is ingrained in the foundation of counseling, why doesn’t self-care come more naturally to counselors? First and foremost, Lawson says, people who end up in the helping professions are naturally inclined to take care of others. Plus counseling, by design, is a one-way caring relationship. At times, Lawson says, counselors let that work mentality “leak over” into the rest of their lives, allowing every relationship to become a caretaking relationship.

“Those drawn to work in counseling may have learned at an early age to become other-focused rather than self-focused,” Venart confirms. “As a result, they may not feel they need or deserve the same nurturing [that] they accept others need and deserve. They may have exceptionally high standards for themselves and yet be compassionate and forgiving of the shortcomings, mistakes or inconsideration of others.”

There’s also a deeply rooted idea that as Americans, we should be self-sufficient and pull ourselves up by our bootstraps, Lawson says. “I would argue it’s good practice to say, ’I need help.’ Asking for help isn’t a sign of weakness. It really is a sign of the commitment to the work that we do.”

The work itself can stand in the way of wellness, Rankin says. “Many counselors struggle just to get through the day, so self-care takes a backseat to limited time and fatigue. Plus, some work environments make it difficult for therapists to engage in self-care because of unusual or long work hours, large caseloads and little or no support.”

In addition, like most people, counselors can grow “comfortable” in their discomfort. Even when their work environments are filled with stress, fatigue, anger and resentments, it can still feel “safe” simply because they know what to expect, Rankin says. Trying to change that work environment, even if for the better, can move counselors out of their comfort zones. “But, as I tell my clients, while you’re helping others, who is helping you? Your work should be only a part of your life,” Rankin says. “Boundaries, including a commitment to self, must be in place so there is a balance and distinction between your work life and your personal life.”

Counselors who have children can feel as though there’s even less time to think about personal wellness, Venart notes. “Counselors who are parents may struggle with feelings of guilt for not being more emotionally or physically available for their children,” she says. “As a result, they may tell themselves they must devote all their nonwork time to their children and that it would be wrong to take time away from the kids to nurture themselves. Yet, when we pay attention to and nourish our own needs, it is far easier to be mindfully present with those we love.”

Although counselors may be full of wellness tips for others, knowledge doesn’t always translate into action for themselves. “We are not so different from our clients when it comes to this,” Venart says. “There is often a gap between what we know in our heads to make sense and how we live our lives.”

“Counselors may have more information about effective self-care practices, but they are as vulnerable to internalized negative messages that discourage or discount self-care as their clients,” she continues. “In addition, counselors may have a false belief that they should be able to heal themselves, that their training as a counselor somehow means they don’t need outside support and that the wellness practices that work for everyone else are somehow too simple for them or just not necessary.”

How can counselors infuse what they know into their day-to-day lives? There’s no easy fix, Burns says, but it can be done. “It’s just like we tell our clients: If we want to see a change occur, we have to take ownership of what we want to see happen and do it. We have to make a choice, take ownership of it and then act on it.” Set a goal, but make it an attainable one, Burns recommends. “We can overwhelm ourselves [if we think] that we have to implement all of these things instead of just focusing on one thing and taking it from there.”

Taking a step toward wellness doesn’t equate to doing everything perfectly from here on out, Lawson says. “I don’t really care that you’re doing it just right,” he says. “I’m more concerned that people are paying attention and making efforts toward it.”

Having a supportive environment can help immensely in improving counselor wellness, says Lawson, who recommends that counselors talk with colleagues about their personal needs and struggles and solicit support for the changes they are trying to make. At Virginia Tech, Lawson came up with a rule to support wellness and life balance: No shop talk over meals. “It’s a small thing, but it can make a huge difference in a work setting,” he says. “But you need someone else to buy in as well. It’s awfully hard to do alone.” Start by finding one person to make changes with, but don’t be surprised if two people turn into a trio and then a culture of wellness catches on, he says.

Venart concurs that peers can make all the difference. “Peer support can be incredibly effective in improving self-awareness and supporting positive growth and wellness,” she says. “Creating personalized wellness goals and committing to them in the company of colleagues can support counselors in turning plans into reality.”

Shedding the day

A foundation for wellness should be built before counselors even enter into their professional lives, Lawson says. “In counselor education, we don’t do as good of a job teaching about risks and how to avoid them or manage them if you bump into them,” says Lawson, who makes an extra effort to talk with his students about wellness in the hopes the message will stay with them when they become professionals.

To help establish this mind-set, Lawson encourages his students to change their clothes after they return home from their internships at the end of each day. “You’re [figuratively] shedding the day, and you can move on to the evening with your family,” he says. “It’s a tiny ritual, but it’s those sorts of things that help us separate our professional life from our home life. The ritual becomes a habit and, over time, that habit becomes part of maintaining your own wellness.”

Kooyman, who teaches school and community counselors, often asks his students to make a list of activities they enjoy doing and then to be deliberate about incorporating enough of those activities into their daily lives. Burns also brings up wellness with her students, asking them how they give attention to the many facets of their lives. Creating a supportive atmosphere for counselor wellness in graduate school is crucial, she says. “That’s a good sandbox. If it can be incorporated there, then those skills can be transferred over when they’re working full time as a counselor.”

As a whole, counselor education programs must do more to promote and teach counselor wellness strategies, Venart says. “While current programs or individual professors may discuss the importance of self-care, I believe it is vital that this focus be interwoven throughout graduate training programs and that students and professors alike be challenged to engage in wellness practices and modify behaviors that clearly impair their functioning, including workaholism. I have a friend currently enrolled in a holistic nursing program where practitioner wellness has been integrated into every aspect of their training. The importance of self-care is overtly discussed and modeled by faculty, and the curriculum of each course includes an emphasis on self-assessment and reflection as well as the development and implementation of concrete wellness plans and practices.”

Venart reminds students and professionals alike that although self-care can appear large and looming at times, the process begins with just one step. “As we see with clients, it doesn’t usually require a heroic effort or a complete life makeover to generate really positive results. Sometimes the smallest changes can make the biggest impact. Never underestimate the power of a restful eight hours of sleep, exercise and good nutrition throughout the day. Lunch with a friend can lift our spirits, and taking a Sunday off to rest and play can help us recharge for the week.”

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Letters to the editor: ct@counseling.org

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Roadblocks to wellness

Burnout, vicarious traumatization, compassion fatigue and impairment are terms often mentioned when discussing counselor wellness and self-care. But what distinguishes one from the other? Counseling Today asked counselor wellness experts to weigh in.

Burnout: Gerard Lawson describes burnout as a slow degradation of a counselor’s ability to empathize with clients over time. Elizabeth Venart says burnout often arises from an accumulation of work-related stress, resulting in feelings of hopelessness and helplessness. “It is typically created or exacerbated by the nature of the work and workplace. As a result, a change in work environment can dramatically improve one’s experience of burnout,” she says.

Vicarious traumatization: The symptoms of vicarious traumatization, or secondary traumatic stress, are much the same as those associated with post-traumatic stress disorder, Sandra Rankin says. Counselors can acquire vicarious traumatization in as little as one interaction when they are affected by the trauma they hear about through clients, Lawson says.

Compassion fatigue: “Charles Figley originally coined the term compassion fatigue [as] an experience in which exposure to the suffering of clients coupled with an inability to rescue them from this suffering results in feelings of depletion, anxiety, depression, resentment and/or emotional withdrawal,” Venart explains. “Counselors experiencing compassion fatigue may deny clients’ traumatic experiences, overdiagnose and pathologize clients, and become increasingly less attuned and empathic.”

Impairment: Venart says the ACA Task Force on Counselor Wellness and Impairment found that impairment “occurs when there is a significant negative impact on a counselor’s professional functioning which compromises client care or poses the potential for harm to the client.” Lawson adds that impairment, which doesn’t always equate to unethical behavior, can lead counselors to tend to their own issues at the expense of clients’ issue. For example, a counselor with grief issues might steer clients away from their own grief or loss issues because the counselor can’t handle talking about them.

— Lynne Shallcross

Getting connected

When counselors are isolated, whether working in rural areas or working as sole private practitioners, maintaining wellness can pose an even bigger challenge. Without other colleagues to learn from, vent with or lean on for support, stress is more likely to build unimpeded. Experts say finding a support system, whether through formal supervision or an informal network of other professionals to meet with for consultation and camaraderie, is vital.

Technology can also help bridge the gap. “With the Internet, e-mail, Facebook and the phone, you can still connect with other people,” says Sandra Rankin, who works in private practice in Austin, Texas. Adds Elizabeth Venart, a private practitioner in Ambler, Pa.: “Post questions and participate in online forums for counselors through sites like LinkedIn and Psychology Today. Join interest networks (electronic mailing lists) through ACA where you can connect with counselors in other geographical areas who share your professional interests.” Find out more about ACA’s interest networks by scrolling to the bottom of counseling.org and clicking on “Interest Networks” under the “Get Involved” tab.

Counselors also recommend checking out local, state, regional and national associations for networking possibilities and attending professional conferences to meet other helping professionals. Leslie Kooyman, an assistant professor at Montclair State University, says counselors also might want to consider consulting. When he worked in private practice, Kooyman split his time between counseling clients and doing consulting work with nonprofit organizations and school systems. Not only does consulting offer a team of people with which to work, he says, but it can also help generate revenue.

Research others in your geographic area who are doing similar work, Venart recommends, then contact them and schedule a time to talk in person. “Even if your ’local’ colleagues end up being three counties or two hours away, they can be a resource for you,” she says. “Perhaps organize quarterly in-person meetings to supplement more regular phone calls and teleconferences. There are several free teleconference services where the only fee is the price of
the phone call through your local phone service provider. One I have
used successfully in the past is freeconference.com.”

— Lynne Shallcross

The amazing profession that keeps on giving

Richard Yep

Giving back to the community” is much more than a catchphrase within ACA. As I look back through the years, I am amazed at the volunteerism and generosity of ACA members. Your strong desire to lend a hand to those in need — wherever they may be — is exemplary. In fact, it is truly one of the reasons that I enjoy my job as your executive director.

This past year at the ACA Conference & Exposition in Pittsburgh, the Association for Multicultural Counseling and Development, an ACA division, organized a very successful community service day that provided counseling services to Pittsburgh’s diverse communities. AMCD launched this service day concept at the 2009 ACA Conference in Charlotte, N.C., where it reached out to local at-risk adolescents to address issues such as anger, gangs and low self-esteem.

Also in Charlotte, Counselors for Social Justice, another ACA division, donated $1,000 to Pat’s Place Children’s Advocacy Center, an organization that connects children who have been sexually abused to area resources. And yet another ACA division, the Counseling Association for Humanistic Education and Development, which has sponsored the Empty Plate Project for many years, collected donations for A Children’s Place, a Charlotte charity that provides support to homeless children.

In addition to these incredible acts of kindness in support of our host cities, conference attendees have developed special programs to address multicultural and social justice leadership competencies that contribute to exemplary practice in dealing with the many injustices that exist in our world.

In March, ACA returns to New Orleans, a city that has surely experienced its share of agony, grief, injustice and incredible loss. Once again, ACA will reach out to the local population to lend its services wherever they are needed — at homeless shelters, in community cleanup and revitalization projects, at social service agencies and in school recovery efforts. The experience will not end after we complete our outreach to the community, however. When conference attendees return to the Ernest N. Morial Convention Center, they will be invited to participate in afternoon workshops on topics of economic and social injustice, marginalized populations and other issues that impact those of you who have dedicated your lives to the helping professions.

If you are attending the ACA Conference, I encourage you to join your colleagues for the 2011 ACA New Orleans Project: Giving Back to the Community. All conference attendees are invited! Details had yet to be finalized at press time, but the community outreach will occur the morning of Thursday, March 24, and the program portion will take place that afternoon.

ACA members have much to offer communities, whether during the ACA Conference or at other times. Members volunteered their time offering disaster mental health services after Hurricanes Katrina and Rita and have been involved in other more recent disaster relief efforts as well. For example, within days of the tragic earthquake in Haiti, ACA developed and posted a 48-minute podcast to help Haitian Americans cope with the disaster that was unfolding in their homeland, set up donation programs through the ACA Foundation and consulted with the Red Cross.

Speaking of disaster mental health, here’s another sign that volunteerism is surging through the ACA membership. The ACA/American Red Cross Foundations of Disaster Mental Health Training course, which ACA offers at no cost to conference attendees, was completely filled in November — five months before the conference. Clearly, growing numbers of counseling professionals are equipping themselves with the skills they need to be ready for the next disaster, and they are willing to leave their families temporarily, take time away from work and go wherever their services are in high demand.

These are just a few examples of the incredible spirit of volunteerism that drives professional counselors to offer their services to those in need — anywhere, anytime. No, “giving back to the community” is no longer just a feel-good catchphrase at ACA. It has caught on and taken a firm hold. And with the help of all of you, it will always remain an integral part of the counseling profession and of ACA.

For additional information on the 2011 ACA New Orleans Project: Giving Back to the Community and the schedule of events, please e-mail Tonya Hammer at tonya.hammer@gmail.com, Jennifer Curry at jcurry@lsu.edu or Michael D’Andrea at michael.dandrea@gmail.com.

I also wanted to express my thanks to those of you who responded to my December column. Your thoughts, ideas and suggestions about the future of the profession certainly helped to stimulate discussion between me and the professional staff of ACA.

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.

How well is your wheel rolling?

Marcheta Evans

What is a resolution? When you think about it, what does it really mean to you? As we begin another new year, I have been reflecting on the many resolutions I have made in past years. They have centered on my physical, mental and spiritual health, my family, how I viewed my job, my leadership role and on and on. The list can seem immeasurable, yet I find myself once again looking at what is ahead of me and contemplating what goals I would like to accomplish for 2011. I must admit, they all seem to have a familiar ring to them from previous years. What about this year will be different from past years? Will I be more successful with some of my health goals? Will I get up every morning, work out and make time for my meditation? I am sure you are asking yourself similar questions as you think about the year ahead.

The cover story in this issue of Counseling Today focuses on how we take care of ourselves as professional counselors. The first thought that came to my mind was, do we take care of ourselves? So many times we find ourselves taking care of the needs and problems of others. Do we heed our own advice and take care of ourselves? I know you are aware of the importance of taking care of yourself. After all, this is what we tell our clients and our students to do. But do you honestly make this a priority as you go about your daily life?

Rarely do people come to see us because their lives are filled with an enormous amount of joy and bliss. Typically, they are coming to us because they need support for a problem or an issue in their life. When you consistently expend energy assisting students or clients in resolving their issues, you must find a way to replenish yourself. As a counselor educator, I constantly tell my students they are the most important tool they are taking into the counseling relationship. If they are not functioning at full capacity, it will have a direct impact on the quality of services they offer their students or clients.

Over the years, the Wheel of Wellness, developed by Melvin Witmer, Thomas Sweeney and Jane Myers in 1998, has continued to impress me as a model not only for our clients and students, but also for us as professional counselors. I know the authors have continued to evolve their model, but the version that resonates with me most personally is the one that places spirituality at the center of the wheel, with the spokes representing self-care, stress management, gender identity, cultural identity and sense of worth. Also included are sense of control, realistic beliefs, emotional awareness and coping, problem solving and creativity, sense of humor, nutrition and exercise. If you were to take a personal inventory of your life right now, how well rounded would your wheel be? If you look at the elementary concept of a wheel, you know that it must be balanced all the way around for it to roll effectively. How do you see your wheel rolling? All of the areas must receive adequate attention for you to be properly nourished and effective in your job.

Upon investigating further, I discovered these authors defined wellness in a 2000 Journal of Counseling & Development article as a “way of life oriented toward optimal health and well-being in which body, mind and spirit are integrated by the individual to live more fully within the human and natural community.” This may seem a little too touchy-feely for some, but when I ponder the life and well-being of professional counselors, this definition is congruent with my philosophy of living. Whether you agree or not, I encourage you to consider how well you are taking care of yourself. If you find you are lacking in any area, I urge you to do whatever it takes to make a change. If you have found that resolutions work for you, go for it. If not, find a model that is effective for you.

I attended a seminar once where the presenter gave me a “tuit.” I looked at it and wondered, “What is this?” After a brief explanation, the presenter informed us that we now possessed “a round tuit,” which basically meant there were no further excuses for not getting things done. You don’t have to wait until you get around to it. I am giving you “a round tuit” to focus on yourself right now!

Underdiagnosed and overwhelmed

Stacy Notaras Murphy January 1, 2011

Picture a fifth-grade classroom. One little boy will not sit still. He constantly interrupts the teacher and gets out of his chair during the lesson. Meanwhile, a little girl sits in the back row and gazes out the window. Ensnared in a daydream, she also has missed the lesson.

Eventually, the school’s counselor is likely to send the boy for evaluation, and his family will begin working with his learning needs. The girl, on the other hand, is likely to be passed on to sixth grade with low academic marks and even lower self-esteem. Both children have attention-deficit/hyperactivity disorder (ADHD), but because it is the boy’s behavior that presents as a “problem,” only he will receive treatment.

Wilma Fellman, a retired licensed professional counselor in West Bloomfield, Mich., and longtime American Counseling Association member, knows this scenario personally. She says she only “woke up” to her own diagnosis during the process of securing help for her son with ADHD 28 years ago. “The specialists decided to look into the parents’ backgrounds, and his father didn’t demonstrate any of the characteristics, but I was the poster child,” Fellman says. “There I was, 30 years old and suddenly putting things together that didn’t make sense to me when I was much younger. I live inside an ADHD body, so I know it’s real. I know the struggle. I also know it’s overdiagnosed and often a catchphrase, but it’s also underdiagnosed, particularly in women, because they don’t cause a problem.”

Kathleen Nadeau, an author, clinical psychologist and director of the Chesapeake ADHD Center in Silver Spring, Md., points to training deficiencies in the mental health field. “We’re so overtrained by the media and by social assumptions that [attention-deficit disorder] has to do with hyperactivity and with tremendously obvious distractibility. We only associate it with kids — [generally] kids who didn’t do well in school — and we associate it with boys. It’s not that women present atypically, [but] I think there’s really inadequate training for psychologists, social workers, counselors and psychiatrists about what adult ADHD looks like.”

Nadeau offers the example of a family she counseled recently. The daughter, who was in first grade, was “utterly charming” despite interrupting Nadeau’s interview. Both of her parents also had ADHD yet presented quite differently from each other. “Dad is bouncing all over the place. It was clear he had some kind of minor business crisis on his hands, but he didn’t want to leave the session,” Nadeau says. “Then there was his wife [who exhibited] much greater self-control but was describing her office as utter chaos. She said, ’I know where everything is, but I tell my boss that if I don’t see everything, I lose track.’ That’s her ADHD.”

The most common complaint Nadeau hears from women with ADHD is that they are overwhelmed with life: kids, house, work, bills, etc. “Many women can identify the point at which the drowning began,” Nadeau says. “[They might say] ’I worked really hard in college and was successful, but my apartment was always a wreck.’ They usually note a point at which the flood came overhead — maybe the second baby was born or they moved into a house with a larger mortgage. They have tremendous problems with lateness, with distractibility. They say, ’I work all day, every day, and I could not tell you what I accomplished.’ The reason she can’t is she lives her life in reactive mode, with no plan or organization.”

Delayed diagnoses

Women with ADHD are often misdiagnosed and sometimes medicated for other disorders, which can lead to a deep dissatisfaction with the mental health field and an increased sense of isolation, says Ellen Littman, an ADHD specialist in Mt. Kisco, N.Y., who has written extensively on the topic. “Almost all of the women I see have been bouncing around the mental health field for some time, having been misdiagnosed, often on a trial of Zoloft or Prozac. They’ve seen a little relief, but nothing significant.”

ADHD is rarely the first thought when a female client presents with symptoms such as exhaustion, trouble concentrating and feeling different from other people. “It’s missed almost all the time,” Littman says, “so by the time you find a woman in her 40s, struggling on her own for all this time, there are so many other problems that she’s developed as a result. It really impairs her life, and she feels alone.”

Raising awareness in the mental health field is paramount, says Littman, who adds that clinicians need to be sensitive to the history of struggle that each client carries. “It’s astounding the statements that psychopharmacologists make to women who are in such a vulnerable position … but finding a woman psychiatrist who understands all those factors is a needle-in-a-haystack experience,” she says. “Women will come in and say the medication and therapy is helping a little, but with years of being told, ’There’s nothing wrong with you. Just try harder,’ they’re not good at advocating for themselves when they go to a psychiatrist. And that becomes another cycle perpetuating low self-esteem. You have to create a safe environment where women feel all of their issues are being validated.”

Nadeau advises counselors to listen closely to their clients and carefully consider whether certain symptoms might be connected with ADHD. “It’s really important to help counselors understand that women with ADHD are very likely to have anxiety and depression [at the same time],” Nadeau stresses. “If you think about it, having ADHD is anxiety-provoking. If I’m running late, if I just got something in the mail, these things ratchet up the anxiety. What is rare is for [adult] ADHD to exist without a coexisting condition. So often the anxiety or depression is very readily diagnosed. All mental health professionals know how to diagnose that. [But with ADHD], sometimes it’s like peeling the layers of the onion.”

There are more than 14 typical ADHD symptoms, Fellman notes. “The tricky part is that almost no one has them all. The combination that Female A may have is 1, 3, 7 and 9, while Female B has 2, 6, 11 and 14, and the two don’t operate at all alike. Once counselors realize [ADHD] doesn’t follow the rules, then they are starting from the right place.”

Littman agrees. “In high school, [these clients with undiagnosed ADHD] didn’t fit in anywhere but soon discovered either through substances or through sex that these were ways to be accepted and to bridge the gap that they were not able to bridge another way. They may have had trouble connecting to others, but with those [behaviors] you get blanket acceptance. You find people in their 20s drinking or smoking pot all the time, doing things to slow their brains down. It’s very rare that they don’t have self-medicating behaviors.”

“There are also usually addictive behaviors,” she continues. “They often start with nail-biting, then food becomes the legal addictive item for girls. It’s unusual to find these clients without some sort of eating disorder.”

A counselor’s attitude can exacerbate the problems of women with ADHD. “A lot of therapists who are trained more analytically don’t really buy the whole diagnosis,” Littman says. They assume that “if there are problems, it must be something you are doing to sabotage yourself by repeating unhealthy behaviors and patterns. That confirms the person’s feeling that she is somehow a loser getting in the way of her own achievement.”

Great expectations

Cultural expectations about female behavior also make it difficult for women with ADHD to thrive. “Usually, girls and women have the additional issue of the sociocultural role of what a female is supposed to be: organized, together, socially adept and good at cooperative activities,” Littman says. “These women are not feeling good at any of those things. They may just tell the therapist they feel different or that they don’t know how to connect. … She strives to compensate and will do anything to [fit] the appropriate sociocultural role, and she is increasingly overwhelmed.”

Littman has found that women with undiagnosed ADHD experience difficult symptoms that may push them toward counseling during certain life stages. “The first [stage] is when they go to college, leaving home and the extreme structure that’s been imposed by a parent or two where everything was figured out for them — laundry, food, etc. Then they go and try to take on those roles themselves and try to fill in a blank slate of a day for themselves. The first year of college for most kids with ADHD is almost universally a disaster: sleeping, partying, drinking.

“If they’re able to get through that piece of it, then you get to the second [stage]. … Life becomes more difficult when you have a significant other [and you’re] trying to accommodate their needs when you’re not even sure of your own. Girls and women tend to focus on what the other person’s needs are, and their own needs are not addressed, not articulated. They cope like that for a while, but when you get into them having a house or an apartment, the difference is exponential.

“The final frontier, if you haven’t seen the client yet, is going to be the second child. There’s just no way [the client with undiagnosed ADHD] can manage. She’s hiding the chaos, but it’s everywhere. It can’t all be done. It’s more likely she will be diagnosed then, but the damage [has already been] done in terms of her self-esteem.”

Nadeau echoes this sentiment. “One of the gender differences is that very often in a workplace setting, women are more likely to be assigned a job that involves organizing other people — the essence of being an ’admin person.’ That’s exactly what’s so hard for these women. Even if a woman doesn’t have that kind of a job, much of the family expects her to be the one to figure out what’s for dinner, when is soccer practice and did you get the gifts for the birthday? So they begin to feel they’re just bad at being a female. Even though a man might be impacted in the same way, the world isn’t expecting him to manage his family in addition to doing his job.”

Career myths

In the 28 years since her own informal ADHD diagnosis, Fellman’s counseling career has focused on helping adults find meaningful work, with an emphasis on ADHD support. “I live and breathe the topic. In fact, I’m in graduate school again going for my doctorate because I’m not finished yet,” she says. Her research is focusing on the validity of Myers-Briggs Type Indicator results for women with ADHD and how the test, and other ADHD stereotypes, might lead counselors to reach inaccurate conclusions about their clients.

“I don’t think most counselors understand [ADHD],” Fellman says. “When you have a woman who goes to a counselor for career development guidance and the counselor has very passing knowledge of what ADHD is, they often use the myths that are associated with ADHD to guide this person. The myths are that everybody with ADHD is jumpy and can’t sit still, so just find them a job or career that has to do with moving around. That isn’t necessarily true. There are an awful lot of women with ADHD who are hyper-focusers. They can sit in one place for days if they are intensely interested. I have had dozens of accountants who are successful and who have ADHD.”

“Another myth is that all people with ADHD are creative and should probably follow that kind of career path,” she continues. “That isn’t true. Some are creative and others are not — just like the rest of the population. A counselor might believe that all women with ADHD are creative, so you [end up with] a client who feels badly for not completing what she should, then you add another negative feeling because she’s not creative enough either.”

“Not all women with ADHD should be entrepreneurs and work for themselves,” Fellman says. “For some, that’s a magic combo; for others, the kiss of death. They try to wear all hats and just can’t do it all. If organizational skills or time management are issues, they feel badly and say, ’I’m supposed to be a good entrepreneur. Why can’t I pull this off?’ Then the counselor is guiding the person into creative, entrepreneurial careers: ’Be your own boss! Find a job that moves around a lot!’ If this doesn’t sound like the client, it’s the last straw, and she says, ’I just don’t fit anywhere. I still don’t fit the diagnosis.’”

Treatment options

Sometimes, simply being diagnosed with ADHD is a tremendous relief for women who have struggled for years with no frame of reference for their experiences. “Psychoeducation teaches them that [ADHD is about] brain chemistry and genetics,” Littman says. “It’s useful to look at [family] history and realize that mom or dad had ADHD, too. [It’s finally] understanding the stories about the family’s ’black sheep,’ or alcoholic, or person who struggled in school or the one who always changed jobs. It just wasn’t named ADHD in those generations.”

Treatment itself becomes about reframing. “It’s not bad wiring. It’s just different from the linear thinkers of the world,” Littman says. “There’s a way to get people to embrace the way they think rather than constantly denigrating it. Reframing is everything. It’s the lens you see everything through, and it leads to feeling more hopeful.” Littman adds that counselors should change the focus of conversation from what the client can’t handle to becoming more confident in redefining what is really important.

Medication is Littman’s final intervention, but she acknowledges that ADHD requires a multimodal treatment process. “It starts with psychoeducation, reframing, getting supports, changing your caseload, learning shortcuts, and then comes medication,” she says.

Nadeau believes in getting the whole family on board during treatment. She recalls encouraging one client to manage her ADHD in part by adding household help. “But then her mother questioned the expense and said, ’How can you tell me finances are tight when you are doing that?’ That’s par for the course, whether it’s a spouse saying. ’Everybody else’s spouse can handle this, why can’t you?’ or something else more critical.”

“The ideal, of course, is to help women with ADHD recognize their strengths and have it become more reciprocal,” Nadeau adds. Educating the family about the condition’s true impact can assist in creating an ADHD-friendly home environment that supports needed lifestyle changes for the client such as getting good rest, exercising regularly and maintaining household routines. Nadeau also recommends that clients find outside support groups, limit exposure to people who don’t understand ADHD, schedule intentional alone time and delegate as many household tasks as possible.

Being encouraged to simplify one’s life is key, Nadeau says. “One of the strongest messages to get across to counselors is that the most destructive thing about living with ADHD is the barrage of criticism you get from others and the imagined criticism that you heap on yourself.”

Stacy Notaras Murphy is a licensed professional counselor practicing in Washington, D.C. To contact her, visit therapygeorgetown.com.

Letters to the editor: ct@counseling.org