Monthly Archives: December 2014

Drawing a circle around denial

By Estela M. Pledge and Daniel J. Campbell December 22, 2014

Group counseling was known to be a beneficial method of treatment for substance abuse even prior to the 1935 founding of Alcoholics Anonymous, but it wasn’t until after World War II that group therapy became a widely accepted form of treatment. It was used in psychiatric hospitals, outpatient treatments, correctional centers, substance abuse treatment and other types of treatment. Group Branding-Box-Groupcounseling lends itself to teaching clients and their families that they are not alone with their problems — that many of their anxieties and fears are shared by others. Today, group counseling is still one of the preferred methods of treatment, not only because of the need for clients to find connectedness but also because of the therapy’s powerful use of peer pressure.

Ethical considerations

One of the central ethical issues in group work is confidentiality. The group leader must not only keep the confidences of members but also convince the members to preserve one another’s confidences. Still, best practice emphasizes the importance of clearly communicating to all members of a group that even though the counselor is obligated to not reveal client information, the counselor cannot guarantee that group members will uphold confidentiality. For this reason, it is prudent to obtain a signed confidentiality form from all participants.

If a group technique is to be effective, it is of utmost importance for the group leaders to have proper training and to conform to the ethical standards of care. The counselors must also possess personal emotional regulation skills, healthy interpersonal functioning and effective group leadership skills. If the counselors do not have these skills, they could lose control of the group exercise. It is very beneficial for the group counselors to possess previous experience working as co-leaders, especially when they use the inner/outer group technique. They will have to rely on each other to observe the group that is not being processed and be able to convey a concern to the inner group leader through something as simple as a raised eyebrow. Group leaders should also understand the purpose of choosing this method, be able to work in partnership and know the group members (both clients and their families).

Conducting the inner/outer group

The inner/outer group technique is helpful in bringing out important issues, both for the clients and the counselors. In the safety of the group, clients’ family members can introduce important issues that help counselors to identify exaggerations, projections, conflicts and other types of miscommunications that can be valuable to discuss in a therapeutic environment.

The inner/outer group uses a co-leadership model that is processed by forming an inner circle made up of family members and an outer circle consisting of the clients. The family members and clients then trade circles and finally end in one large circle.

There are two primary goals for the inner/outer group. The first is to provide a safe environment for family members to voluntarily share how their loved one’s substance use has affected them. The second goal is to provide the clients with an opportunity to listen to the hurt of the families. This helps to reduce denial and minimization, especially as it pertains to
the family.

The success of the inner/outer group technique hinges on the ability of the counselors to screen group members for suitability. Therefore, it is essential for the group leaders to meet prior to conducting this technique to review the preliminary screening. It is preferable for the counselor who usually works with the substance use clients in group to again serve as the group leader in this exercise. The counselor who is familiar with the family members will work with the family.

It is the responsibility of the group leaders to not jeopardize anyone’s well-being and to follow all ethical guidelines. No member should be coerced into participating. Clients need to be informed of the importance of being open to honest feedback and allowing family members to be involved in the exercise.

On the other side, family members are more likely to feel safe and to participate in this technique if the counselor has established credibility and trust with them and if they feel that the counselor understands what they are going through. Most family members welcome the opportunity to share their feelings because, often, their loved one hasn’t wanted to hear or believe that the pain caused by his or her substance use has been that “bad.” Frequently, family members approach the inner/outer group exercise saying, “It’s finally my turn to be heard.”

The group leaders must agree that the technique will be canceled if anyone is reluctant about or unsuitable for the process. Because young children may not understand the process, it is recommended that all participants be at least 12 years old.

The total group size should not exceed 16. This allows ample time for everyone to share and feel like they are being heard. For instance, there may be six clients and 10 family members, or there may be nine clients and seven family members as, occasionally, there will be a client without any family present. But this too provides opportunities for learning because it is not unusual for a person to lose family support due to the inappropriate behaviors associated with the substance use. It may also be that a client’s family is unable to attend for other reasons. A small group of as few as five participants can be workable, mostly because the family members are eager to have “their chance.”

The important point is for the group to be kept manageable, both for the group leaders and the time allotted. The time will depend on the total number of clients, but experience has shown that the process works well if 45 minutes is allocated for each session of the inner, outer and then large group to debrief.

Keeping in mind the ethics of informed consent, it is imperative that each group leader meets with his or her respective members at least 10 minutes prior to the session to again check and clarify the process with everyone involved. Group leaders must concur that the technique will be canceled if anyone is disinclined to participate. It is a good idea for the group leaders to decide ahead of time on some discreet signal that the technique is a “no go” in order to protect confidentiality. In such cases, the clients and family members can be formed into a large group as the group leaders work on restabilizing the group. The process can be started by discussing the many reasons that it is difficult for participants to share and to trust again. The inner/outer group technique is less likely to be canceled when members are effectively screened beforehand.

This technique should be conducted only once per group. If it is an open group, care must be taken that no member has participated previously.

The inner/outer group process is less threatening and more relaxing when an atmosphere conducive to interaction and safety is created. This can be done in part by using lamps that are softer than overhead lights or by using lights with dimmers. There should be no distractions of any kind, including cell phones, smartphones or other electronic devices.

The inner group, which is composed of family members, should sit in a close but not tight circle. Always have a box of tissues handy, preferably on a small table in the center of the circle. Family members tend to feel more open to share when they do not make eye contact with their loved one, so it is important that each client sits almost directly behind his or her family member.

The outer circle is then formed with the clients. The outer co-leader should be positioned by sitting opposite the inner co-leader. This allows the outer co-leader to observe the reactions of the outside members for later processing. In this way, family members are protected from responding to the reactions of their loved ones because in this exercise, clients are expected to just listen.

The inner group

Once everyone is seated, the inner group co-leader should again review the group rules: use “I” statements, no blaming, share your own feelings without projecting. The inner group co-leader should start off by acknowledging that this technique can provoke a little anxiety and asking everyone to take a couple of deep breaths to help relax. The family members should then be reassured that the inner group co-leader is there to assist and support them.

The process should start with the person the group leader knows is most likely to share effectively, thereby modeling for the rest of the family members. Typically, this is someone who has been an active participant in the family sessions.

The process could go something like this: “I know that you have already shared what it’s been like for you to live with someone who has an addiction, but for the sake of the other members, would you please briefly share again?” This is also a good place to inquire about what the person’s hopes and fears may be as his or her loved one is in treatment.

With the newer family members, ask questions such as “What has it been like for you to be in this relationship?” and “What are your expectations now that your loved one is in treatment?” Another question might be, “Is there something you would like to say to your loved one at this time?” This can be a good closing question because it tends to be answered with expressions of love and hurt, yet also hope, and this often invokes tears.

Once everyone in the inner group has had a chance to share, the group leader should summarize and acknowledge the work that has been done by thanking the inner group and reminding everyone to maintain silence while trading places with the outer group.

The outer group

The process starts again with the outer group now becoming the inner group and the outer group co-leader becoming the inner group co-leader. This time, family members sit behind their loved one. The current inner group leader once again reviews the group rules and asks clients to share their reactions to what they heard from their family members. The group leader might also point out behaviors that he or she observed during the previous group. For example, “I noticed tears when your family member was talking about _______. Tell me what the tears were about.”

It is important that this part of the process focuses on reactions to what was previously said in order for the clients to let go of any minimizing or denials of the effects that their substance use has had on their family members. This also helps to validate the family members. Once again, the group leader could summarize and end the session similar to the way the first session was concluded.

The large group

All members are then asked to form a large group circle. While the large group is being formed (the chairs placed in one large circle), the lights are turned back up. This seems to help participants make the transition back from the intensity of the small group work. During this transition, families often hug each other and cry, which speaks to the power of the technique.

In the large group, with the co-leaders sitting opposite each other, debriefing starts by asking for reactions to the inner/outer group process. It is more effective to call on each member rather than waiting for someone to start the process so that everyone has a chance to debrief. Each group member is asked merely to respond to the technique. Otherwise, there is a tendency for members to want to comment on what was last said by their loved one.


It cannot be emphasized enough that the success of this technique depends on proper screening and reminding all the participants of confidentiality. Also be prepared that at the next group session, clients may want to reflect on how difficult it was to hear their family members’ comments and see their anguish. Because as long as they did not hear and feel this pain, they could continue to deny that their behaviors affected others or minimize its impact. It is also common for clients and family members to later share that their family has grown closer since the inner/outer group process.


Estela M. Pledge is a licensed clinical professional counselor living in Macomb, Illinois. In addition to maintaining a private practice, she is a counselor and clinical supervisor at the Alcohol & Other Drugs Center at Western Illinois University. Contact her at

Daniel J. Campbell is a master’s-level graduate student in the clinical community mental health program at Western Illinois University and a graduate assistant at the Alcohol & Other Drugs Center.

Letters to the editor:


The powerful perspective of body satisfaction

By Juleen K. Buser and Rachael A. Parkins

Every January, right as the new year begins, we are saturated by commercials for diets, advertisements for exercise machines and stories of people whose lives were transformed upon Branding-Box-body-satisfactionattaining the elusive goals of slimness and fitness. This message is an undercurrent throughout the entire year, of course; it just becomes especially blatant and constant in the days leading up to and immediately after New Year’s resolutions.

But the messages about being thinner, fitter, sleeker and more attractive are rarely absent — particularly for women. In fact, in a quite alarming example of the consistency and doggedness of this message, a few years ago I (Juleen Buser) watched a newscaster comment on National Eating Disorders Awareness week. This alert about the annual marking of a week to increase awareness of the agony and perils of eating disorders was almost immediately followed by a commercial on the latest weight loss tool promising to help women shed those extra pounds of flab and fat.

The problem of body dissatisfaction among women is pervasive and persistent. In a 2014 study published in the scientific journal Eating Behaviors, Elizabeth Fallon, Brandonn Harris and Paige Johnson reported that 13.4 percent to 31.8 percent of adult women experience body displeasure. Moreover, these authors noted that young, middle-aged and older women all reported body dissatisfaction.

A prominent strand in the literature is the role that the media play in fostering and maintaining this rampant, steadfast body dissatisfaction. A meta-analysis conducted by researchers Lisa Groesz, Michael Levine and Sarah Murnen in 2002 pointed clearly to the detrimental impact of the media as it relates to female body image.

As counselors, we are bound at some point to encounter a client who has dealt with the negative impact of the media’s obsession with body size and shape. Ruth Striegel-Moore, Lisa Silberstein and Judith Rodin wrote a seminal article in 1986 (“Toward an understanding of risk factors for bulimia”) that discussed how incredibly common it is for women in Western society to struggle with body dissatisfaction. The concern is so typical, in fact, that it may actually be unusual to identify a woman who expresses happiness and satisfaction with her body.

We, the authors of this article, wanted to hear the perspectives of women who expressed the uncharacteristic view of body satisfaction. We thought that much could be learned about mental Body image authorshealth from women in college who were able to assert satisfaction with their bodies despite the many media messages lauding the ideal of thinness. Thus, we embarked on a research project in which we interviewed nine college women about their experiences of body satisfaction.

We asked these women questions about their emotions and cognitions regarding their body size and shape, their history of body image attitudes and views, and how they cope with the external pressures for thinness. In what was often viewed as an unexpected inquiry, we also asked them questions about the connection between their spirituality and body image. We chose women who specifically expressed having both body satisfaction and a spiritual belief system because we were curious about the ways in which spiritual beliefs might play a role in body satisfaction. The full empirical findings of this study are available in an article we published in the April 2013 Adultspan Journal, “‘Made this way for a reason’: Body satisfaction and spirituality.” This Counseling Today article is an adaptation of that article; here, we focus more closely on the practical counseling implications of our findings.

The importance of the body

Our findings uncovered a striking contradiction. Many of the women we spoke with felt that their bodies were both more important and less important than the societal messages about female physical appearance.

They viewed their bodies as more important than the societal narratives in that the media images of thinness did not disrupt their core belief in personal beauty. Some women talked about Photoshopped images and the erroneousness of the media’s idea of beauty, explaining that they were able to distance themselves from the models by recognizing that their bodies were simply different than the ones in the media. To these women, their bodies and the bodies in the media were incomparable.

On the other hand, they also placed less importance on their bodies in that many of these women did not emphasize physical size and shape over other significant areas of life. Media narratives often would have us believe that a physically fit, attractive body should be a primary value for women. Some of the women we interviewed communicated aspects of their lives that they felt were more valuable than their physical bodies. For example, one participant said: “I mean, your weight compared to, like, the time you could spend with your family. … Why are you wasting your time staring in the mirror for an hour?” 

These findings around the importance of the body have potentially powerful implications for counseling. When working with women who express body dissatisfaction (that common, persistent displeasure counselors are bound to encounter in clients), the views of these women who were able to hold onto body happiness could be helpful. Counselors may be able to pair the beliefs that many of the participants of this study possessed with different therapeutic methodologies. For example, counselors might use cognitive therapy techniques that help clients alter distorted thoughts by replacing them with more rational beliefs. A client who found she was frequently comparing her body with the bodies often seen in the media may be able to use thought replacement, for instance. She could substitute thoughts that engender body comparison with a statement such as: “My body is incomparable to that image because it is falsified, making it unattainable.”   

Counselors can also work with clients to shift their focus and priorities. Clients may benefit from focusing less on their body shape and size and focusing more on other aspects of life. For example, clients might come to counseling with the identified problem of a distorted body image and a self-image closely tied to body size and shape. A counseling session may be the ideal opportunity for a counselor to help shift these common distortions by pointing out the dissimilarity between the client’s long-term goals and the value the client is placing on her body image. For example, counselors can draw from principles of acceptance and commitment therapy (ACT) when working with clients struggling with body dissatisfaction.

Adria Pearson, Michelle Heffner and Victoria Follette, authors of Acceptance and Commitment Therapy for Body Image Dissatisfaction, applied ACT to the treatment of body displeasure and noted the benefits of helping clients move beyond a focus on body size and shape to live a life in tune with personal values. For example, a counselor might ask a client to create a list of morals, values and attributes that she would like to work toward having or may currently see in herself. This would be a crucial opportunity to point out to the client the incongruence between her morals/values and the concentration she may be placing on her outward appearance.

Spirituality and the body

Initially, almost all of the participants in our research project were a bit staggered by the notion of a connection between their spirituality and their body image. Yet, despite early confusion over or even rejection of this connection, many were able to see and give examples of how their body image and spiritual beliefs could be correlated.

One way in which these two components were tied together for some participants involved the idea of spiritual control over one’s body. Specifically, these women accepted certain limitations concerning their ability to control their physical bodies. They gave ownership of these limitations to a higher power, noting that God “made me how I am” and “I just feel like maybe I am a certain way for a reason, and God wants me to be happy with myself.”

Again, these findings are rich with potential counseling implications. First of all, the participants’ initial surprise, confusion and hesitation concerning a potential connection between their spirituality and body image suggests that counselors may have to take the initiative in broaching these topics. Although such a connection may be relevant, clients simply may not think about the intersection of these two domains and, consequently, could miss a very salient and therapeutically beneficial exploration.

Counselors can begin the conversation with open questions that give the client a chance to think about (likely for the first time) possible connections between spirituality and body image. Potential questions and comments include:

  • “You mentioned having a spiritual faith a few sessions ago. I am curious about ways in which your spiritual beliefs might play a role in how you feel about your body.”
  • “Tell me about your spiritual practices (for example, prayer, meditation). What things do you focus on during those times? Do your feelings about your body relate to these spiritual practices?”
  • “Are there ways that God or a higher power influences the way you feel about your body? Tell me more about this connection.”
  • “What aspects of your spiritual faith are relevant to body image concerns? Are there certain [theological principles, sacred texts, underlying philosophies, etc.] that discuss the physical body?”

For certain clients, this connection between spirituality and body image may be personally meaningful and significant. In such instances, counseling can delve more fully into a discussion of the ways that a client’s spiritual beliefs could foster body satisfaction. When discussing the spiritual belief systems of clients, however, counselors will want to be cautious not to offer spiritual guidance or instruction to the client. Rather, counselors can remain in an encouraging role, asking open questions and fostering client exploration of spiritual and body beliefs.

For example, a client struggling with body displeasure may believe in her complete ability to control her body size and shape. Disordered eating behaviors may result in part from this belief in personal agency over weight and shape. Yet, this client may possess a spiritual belief system that contains theology about the sovereignty of a higher power.

In such a case, a counselor could help the client explore the ways in which her spiritual views (of little control) might relate to or inform her body image views (of complete control). A client may then begin to apply her spiritual beliefs about divine power to her body size and shape. She may ultimately see her physical body as created by a higher power and thus not fully within her control to manage through a strict diet and exercise regimen. This spiritual belief system may give her the relief of accepting her body.


Inundated by media images of thinness, many women are vulnerable to the ensuing effects of body dissatisfaction and unhappiness. Yet, for some women, attitudes of body satisfaction persist despite these external pressures and societal mores. As counselors, we can learn from these women. The factors that allow them to hold onto a belief in the beauty of their bodies can help us in our work with clients who are struggling with beliefs about the inadequacy and unattractiveness of their bodies.


Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Juleen K. Buser is an assistant professor at Rider University in Lawrenceville, New Jersey, and a past president of the International Association of Addictions and Offender Counselors. Her research focuses on both adaptive and maladaptive coping strategies such as eating disorders, nonsuicidal self-injury and spiritual coping styles. Contact her at

Rachael A. Parkins is a primary therapist at the Renfrew Center in Radnor, Pennsylvania. She received her master’s degree in clinical mental health counseling at Rider University. Her research includes emphases on eating disorders, body image, coping and spirituality.

Letters to the editor:

Confronting loneliness in an age of constant connection

By Laurie Meyers

In the 21st century, we have more ways to communicate and get information than ever before. News headlines and celebrity gossip reach millions of people in seconds on Twitter. We share our lives Branding-Box-Lonelywith friends and family on Facebook, post our pictures on Instagram, look for jobs on LinkedIn and share our passions on blogs and other social media outlets. When we want to talk to loved ones in far-flung locales, we no longer need to limit ourselves to the telephone — not when voice and video are just a Skype call away. But with so many ways to connect, why do we often feel so alone instead?

“One Is the Loneliest Number,” “Only the Lonely,” “Sgt. Pepper’s Lonely Hearts Club Band.” Popular culture is filled with the laments of the lonely. It has ever been thus: Loneliness is part of being human. The research on the prevalence of loneliness is mixed, but some experts believe that the number of lonely people is increasing, and some counselors report an increase in clients struggling with this issue. These professionals think that certain aspects of modern life, such as dramatic differences in the way we communicate, our overstretched schedules and our frenetic pace, can increase feelings of loneliness.

Whether or not loneliness is becoming more widespread, a 2010 AARP survey indicates that it is certainly a common issue in adults older than 45. Overall, 35 percent of survey respondents reported being lonely.

In a 2010 article in the Annals of Behavioral Medicine, “Loneliness Matters: A Theoretical and Empirical Review of Consequences and Mechanisms,” John T. Cacioppo, a psychologist who specializes in the study of loneliness, and his co-author, Louise C. Hawkley, published research indicating that loneliness is common in children and adolescents as well. Up to 80 percent of individuals younger than 18 reported feeling lonely at least sometimes.

The same study found that as many as 40 percent of those over age 65 report being lonely and that, in general, loneliness increases with advanced age. Researchers are concerned that as the population of older adults increases in the United States, loneliness will become a significant societal problem.

Psychiatrist Frieda Fromm-Reichmann is considered a pioneer in loneliness research. In her seminal article “Loneliness,” published in 1959 in Psychiatry: Journal for the Study of Interpersonal Processes, she asserted that loneliness (which she defined not as the state of being alone but rather as a lack of intimacy) played an integral role in mental health issues. She also posited that the lack of significant research into loneliness was due to people avoiding the topic because loneliness represented such a painful and frightening experience.

Since Fromm-Reichmann sounded the alarm on loneliness, however, a substantial amount of research has been conducted on the condition and its effects on the human body and psyche. It turns out that loneliness is not just emotionally painful — it can also lead to sickness and possibly even death.

As Fromm-Reichmann maintained, being alone is not the same as being lonely. The difference lies in perception. Someone can be surrounded by people yet feel totally disconnected. Conversely, a person who spends a significant amount of time alone might feel perfectly complete.

In addition, transient bouts of loneliness are not uncommon; almost everyone gets lonely from time to time. But problems arise when loneliness comes to stay. Research conducted over the past few decades has shown that chronic loneliness poses a huge health risk. In a 2010 PLOS Medicine study, researchers found that chronic loneliness is as dangerous or more dangerous than other established risks to mortality such as smoking and obesity.

The specific negative effects of loneliness on health are myriad. As Cacioppo and Hawkley noted in their Annals of Behavioral Medicine study, “Social isolation plays an important role in health and longevity, in part through its association with poor lifestyle behaviors such as lack of physical activity.”

They went on to write that loneliness can increase the risk of depression, high blood pressure, high cholesterol, cardiovascular problems, cognitive decline and Alzheimer’s disease. Loneliness also increases cortisol and systemic inflammation and causes sleep difficulties.

All of these risks are compounded by the effect of loneliness on physical activity. According to a 2009 Health Psychology study, “Loneliness Predicts Reduced Physical Activity: Cross-Sectional & Longitudinal Analyses,” loneliness in middle-aged and older adults is an independent risk factor for physical inactivity. Loneliness also increases the likelihood that people will continue to be inactive over time.

The question is, what is at the root of modern-day loneliness? A significant amount of discussion — and a growing body of research — has centered on whether the Internet and online activity might be an important factor. The answer is … maybe. It depends. A 2013 report from the National Bureau of Economic Research, “What Are We Not Doing When We’re Online?” found that online activity is partially crowding out other leisure activities. Part of most people’s online activity does include interacting with others, but on the whole, we’re probably having less real-life social contact.

However, a 2009 study in the journal CyberPsychology & Behavior, “Loneliness as the Cause and the Effect of Problematic Internet Use: The Relationship Between Internet Use and Psychological Well-Being,” found that Internet use did not have a significant effect on most people’s levels of loneliness except for with those who were already lonely.

So perhaps technology’s loneliness effect is dependent on how someone uses that technology. Still, some counselors think that technology is actually changing the way we communicate, leading to a general social disconnect that increases loneliness.

All the lonely people

“I think modern society itself can cause certain kinds of disconnection,” says Everett Painter, an American Counseling Association member and college counselor at Walters State Community College in Morristown, Tennessee. The breadth and volume of information people receive from so many different sources can be overwhelming, notes Painter, who presented a session at the 2014 ACA Conference that examined the effect that social media and technology have on personal relationships.

His view is that processing this surfeit of communication requires substantial energy — energy we might otherwise spend engaging with friends and relatives and cementing the personal bonds that allow us to feel connected. While smartphones and social media outlets allow people to communicate on multiple platforms, many of those connections are virtual rather than face to face, and not always in real time. Online activity can also eat up a substantial portion of our workdays and leisure time, which may mean time away from the important relationships in our lives, Painter notes.

“For some people, online communication can replace face-to-face communication, and I think that we need that human connection for our health,” he says.

Gerald Opthof, an ACA member and licensed professional counselor (LPC) in the Morristown, New Jersey, area, agrees. Opthof, who specializes in addiction issues but also sees couples and individuals for a variety of other reasons, says that he has noticed a significant amount of loneliness in his client base. Like Painter, Opthof believes much of the loneliness he is seeing is related to the isolation and disconnection that online communication can cause.

“With social media, smartphones, the Internet, we are more in touch with what is occurring with others,” Opthof says. “However, we are not [really] connected to individuals. We don’t sit and talk. How many times are we at a restaurant and we see people at the same table all looking at their phones?”

Socializing online just feels easier and emotionally safer for some people. However, online activity can also function as a way to hide.

“When a client engages with people via social media forums such as Facebook, Twitter, Instagram, Snapchat and others, it keeps an emotionally protective barrier in place,” says Amy Lasseter, an ACA member and LPC in Athens, Georgia.

Lasseter says that loneliness has been “popping up” more and more frequently in her practice. In some cases, she says, social media use seems to cause clients to unintentionally start the cognitive process of comparing their lives to the lives of others. “This comparison can lead to an increase in feelings of failure and reinforce emotional distance, which may lead to greater emotional isolation,” she says. “It can become a dangerous cycle.”

For certain people, social media has also turned the idea of making friends and connections into a numbers game, complete with “winners” and “losers.”

“The Internet and social media have made it possible to connect with more people, which may have increased the expectation for some people that they should be connected to more people,” observes ACA member James Huber, a licensed marriage and family therapist in Reading, Pennsylvania, and an associate professor of counseling psychology at Holy Family University in Philadelphia. This can create pressure for relationship quantity over relationship quality, and if a person’s numbers are “low,” it might lead the person to feel lonely, Huber says.

This feeling of needing to measure up can extend to other parts of life. Lasseter, for one, thinks that excessive self-expectations are becoming more common in today’s clients. “[I’m] seeing an increase in the need for perfection and the fear of failure,” she says. “These things have formed a continuum, with perfection on one end and failure on the opposite end. As a society, we’ve forgotten that our species learns by doing and that we rarely get something ‘right’ the first time.”

As with the social media “life comparisons” that Lasseter notices clients engaging in, this fear of failure and need for perfection can lead to low self-esteem and isolation, which often lead to loneliness.

Of course, social media and technology-enabled communication are not the only causes or contributors to loneliness. But all causes seem to share a unifying theme: the lack of connection.

“We are always on the run,” Opthof laments. “People are working more trying to provide for their families, and there isn’t enough time to get things done and be everywhere we have to be. This keeps us isolated.”

Opthof notes that throughout life, people go through transitions such as graduating and leaving behind their social circles, experiencing the breakup of relationships and enduring the deaths of loved ones. These transitions can fragment old relationships and require forging new connections.

Making connections

The counselors interviewed for this article agree that the principal antidote for loneliness is connection — both with oneself and with others. Research supports this. In a 2011 meta-analysis published in Personality and Social Psychology Review, Cacioppo and colleagues identified four primary intervention strategies for loneliness: improving social skills, enhancing social support, increasing opportunities for social contact and addressing maladaptive social cognition.

To encourage clients to reengage and connect, Lasseter requests that they create a bucket list containing activities they’ve enjoyed in the past as well as other activities they’d like to try for the first time. The list might include anything from traveling to taking a pottery class to learning a new language.

“I also try to help clients identify how their emotional boundaries have kept them safe in the past and how they are helping [or hurting] them now,” Lasseter says. She asks clients struggling with loneliness to identify ways that they struggle with confidence and then encourages them to push beyond their current boundaries. “The bucket list is great for this because it is filled with things they already want to do,” she notes.

Similarly, Myrtle Alvarez, an ACA member and LPC in Florence, South Carolina, suggests that clients explore groups and activities that might be enjoyable to them, noting that this could include joining a book club or church group, doing volunteer work or even just walking dogs at the local shelter.

“I encourage my clients to create a new narrative for themselves. Sometimes the things we tell ourselves become self-fulfilling prophecies,” says Alvarez, who has noticed loneliness becoming a prominent issue among clients. Rather than dwelling on their loneliness or critiquing themselves too harshly, Alvarez instructs these clients to “speak kindness and encouragement [to themselves]. Speak gain and not loss. Others will see this and, who knows, you may attract another lonely person and find healing between the two of you.”

Of course, there is no one antidote to loneliness for clients. Reaching out and connecting is a very personal process.

Huber was counseling a woman in her 30s who had recently divorced. In the process, she had lost the connection not only to her ex-husband, but also to some of their mutual friends. The client was self-aware and realized she needed to form some new relationships, but the strategy she was using wasn’t working.

“[She] was trying to meet new people and potential dating partners by going to the popular local bars,” Huber recounts. “She explained that she really didn’t like to drink, and the bar scene made her feel even more lonely.”

When Huber realized this tack wasn’t appropriate or comfortable for his client, he prescribed a different way for her to form connections organically. Huber gave her a kind of mantra that he has found to be particularly effective for clients who are struggling with feelings of loneliness: “Pursue interests, not individuals.”

“She liked singing, hiking and reading,” Huber says. “So over the next month, she joined her church choir, went on the monthly Saturday morning group hike with a local trail club and started to volunteer at a learn-to-read adult literacy program. She began to enjoy her post-divorce life more and found herself less lonely and more confident when she did meet eligible men.”

Huber believes counselors need to tailor their approaches and strategies for each individual client rather than trying to prescribe a one-size-fits-all solution for loneliness. For example, he recalls another success story with a client who was quite different from the 30-something woman who had gotten divorced. This client was “a 16-year-old popular athlete with lots of friends, but he found himself alone at home watching ESPN on weekend nights because he chose not to go to underage drinking parties or hang out with peers ‘just looking for trouble,’” Huber says. “As he put it, ‘It can be lonely doing the right thing.’ The approach with him involved affirming his decision-making and using his existing strengths to build contingency plans for weekends.”

“Since he played football, we used the concept of ‘calling an audible’” — changing the “play” — “when he needed to find meaningful options when friends were engaged in undesirable activities,” Huber says. “He felt connected to others [when doing] service projects, so he began to participate in a program that involved visiting older adults, to walk the neighbor’s dog or to referee basketball at a local youth center when he needed alternative social connections.”

Huber says counselors might also consider using other techniques he has found useful for clients dealing with loneliness:

  • Reframe loneliness from being a “sign of a problem” to a “signal to change.” Huber validates the client’s feelings of loneliness but also encourages the client to use those feelings as the impetus to practice and utilize the skills he or she has learned in counseling rather than just giving up.
  • Focus on the client’s strengths, interests and efforts early and often. Huber discusses the client’s feelings of loneliness but expands the discussion with a verbal and written inventory of the person’s strengths and interests. Huber asks the client to consider scenarios in which he or she might potentially develop or may already have connections. These scenarios include groups and environments such as work, school, recreation networks and religious communities.
  • Describe therapy as an opportunity to practice relationship-building skills. “Practicing relationship skills in session involves identification, preparation and rehearsal of relevant skills in therapeutic role-playing,” Huber says. “For example, if the client is learning to initiate and maintain small talk when meeting new people, then we practice using these skills in a variety of typical social situations.” During these role-play scenarios, Huber and the client discuss behaviors that help people connect, such as showing interest, expressing care and respecting others. 
  • Explore the “loneliness paradox”: Not everyone who is alone is lonely; not everyone who is lonely is alone. Huber and the client dissect the paradox by discussing the difference between being alone and being lonely.
  • Define elements of “healthy solitude” versus default loneliness. “Healthy solitude is the choice to occasionally be alone [and] nourish mind, body and spirit,” Huber explains. “Loneliness is a feeling of being separated, isolated or disconnected from others without a choice.”
  • Shift the focus of treatment away from chronic feelings of loneliness and toward cognitive choices. In other words, work with the client on changing maladaptive thinking that can perpetuate loneliness by shifting the client’s perception of self and others. Huber helps shift the client’s negative perception of self by targeting automatic negative thoughts such as “It’s no use trying” or “Nobody would want to be with me.” He and the client work together to edit these habitual thoughts to instead create a mindset conducive to overcoming loneliness. For example, instead of dwelling on all-or-nothing or self-limiting thinking, Huber encourages clients to make statements such as “I could try several things to meet more people; some might work, some may not” or “I have some qualities that people may enjoy.”
  • Teach clients to rehearse and follow the three-step ACT mantra when they are feeling lonely:

Adjust your attitude. Instead of thinking, “Nothing will help,” try “Something may help with practice.”

Cultivate a connection: “Reach out to at least one person for support when practicing new skills,” Huber urges his clients. “You don’t have to go it alone.”

Try something tangible: “Analysis can lead to paralysis,” Huber says. “Instead of wondering about going to a cooking class, go to a class. Instead of thinking about calling a classmate, make the call. Instead of hoping you will be invited to dinner, invite someone for a meal.”

Opthof uses rational emotive behavior therapy and cognitive behavior therapy to help clients struggling with loneliness to reframe. He works with clients to get them to rethink their situations and look at them from a more rational view. He also encourages clients to confront their loneliness by engaging in other pursuits. Opthof enhances this work by encouraging clients to consider pursuing a whole-person, mind-body approach.

“I often spend a session with them discussing their diet, making sure they are eating as healthily as possible and encouraging them to get moderate exercise such as just taking a walk around the block,” he says. “I also recommend they look into yoga or meditation.”

Opthof also encourages clients to cut back on activities that distract and isolate. “The major tip that I give my patients is to cut back on the disconnection items — turn the phone off 30 minutes before going to bed, shut the phone off in the car, read email only a few times a day,” he says. “I encourage my patients, lonely or not, to focus on the here and now, [to] be in the moment. Often clients report that they feel less lonely when they try a few simple steps.”

Addressing loneliness also requires clients to foster a connection with themselves, says Marie Holland, an ACA member and LPC in Nags Head, North Carolina. She helps clients to increase their self-understanding by being mindful of their emotions. Holland also encourages the therapeutic relationship through validation. She lets clients know they are being heard by asking them questions and making it clear that she is open to whatever they have to say.

Holland has found group therapy helpful for uncovering and exploring self-esteem issues with clients. Often, low self-esteem can be at the root of an individual’s isolation and feelings of loneliness. In group, she says, clients feel safe revealing esteem issues because they are surrounded by people struggling with the same problems. Therefore, they feel less likely to be judged.

Holland also addresses clients’ negative self-image by helping them examine the self-judgments they make. She also guides them away from focusing on thoughts and encourages them to be aware of what they are feeling through mindfulness and meditation. In addition, Holland uses progressive muscle relaxation and guided imagery with clients.

Holland also uses an active approach to help clients combat loneliness. “The practice of role-playing with assertive communication skills is extremely helpful because it allows for the individual to experience success and gain confidence in their new skills,” she says.

Finding community

Although relying solely on technological sources for a social life can be harmful, clients can use online tools — particularly social media — to make new connections and strengthen old bonds.

People may even be expanding their social networks through social media by finding old classmates and long-lost friends. A 2011 Pew Research survey on social media found that Facebook users are more likely to have a larger number of close social ties. With that survey population, at least, Facebook seemed to encourage the development of intimate personal ties. The survey also found that people are increasingly using social media to keep up with their close friends; 40 percent of users have “friended” their core confidants.

Although it’s true that social media can be used to maintain or even enhance a person’s circle of friends, Opthof, for one, thinks people need to regularly get offline and make it a priority to interact with the people around them. Community is an important source of connection — one he feels we too often ignore in today’s society.

“When I walk around my neighborhood, there’s no one sitting on the front stoop or porch. We’ve gotten away from that. Now we all have decks,” he laments.

Opthof says he once enjoyed waving to people as he walked around, but now there’s nobody to wave to. All his neighbors are inside or behind the backyard fence — on their decks.


To contact the individuals interviewed for this article, email:



Laurie Meyers is the senior writer for Counseling Today. Contact her at

Letters to the editor:

Unhappy holidays: Helping clients through the ‘holiday blues’

By Bethany Bray December 17, 2014

The holidays are supposed to be the “most wonderful time of the year,” right? After all, the greeting cards and carols of the season are filled with words like “cheer,” “joy,” “merry” and “happy.”

For many people though, the holidays invite the opposite: dread, deep sadness or a resurgence of anxiety, grief or other mental health issues. Sometimes dubbed the “holiday blues,” the pressure of Gingerbread man cookie with frownfamily gatherings, gift giving, religious traditions and social commitments can be overwhelming.

Therapeutic issues that a client and counselor have been working on throughout the year are often magnified throughout the holidays, says Lauren Ostrowski, a licensed professional counselor (LPC) who works at a community counseling agency in Pottstown, Pennsylvania.

“I have some clients who are upset at the holidays, from Halloween through Valentine’s Day,” says Ostrowski, an American Counseling Association member. “Even New Year’s — it’s a time of new beginnings, and people notice what they don’t have, who’s not at the table and what they haven’t accomplished, and it perpetuates the whole cycle [of struggle].”

For counselors, the key to helping clients through this difficult time of year is to plan ahead and talk about the pressures of the season before they climax, agree Ostrowski and Christian Billington, a licensed marriage and family therapist candidate in Denver. Counselors can offer clients an array of coping mechanisms, from self-care strategies to the realization that they can’t please everyone.

Billington, an ACA member who specializes in grief, loss, couples and families, suggests that counselors work through anticipated stressors ahead of time, “like a rehearsal.”

“Preparation can be important if stressful family events are inevitable,” he says.

For clients who face tense family situations, Billington suggests counselors discuss and identify triggers with the client and develop an “exit strategy” for get-togethers ahead of time. Most importantly, he says, talk with the client to ensure they have a trusted person, such as a spouse, they can talk to and “debrief” with at short notice during the holidays.

Ostrowski says she will work with a client to create a “road map” plan for holiday events and traditions. This way, the client can see all the things they look forward to and use the happiness from those events to counterbalance those that are less enjoyable, she says.

She encourages clients to make sure the things they want to do – perhaps a tradition from their childhood or a favorite side dish for the holiday meal – are included on their road map. At the same time, she tells them they should not feel obligated to continue traditions they don’t like.

“I talk a lot about how it’s impossible to make everyone happy” at the holidays, says Ostrowski.

Janis Manalang, an LPC and owner of counseling centers in Sterling and Alexandria, Virginia, stresses that clients must learn to be honest with themselves and recognize their boundaries, particularly at this time of year.

Clients who like to please others should “learn to draw a line in the sand with families or friends so they do not feel obligated to do something with them or give gifts,” says Manalang, an ACA member who is working on her doctoral dissertation on counseling education and supervision at Argosy University. “It’s always best to be honest with what you can participate [in] … understand that there will be people that we can not control and accept that we can only control ourselves.”


Key takeaways for counselors about this multifaceted issue:


Missed appointments

Ostrowski says her rate of client no-shows and appointment reschedules spikes during the holidays. For clients prone to struggling this time of year, missing an appointment tends to make issues even worse.

When appropriate, Ostrowski says she will point out to clients that they said they needed help getting through the holidays but didn’t show up for their appointment. In other cases, she uses her office’s holiday closure as a way to bring up discussions about scheduling and ensuring that clients get as many sessions as they need.

Counselors should also make sure that clients have an emergency number they can call while the counseling office or clinic is closed for the holidays.


Travel and homecoming

Christine Forte, an ACA member and licensed mental health counselor in private practice in Shanghai, China, works to prepare her clients for the emotional impact of traveling home, often after being away for long stretches of time. In such situations, it’s important to remind clients that it is unlikely they will have enough time to see all the people and do all the things they’d like while home.

“What do they really want and what do they find it most important to spend their time on?” Forte asks these clients. “Be realistic in making plans, and allow time for rest and relaxation as well. One thing that I encourage is to be as clear as possible ahead of time to their families about what they will and won’t be able to do. Family and friends can expect that expats will simply slot back into life at home when they return at the holidays, but it simply isn’t the case.”


Family dynamics

If the idea of a family get-together with “feuding relatives” is too stressful, Billington suggests that clients keep them off the invitation list or consider hosting separate get-togethers so the client can avoid becoming the middleman or peacemaker.

Forte encourages clients to take a step back and simply observe when family friction arises. “Awareness can be a powerful tool toward change,” says Forte. “I encourage clients to step back and observe as much as possible. Observe the patterns, observe their family member’s behavior, observe how they tend to respond [to one another]. … [Clients] can’t control what their family members are doing, but they can control their own behavior and practice reacting or interacting in new ways.”


Grief or anniversary of trauma

The holidays can be especially hard for clients who have experienced a recent loss and those for whom the season marks the anniversary of a death, crisis or other trauma. Counselors should be intentional about checking in with clients who fall into this category, says Billington.

“Anniversaries and holidays can be harder when a loss has been experienced because someone or something is missing and things are not the same,” he says. “This can be particularly triggering. In the context of grief and loss, I encourage clients to be prepared for these triggers and discuss the surrounding anxiety, concerns and worries as a proactive approach to anticipating triggers, almost as a rehearsal.”

Ostrowski suggests that clients mourning the loss of a loved one involve that person’s memory in holiday celebrations, such as making and displaying an ornament that reminds the client of the deceased.


Avoidance doesn’t work

Even clients who make a deliberate choice not to celebrate the holidays will still hear holiday music and see decorations everywhere they go. Reminders of the holidays are unavoidable, says Ostrowski.

“I would much rather [that clients] say, ‘We’re not talking about Christmas until after Christmas,’ and we can work on other issues and have an alliance through the holidays, rather than [these individuals] just isolating themselves,” she says.

For those clients who go into “survival mode” between Thanksgiving and Christmas, Ostrowski has them focus on the fact that the Christmas tree won’t be up for the entire year, the season will pass and there are new times ahead.


Client self-care

Self-care can be one of the most important coping mechanisms for clients during the holidays. This can range from small interventions such as breathing and relaxation techniques to more intensive methods, such as taking a trip away.

Ostrowski worked with one client to help her plan a special day of her own in the middle of the holidays, complete with activities she enjoyed and a favorite meal. Having a special day to look forward to helped offset the stress she felt around the rest of the season, Ostrowski says.

Another intervention Ostrowski suggests for clients is a gratitude journal – an idea she got from Liana Lowenstein, a well-known Canadian social worker. The client records one positive thing or event that happens each day. Ostrowski has clients start the journal before the holidays, when the weather is warmer and the days are longer. During the holidays, clients can then flip back to the start of the journal to remind themselves of a less stressful time.

For clients who feel an increase in depression or anxiety as the weather turns colder and the days become shorter, Manalang recommends the use of a light therapy lamp.


Loneliness and homesickness

Self-care in the form of planned activities can also help clients who are lonely or far from loved ones through the holidays.

Volunteering and participating in community events can be a powerful and rewarding intervention for clients who are lonely, says Billington. He also suggests that clients make a “plan of action.”

“For example, making a list of things the client likes to do, and if the loneliness birds come home to nest, the client can refer to the list and undertake some of these activities,” says Billington. “Taking a trip away can also palliate some of the symptoms of loneliness.”

With clients who cannot travel to see family or loved ones, Forte stresses the importance of preplanning local get-togethers and outings.

“Especially if it’s the first time they’ve spent the holidays away, it can be a time of really strong homesickness,” she says. “I always encourage people to make plans in advance with people from their community who will be around or on their own at Christmas. Having a fun day with friends or a meaningful day doing some type of community service can help to mitigate the sadness that might otherwise be there. I’ve found this helps a lot personally in years that I had to spend Christmas away from my family, and I’ve also found that having the plans in advance helps to dissolve some of the negative anticipation. It won’t be the same as being home with family, but it could be more fun than they think.”


Gift giving

The pressure of holiday gift giving can be a major stressor for some clients, especially if they have limited income.

The task of giving gifts and, in turn, pleasing the recipients can be tied to self-worth, notes Ostrowski.

Billington says he reminds clients that “the objective of any gift is thoughtfulness. … Helping clients understand the thought behind gift giving can help alleviate some of the stress and pressures of this ritual. In fact, making time in a session for a client to practice some art/craft therapy can be a good way to have fun, learn more about the gift recipient and the client’s world, and create a thoughtful gift.”


Talk about the holidays year-round

Ostrowski says she asks new clients if the holidays present a challenging time for them at intake, no matter what time of the year it is. “If you find out the week before Christmas, it’s kind of too late,” she says.

Asking clients about their mindset related to the holidays is comparable to asking them about their sleeping habits as they start counseling, Ostrowski says.

“You find out they’re not sleeping [that way], and they would never volunteer [that information],” she says. “This is the same thing. Clients don’t often tell me without my asking whether the holidays are a difficult time or not.”


On the other hand …

The holidays can also be a client’s favorite time of year. In such cases, a counselor might help the client remember this happy season at other times of the year when he or she is struggling.

“Remember that [the holidays] won’t always be negative [for clients],” Ostrowski says. “The key is to discuss it.”




Related reading


Ostrowski recommends this page of resources from Psych Central (which she also distributes to clients who struggle during the holidays):


From See the Triumph, a blog, social media and research project started by two counselors and ACA members about issues of domestic violence:


Tips for managing the holiday blues from the National Alliance on Mental Illness:


ACA Counseling Corner article: Holiday depression: Fixable and something not to be


Tips from the American Foundation for Suicide Prevention:




Bethany Bray is a staff writer for Counseling Today. Contact her at


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America’s mental health disparities

By Bethany Bray December 11, 2014

When it comes to mental health care, how does your home state rank?

The advocacy organization Mental Health America (MHA) recently compiled a state-by-state ranking of mental health indicators nationwide.

The 50-page report exposes disparities across the United States, not only in the availability of mental health services but also in the number of uninsured individuals, the overall prevalence of mental illness, the frequency of drug or alcohol addiction, the number of suicide attempts and other factors.

MHA weighed a state’s prevalence of mental illness against its availability of mental health care to Rank Map_w_wordscompile an overall ranking. The states that rose to the top of this list are in New England: Massachusetts, Vermont and Maine. Conversely, the worst-ranked states are Nevada, Mississippi and Arizona.

For the report, MHA compiled mental health information about residents of all 50 states and the District of Columbia, culling data from numerous surveys, including the Substance Abuse and Mental Health Services Administration’s National Survey of Drug Use and Health and the National Survey of Children’s Health.

Some highlights of MHA’s findings:

  • The top five states based on the lowest prevalence of mental illness and the highest rates of access to care are Massachusetts, Vermont, Maine, North Dakota and Delaware.
  • States with the highest prevalence of mental illness and lowest rates of access to care are Arizona, Mississippi, Nevada, Washington and Louisiana.
  • Across the United States, the average rate of adults who are mentally ill and also uninsured is 3.5 percent. The best-ranked states in this category are Massachusetts (0.9 percent prevalence), Connecticut (1.4 percent), Hawaii and Vermont (both 1.5 percent), the District of Columbia (1.6 percent) and Delaware (1.7 percent). The states with the highest percentage of mentally ill adults without insurance are Alabama (6.3 percent), Mississippi (5.6 percent), Utah (5.5 percent) and Idaho (5.4 percent). Arizona, Nevada and West Virginia were next on the list, all with 5 percent prevalence.
  • States with the highest rates of access to mental health care are, in order, Vermont, Massachusetts, Maine, Delaware and Iowa.
  • States with the lowest rates of access to mental health care are, in order, Nevada, Mississippi, Alabama, Louisiana and Texas.
  • The highest rates of emotional, behavioral and developmental issues among youth occur along states just to the west of the Appalachian Mountains. This area also has some of the highest rates of poverty and social inequality. However, this area also shows some of the lowest rates of substance use among youth.
  • The average rate of adults with dependence on alcohol or illegal drugs across the United States is 8.46 percent. Compared with this average, the District of Columbia, Rhode Island and Montana are the three worst-ranked states, with 13.78 percent, 10.91 percent and 10.38 percent prevalence, respectively. The top-ranked states are Alabama (6.58 percent) and Utah (6.79 percent).
  • The states with the highest rates of youth with emotional, behavioral or development issues are Kentucky, the District of Columbia, Arkansas and Maine; the states with the lowest rates are Alabama, South Dakota, Colorado and Utah. Across the United States, the average percentage of youth with emotional, behavioral or development issues is 8.5 percent. Kentucky’s percentage (13.95) is more than double that of Alabama (6.87 percent).
  • New Mexico, Washington, Oregon and Utah had the highest prevalence rates of “youth with at least one major depressive episode,” while the District of Columbia, North Dakota, New York and New Jersey had the lowest rates.


MHA’s report, titled Parity or Disparity: The State of Mental Health in America 2015, was released earlier this month and is available at

“This report paints a picture across the entire nation of both our mental health and how well we are caring for the people who need assistance,” said Paul Gionfriddo, MHA CEO, in a press release. “Sadly, disparity – more than parity – is the rule.”

Founded in 1909, MHA is a nonprofit based in Alexandria, Virginia, with 240 community affiliates across the nation.





Bethany Bray is a staff writer for Counseling Today. Contact her at


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