Monthly Archives: April 2016

The tangible effects of invisible illness

By Cathy L. Pederson and Greta Hochstetler Mayer April 26, 2016

A variety of invisible illnesses can greatly impact both the physical and mental health of individuals. Some of these illnesses are debilitating, preventing participation in the normal activities of daily living. Examples include chronic fatigue syndrome/myalgic encephalomyelitis, Ehlers–Danlos syndrome, fibromyalgia, lupus, Lyme disease, multiple sclerosis, myasthenia gravis, postural orthostatic tachycardia syndrome (POTS), regional complex pain syndrome and Sjogren’s syndrome.

These disorders disproportionately affect women and are not well understood by the health care Branding-Images_invisibleestablishment or the general community. Lack of understanding can lead to feelings of alienation and hopelessness for those suffering from these disorders.

Such was the case for Natalie (case study used with permission). Seemingly overnight, she transformed from a vivacious teenager at the top of her eighth-grade class to being virtually bedridden with fatigue, dizziness and chest pain. She visited a series of doctors in search of relief. A few months later, at age 15, Natalie’s life changed forever when she was diagnosed with POTS and Ehlers–Danlos syndrome, neither of which is curable or easily managed medically.

POTS is a disorder of the autonomic nervous system in which blood pressure, heart rate, blood vessel and pupil diameter, peristaltic movements of the digestive tract and body temperature are affected. Natalie’s Ehlers–Danlos syndrome caused additional pain — her connective tissues were weak and her joints would easily dislocate. During her freshman year of high school, Natalie was bound to a wheelchair. But as a sophomore, her dizziness and other symptoms were better controlled, so she went roller-skating with friends. She broke her wrist and injured her neck that evening, and her fall triggered debilitating migraines.

Although not widely studied, rates of suicide are believed to be higher in people with chronic or terminal illness. It is unclear if physical illness alone leads to risk of suicide or whether having an illness increases the chances of developing depression or hopelessness, which then increases suicide risk.

Painful, chronic illnesses and illnesses that interfere with a person’s everyday functioning are believed to be risk factors for suicide, especially among older adults. Some illnesses associated with increased suicide risk are AIDS, certain forms of cancer, Huntington’s disease and multiple sclerosis.

Risk of suicide is often linked with co-occurring mood, anxiety and substance use disorders in this population. However, people with invisible illnesses may not necessarily be clinically depressed or anxious; instead they may feel hopeless about their prognosis, experience real and anticipated future losses, and suffer from chronic pain — all of which are potent risk factors for suicide. The basic science of these individuals’ physical condition is not well understood, which makes developing medications to treat them difficult. Most treatments are aimed at individual symptoms rather than the root cause of the problem.

It takes Natalie three times more energy than normal just to stand because of her POTS. Even making minor movements around the house and engaging in daily routines, including eating meals and showering, can be exhausting for her and increase her symptoms. Her quality of life is similar to those with congestive heart failure or chronic obstructive pulmonary disease.

At 16, Natalie endured weeklong hospitalizations for headaches and other POTS symptoms. Medications didn’t offer relief. An honor student, Natalie missed more than 70 days of school during the last half of her sophomore year. She was no better by the end of her junior year and eventually dropped out of high school. She was behind in her work and struggled to complete projects and tests that would have been easy for her when she was healthy. “It was heartbreaking,” said Natalie’s mother about seeing her daughter transform from high achiever to high school dropout.

Natalie’s family had done everything right. They took her to see physicians, followed all prescribed treatment regimens, put her in counseling and supported her through her illness. Unfortunately, medical help was evasive and mental health care was marginal. Over time, Natalie’s friends drifted away. She couldn’t be physically active, participate in community events or hold a job. Eventually, she confronted insidious suicidal thoughts.

Working with those who are chronically ill

Many chronic illnesses are not terminal conditions, but they can severely impact a person’s quality of life for decades. For example, imagine that you have POTS. You feel lightheaded every time that you stand, and you faint several times per day. You experience neuropathic pain that feels like bees stinging your arms and legs. Hot flashes arrive without warning, and you begin to sweat. Despite possessing above-average intelligence, you have difficulty concentrating and analyzing problems. Simply taking a shower drains your energy, and it doesn’t replenish itself. Your physical isolation and illness create feelings of being misunderstood and not belonging.

These feelings only increase when you finally venture out of the house. People congratulate you on your “recovery.” Friends tell you how good you look. Distant relatives offer advice about how to get better. Even worse, you are bullied, called a faker or are the target of other derogatory comments. Your boss suggests that you would feel better if you only ate right and exercised. Even your spouse says, “Just get over it!”

Counselors should not fall into these traps when working with these clients. For someone who is chronically ill, even hearing “you look good” might be equivalent to “I don’t believe that you are really sick.” Normal niceties take on special meaning and ring hollow for those with chronic illnesses.

For most people, a doctor’s visit will result in control of their illness and restoration of their health. This isn’t true for many individuals suffering from chronic, invisible illnesses. Not only are they grieving their loss of health because of their physical condition but, often, they also feel dismissed and even traumatized by their health care practitioners.

Many with chronic illness feel ignored or abandoned by doctors and nurses. Some individuals have even been told to stop fainting or to bring down their heart rate, as if they are making choices meant to curry attention. Many physicians aren’t educated about these debilitating illnesses, and specialists in these fields often have waiting lists that are years long. Imagine how such repeated, negative experiences might erode hope for recovery and lead to suicidal thinking. What is a patient to do? In the case of those with POTS, the incidence of mental illness is the same as is found in the general population. The seemingly paranoid behavior these individuals demonstrate related to their health can be the result of medical mistreatment and neglect, and it is often justified and understandable.

Sadly, invisible illness can put even the strongest relationships in jeopardy. As days turn to months and years, the constancy of chronic illness can wear on marriages, friendships and family relationships. Missed holidays, birthdays and other social events leave loved ones feeling betrayed and wondering if the person who is chronically ill could make more of an effort to be present. Friends and family members often doubt whether their loved one is sick. Some acquaintances become confrontational with the person who is chronically ill, whereas others turn passive-aggressive. Because a person’s hair doesn’t fall out with chronic fatigue syndrome, no skin lesions appear with multiple sclerosis and no significant weight loss takes place with fibromyalgia, it is easy to forget the internal battles being waged every day by those with chronic illness.

Counseling professionals are well-positioned to address the fallout of living with chronic illness. Counseling can provide something that those with chronic illness who are feeling suicidal desperately need but are often missing — a safe place where they can be heard, validated and comforted. Most important, counselors are particularly skilled at uncovering suicide risk, advocating for underserved populations and providing clinical management of complex cases.

In Natalie’s case, she was depressed from grieving her loss of physicality, friends and school. She had found some relief through the use of an antidepressant and went to counseling regularly. In the midst of a flare, her physician switched Natalie to Prozac, which she had taken previously, without considering the fact that it might increase suicidal ideation in teenagers. Natalie never mentioned the suicidal thoughts to her family or doctor. Shortly after titrating to 30 milligrams, the 17-year-old attempted suicide.

Consider physical illness part of the problem

Many people with debilitating and invisible chronic illnesses are told that it is all in their heads. As a counselor, you may be the first person who truly listens and tries to understand what is happening in the individual’s life. Don’t be afraid to suggest that someone who has especially dry mouth and eyes (Sjogren’s syndrome), fainting episodes and difficulty thinking (POTS), debilitating fatigue that can’t be attributed to known causes (chronic fatigue syndrome/myalgia encephalomyelitis, POTS, fibromyalgia, lupus) or chronic pain (complex regional pain syndrome, fibromyalgia, POTS) should get a thorough checkup with a good physician.

Consider working collaboratively with these physicians as a multidisciplinary team. Recommend someone who is a knowledgeable problem-solver to investigate underlying physical causes for the person’s anxiety or depression. In addition, assess regularly for suicide risk, especially during transitions in levels of care, and take all warning signs and risk factors seriously. Labeling a person’s symptoms as part of a recognized disorder will often be a great relief to the person psychologically.

Physical limitations and their effect on counseling

As a result of chronic illness, routine activities can cause debilitating fatigue. Standing, walking, showering, riding in the car and even attempting to focus on a conversation can quickly exhaust those with chronic illness. As their fatigue increases, brain fog also tends to increase.

As counselors, it is important to understand and recognize the effort it takes for these clients to walk through your office door. Offering small encouragements will reinforce the proactive effort they have taken to maintain their mental health and improve their quality of life.

Also note that many people with invisible illness are particularly sensitive to light, noises and smells. This is particularly true when they are flaring. Simple gestures such as closing the blinds or turning off fluorescent lights may help them conserve their energy for their work with you. Similarly, avoiding the use of candles, strong scents or incense can be helpful.

Differentiating the physical from the psychological

When working with clients who are chronically ill, differentiating their physical issues from their psychological issues can be difficult. Consulting with knowledgeable health care specialists is essential. Taking the time to learn about a client’s chronic illness can greatly increase empathy, provide authentic understanding and help in guiding the person to proper medical care.

Counselors should be aware that the coping skills people use to deal with symptoms of chronic illness can look like warning signs for depression or suicide. For example, coping skills to manage many invisible illnesses, such as staying in bed and avoiding the shower, may be unrelated to depression or risk of suicide.

In addition, dysregulation of the autonomic nervous system causes surges of norepinephrine that can lead to insomnia, anxiety or panic attacks. A person’s lack of appetite can be related to gastroparesis (paralysis of the stomach) or other digestive motility issues. Debilitating fatigue and difficulty focusing/concentrating are also common problems connected to many invisible illnesses.

At the same time, it is important to remember that individuals with chronic illnesses that involve functional impairment and chronic pain are at greater risk for suicide, so warning signs such as suicidal thoughts and threats, previous suicide attempts and hopelessness must be taken seriously. In Natalie’s case, she had confided her suicidal thoughts to her counselor. Unfortunately, her parents and doctors were unaware of the extent of Natalie’s overwhelming emotional pain until she attempted suicide.

Follow-up care after hospitalization is critical

Pursuing inpatient hospitalization for people at serious risk of suicide can be a life-saving step. However, the current health care environment poses challenges to accessing timely, quality care when needed, even for those at imminent risk for suicide. Inpatient stays are difficult to secure, and lengths of stay are minimal at best.

Individuals often transition from an inpatient level of care to outpatient settings before their stabilization, and this is not easy for individuals with chronic illness or their families. In addition, being hospitalized for mental health problems can be further stigmatizing and demoralizing for the person with chronic illness.

The period immediately following hospital discharge is particularly dangerous for people at risk for suicide. Counselors operating from a multidisciplinary framework can mitigate this risk (with permission of the person with chronic illness) by coordinating care with hospital staff, medical specialists and key family members.

Providing continuity of care also helps with stabilization, engagement and retention in aftercare. Long-term counseling is necessary to strengthen the person’s reasons for living and to uncover the problematic situations and underlying psychological vulnerabilities that led to the suicidal crisis.

“After 12 inpatient days and nine partial hospitalization days, I’m starting to feel confident that she is on the road to recovery,” Natalie’s mother reported. Natalie’s medications were changed, and she passed the GED test in lieu of her high school diploma. She is now on the road toward college. We hope that sharing her story can help to prevent suicide attempts in other young adults with chronic illness.

 

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Cathy L. Pederson holds a doctorate in physiology and neurobiology. She is a professor of biology at Wittenberg University and founder of Standing Up to POTS (standinguptopots.org). Contact her at cpederson@wittenberg.edu.

Greta Hochstetler Mayer holds a doctorate in counselor education and is a licensed professional counselor. She is the CEO and initiated suicide prevention coalitions for the Mental Health & Recovery Board of Clark, Greene and Madison Counties in Ohio. Contact her at greta@mhrb.org.

Letters to the editor: ct@counseling.org

 

Nonprofit News: How to make money in states that allow discrimination

By “Doc Warren” Corson III

In many states within this nation of ours (I’m talking the USA, folks), laws are being passed that support the right of the shopkeep, counselor or business owner to deny service to those whom they find objectionable, so long as these objections are based on religious or personal conviction. Run-of-the-mill “isms” such as racism and sexism are still found to be objectionable, but if they are blanketed in “deeply held religious convictions” or, in some areas, “deeply held personal convictions,” then they are protected in some states regardless of a profession’s codes of ethics, not to mention morals and decency.

Originally, I planned to make the ACA (American Counseling Association) Code of Ethics the cornerstone of this column. I painstakingly reviewed the ethics code for information related to counselors working with individuals who are different from (or hold different beliefs than) the counselor. In fact, I used this information as the basis for a presentation I gave recently at the ACA 2016 Conference in Montreal. The presentation was titled “Counselor, Get Over Yourself.” In doing the research, it was fascinating to me that one cannot get past the ACA Code of Ethics Preamble before reading that it is not about the counselor but rather about those whom we serve that matters.

Even so, being a pragmatic fellow, I abandoned this argument because it appeared to me that folks who support such laws might simply disregard the counseling profession’s code of ethics — as the laws had. State law trumps ethics. No, really, it does; it says so in the ACA Code of Ethics. You know, the one that some counselors are not following.

Of course, just because a law says that you MAY discriminate does not mean that you have to. For those counselors who choose not to discriminate despite having a practice in those states that allow for it, I’d like to provide some thoughts on ways to make a TON of money (and a lot of difference to those in need).

First, find a sign maker in your area and get the biggest sign that you can afford and that zoning regulations will allow. Keep it simple. Something like “Welcome, ALL ARE EQUAL here.”

That should do the trick. Plant that sign at every entrance to your practice and let the world know that you get it — that it IS about your clients and that you will show them the unconditional positive regard 12966372_10209197557926071_690134338_nthat Carl Rogers spoke of throughout his career. Consider taking a picture by the sign and putting it on your Facebook page, professional website and other social media venues. Send out press releases showing that you are a clinician for the people — ALL people.

Now that you have your sign up, be prepared for some backlash. Sure, some folks may call your office to tell you that “it’s Adam and Eve, not Adam and Steve!” And a few folks may call, email or post that you are the bigot because you are trying to deny them their “God-given right” to condemn, scorn, deny and otherwise marginalize the already marginalized. Treat them with kindness too. I typically simply say, “I’m not trying to change you, my friend. I’m simply letting the world know that ALL are welcome here, including you. Perhaps you’d like to make an appointment to discuss this anger of yours?”

Yes, many a dial tone has followed that sentence, but I’ve also had some powerful sessions with some folks who started off totally angry with me and my profession.

As an inclusive clinician, you will work with folks whose thinking is totally different from your own. To me, that’s the cool part! We are in a field that can teach us while we are getting paid. We can learn about those who are different from us, and they can learn from us as well. It really can be a win-win situation if we allow it to be.

So, you have your sign, you have your sites, you have your press releases in hand, and people are starting to respond. Many will respond favorably, depending on where you are, of course. Some of those giving you a positive response may ask you to speak at equality-based events or write something for their newsletters and other printings. You likely will find a new demographic or at least an increase in a demographic that might not have been part of your practice before.

Nicknames may follow. Some groups have referred to me as the “gay doctor” or “the fetish doc” (meant by them as a compliment, I assure you). When I mentioned to one particular group that I am heterosexual and was thus confused why I was known to many as the “gay doctor,” the group replied, “That means you are safe to work with. Our association members have been told that they can go to you without harassment or condemnation. You ARE the gay doctor because you are the safe and accepting doctor.” The fetish community said much the same thing with a minor twist: “You may live vanilla, but you don’t condemn those who like some flavor.”

I’m often amazed by how many of these minority groups can be so open and accepting of others with divergent viewpoints while they themselves are facing so much anger. We as a society can learn so much from them.

But if I can’t get you to do the right thing based on ethics or morals, perhaps you will consider doing the right thing for monetary reasons. All people have money to spend on services, even those who are (gasp) different from you. This is one of the few times that simply caring about others can also be very profitable.

Take my charity. It was founded in 2005 with a very clear goal in mind, which was simply to do good. There were no plans for expansion or adding staff. It was meant to be an old-fashioned one-doc office. That’s it, nothing more. I began seeing clients in 2006.

Then the community got involved. Within months, I was inundated with potential clients and found myself working over 100 hours per week (even with an unlisted office number) and still turning folks away. Over the years, we added to our original office. Then we bought a farm to house our therapeutic farm program. We have had as many as six clinical interns at one time and have recently started hiring licensed professionals to help with the onslaught. I can only imagine what we might be able to do if we ever advertised.

You have a choice here. You can let oppressive laws enter your practice, or you can follow your morals and the ACA Code of Ethics. As for me, I’ve found acceptance to be a wonderful thing.

 

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Dr. Warren Corson III

Dr. Warren Corson III

“Doc Warren” Corson III is a counselor, educator, writer and the founder, developer, and clinical and executive director of Community Counseling Centers of Central CT Inc. (www.docwarren.org) and Pillwillop Therapeutic Farm (www.pillwillop.org). Contact him at docwarren@docwarren.org.

Salutogenesis: Using clients’ strengths in the treatment of trauma

By Debra G. Hyatt-Burkhart and Eric W. Owens April 25, 2016

Mark was 16 when he found himself in a youth detention facility again. The reasons for his incarceration aren’t necessarily important; he had committed plenty of crimes in his life. His past actions came as no surprise. His father had been incarcerated for the entirety of Mark’s life. His mother was addicted to methamphetamines and often prostituted herself to pay for her addiction. Mark had been physically, emotionally and sexually abused throughout his life. He had also watched as his cousin was shot and killed.

Branding-Images_SalutogenesisMark had been in and out of the Child Protective Services system since the age of 2 and the criminal justice system since he was 12. Mark was often defiant and oppositional when he was in placement or incarcerated. Yet again, Mark’s counselor was asking him why he kept fighting with staff and losing privileges. In a defiant, yet blunt, sad and hopeless way, Mark responded, “There’s nothing anyone can do to me in here that can hurt any worse than what people have done to me out there. They’ve got nothing on me.”

It’s easy to assume the worst from that statement. We can look at Mark’s history of trauma and conclude that he will likely never break the cycle. It’s also easy to assume that “out there” means society and “in here” means prison.

But what if we reframe Mark’s words? What if we step away from our assumptions about trauma and its effects and instead view Mark’s past as a gift of sorts? If Mark points to his chest when he says “there’s nothing anyone can do to me in here …” does this dramatically change our understanding? “In here” can just as easily mean within Mark as outside of him. After surviving everything that had happened to him out there, Mark could certainly survive in here too. Perhaps Mark could find strength from his past and learn from it.

The concept of posttraumatic growth is an important one. If we assume from what Mark said that his path is predetermined, then we are not very well-equipped to help him foster change. From the counselor’s perspective, if the belief is that Mark continually engages in self-defeating behaviors and doesn’t think things can ever change, all we see is resistance to the counseling process. We don’t see the attempts at self-preservation and the potential that Mark has; we see a defiant, angry, wounded young man who doesn’t want his life to be different. But if we look at Mark’s words and behaviors through a different lens, maybe we can help Mark see himself through that lens as well.

Pathology of the profession

Treating trauma has become an increasingly important aspect of the counseling field. Clinicians can quickly point to the symptomology in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and assign a diagnosis of acute stress disorder, posttraumatic stress disorder (PTSD) or reactive attachment disorder. Ongoing research has helped us to make major strides in explaining how the body reacts to trauma and how brain function changes after the experience of a traumatic event. Gone are the days of referring to someone as “shellshocked.”

Now we also recognize that trauma isn’t necessarily the result of a one-time, catastrophic event. Instead, trauma can be cumulative, and mental health professionals have even established labels such as Type I and Type II trauma to help clarify the distinction between catastrophic and ongoing exposures.

However, in a race to count symptoms and assign diagnoses, we may forget that trauma is best defined by the client’s experience. That is, if the client believes that he or she has experienced a traumatic event, then the reality is that the client has experienced a traumatic event.

A larger question may be, what has all of the attention on trauma done to the counseling profession? Rooted in a wellness model that focuses on holism, the profession of counseling attempts to set itself apart from its counterparts in psychology and psychiatry. The notion of professional counseling was, and hopefully still is, to focus on a client’s strengths as a pathway to mental health. Although understanding symptoms and diagnoses is increasingly important in the world of managed care, a diagnosis born of a set of symptoms does not necessarily drive the most effective treatment strategies.

Yet the focus on client strength has become less important in our daily work. When we conduct an intake for a client who has experienced a trauma, what do we look for? It’s common practice to focus on the client’s symptoms and daily struggles, but not as common to delve into the positives the client brings to therapy. The words we use and the questions we ask send critical messages to our clients, especially those whom we are meeting for the first time.

How many pages of most intake forms are devoted to pathology as opposed to strength? When we do ask about client strengths, too often it is not so that we may later return to those strengths in our work, but rather so that we can demonstrate to someone else that we completed the brief section of the intake form that asks about them.

When a client such as Mark tells us his story, too often we immediately make conclusions about his functioning and prognosis. In an effort to avoid “retraumatizing” a client, we may intentionally sidestep important client data. Does our concern about retraumatization translate to an assumption that the client is fragile and must be handled with sympathy or even pity? It seems counterintuitive to assume that Mark is fragile after everything he has survived.

None of this discussion is to imply that trauma isn’t serious and shouldn’t be treated as such. The experiences that our clients bring to therapy are often horrific, and there is simply no other word to describe them. The wellness perspective of professional counseling is rooted in the notion that we must respect the client’s experience and should meet clients where they are. What we are suggesting here is not a “you’re fine, it’s not a big deal” approach to treating trauma. Quite the contrary, appreciating the traumatic experience of the client and empathizing are characteristics critical to successful outcomes.

However, the very forces that have shifted our professional focus toward pathology and symptomology may very well assist us when it comes to moving back to our profession’s roots. Our goal is to move away from pathology and toward solution-focused, strength-based approaches to the treatment of trauma. These approaches not only benefit our clients by respecting autonomy and resilience, but they also benefit our profession by keeping us true to our historic roots.

Salutogenesis

As we attempt to reconcile the horrors of trauma with a model based in wellness, strength and holism, we are brought to the work of medical sociologist Aaron Antonovsky. Antonovsky defined health as more than a dichotomy of sick versus well. Instead, he argued that physical health exists on a continuum, and that wellness is more than simply the absence of illness or disease.

Antonovsky sought to discover why people who are exposed to the same stressors may have very different outcomes related to physical health. Although stress is ubiquitous, Antonovsky noticed that disease is not, and he sought answers as to why that is. In the process, Antonovsky developed the term salutogenesis, which comes from the Latin salus, meaning health, and the Greek genesis, meaning origin.

If salutogenesis is the origin of health, what does this term mean for professional counselors? Simply put, as counselors, it is important for us to examine what it means to be mentally and emotionally healthy. It means that mental health is not merely the absence of mental illness, as defined by the deficient symptomology described in the DSM-5, or, worse, being defined as subsymptomatic due to having an inadequate number or severity of symptoms. Instead, salutogenesis in counseling suggests that mental health exists on a continuum between asymptomatic and diagnosable mental illness. Salutogenesis suggests that mental health is more than simply lacking a diagnosis. Instead, mental health incorporates a holistic vision of the self. It is, in fact, the essence of the counseling profession.

Furthermore, salutogenesis captures the notion that many people may be exposed to the same stressor yet experience different outcomes. Again, stress is ubiquitous, but mental illness is not. Three passengers may be riding in a car that is involved in a severe accident. All three passengers experience the same accident and may have similar physical injuries yet still experience vastly different psychological results. One passenger may experience acute PTSD, whereas another might simply have a nervous reaction when hearing the squeal of tires. The third may become a race car driver without so much as a second thought concerning the accident.

Salutogenesis examines the factors that individuals possess that help them overcome stressors such as traumatic exposures. Furthermore, salutogenesis examines why one person may define an experience as traumatic while another person does not. In this, Antonovsky’s work intersects with that of Urie Bronfenbrenner, who discussed risk and protective factors. Risk factors are those that may disrupt one’s developmental processes; protective factors are those that mitigate risks.

Bronfenbrenner described human development as a process inexorably tied to the influences of the systems in which a person functions. He described far-reaching influences, such as world politics and societal norms, and influences that are close to home, such as family dynamics and peer relationships. Because every person has a different set of systems, every person experiences the interaction between himself or herself and his or her environment in a different way. It is these differences that create our individual perceptions of events and our unique sets of risk and protective factors. As counselor clinicians, the questions become how we can use these unique experiences and characteristics to promote wellness, and how we can help our clients return to wellness should they experience a traumatic event.

A shift toward strength and growth

Antonovsky examined wellness through the notion of “sense of coherence,” which is a construct that helps us connect mental wellness to systemic influences, risk and protective factors, and individuals’ perceptions. Sense of coherence is really about meaning making. It is about the degree to which people believe they have what it takes to understand the world around them (comprehensibility) and possess the resources and skills to meet the challenges of that world (manageability), and that these challenges are worthy of the efforts to surmount them (meaning). When these three factors align from a position of strength, mental wellness is likely.

Let’s return to our example of the three individuals in the car accident. Each person experienced this event in his or her own way, and each made sense of it in a unique manner. Perhaps the person with acute PTSD was unable to manage the stress presented by his injuries or the emotionality of the accident. Maybe another passenger ruminated on concerns that such an accident could happen again and worried that she wouldn’t be able to handle it happening again.

There are no clear answers, but what is evident is that the passengers who experienced ongoing stress reactions were not able to make sense of the event or find the resources within to meet the significant challenges of the experience. These passengers experienced a diminished sense of coherence. But one of the great things about human beings is that we are continually experiencing growth and change. The circumstance of a lack of diminished sense of coherence isn’t necessarily permanent.

As we look at our work with people who have experienced trauma, like the people in the car accident, we can use a focus on sense of coherence to promote a return to wellness. Helping clients gain an understanding of their experiences and assisting them in finding their inherent strengths shifts our work as counselors into a salutogenic approach. We can validate the trauma while putting the experience in a context that allows clients to see their own potential. We can nudge them toward creating an inner narrative that places them in a position of strength and power over their experience. We can focus on changing the “why me?” to “why not me?” We can help clients look at the protective factors and unique strengths they possess that have helped them survive thus far. Because on whatever level, if they are in your office, they have been surviving. When clients can find those strengths, we can help them move beyond surviving to thriving.

Humans are resilient by nature. When we look at the statistics regarding how many of us will experience a traumatic event, the numbers are pretty grim. Using a broad definition of trauma — one that validates that trauma is in the eye of the beholder — nearly all of us are likely to have some traumatic exposure. Yet those who suffer from acute stress reactions as a result of such exposure are generally believed to be less than 20 percent. In other words, recovery and resilience are normative. In fact, a growing body of work is focused on the experience of growth after and as a result of traumatic experiences.

In their work, Richard Tedeschi and Lawrence Calhoun have been exploring the ways in which people grow from negative experiences. We are all likely familiar with someone who has grown from a negative event. Maybe a loved one survived a potentially terminal illness that created in them a mentality of “life is short; carpe diem!” Perhaps an accident promoted awareness that life is fragile and that the most important things are relationships with loved ones.

Tedeschi and Calhoun identified five domains in which such posttraumatic growth is likely to occur:

1) Changes in the perception of the importance of relationships

2) Increases in spirituality

3) An increased sense of self and personal strength

4) A broadening of the sense of possibilities for one’s life

5) Increased appreciation for life

As we look at meaning making, sense of coherence and systemic interactions, it makes sense that these areas would emerge. If we can approach our clients from a salutogenic perspective, we may even be able to promote such growth.

Putting it into practice

So, what does all of this look like when we are working with clients? Again, this should not be confused with a Pollyanna view that everything is great. It is not a dismissal of the negative symptomology or the suffering that a client may be experiencing. Instead it is the process of leaning in to find the client’s strengths that are present even in the midst of despair.

The thing is, clients may not have the slightest inkling that they have any strength left. They may believe that this experience has taken everything from them. It is our job as counselors to find even the tiniest spark of ability and fan that flame until it burns bright enough for them to see it. We explore from a strength-based approach. We ask strength-based questions such as “What was working before? What is going well? What resources do you have? What if a miracle happened? What gives you meaning?” Clients may not have answers in that moment, but we can help them to find answers.

We personally love the question, “What do you ‘groove’ on?” We ask clients what is present in their lives that makes them smile, gives them a lift and helps them find peace, even if those things come in the smallest of measures. We can use that information to connect clients to other strengths upon which they can build, much like stacking blocks. We can promote a feeling in our clients that they are the experts on themselves, and they can help us to promote their positive change. We can empower our clients to believe that they are capable of coping. We can help them draw on both their inner reserves and the external resources that they might be having difficulty accessing.

We aren’t suggesting that a salutogenic approach is easy, nor is it a panacea for all people in all circumstances. As professionals, we know that we must meet our clients where they are. Validation of a client’s experience and careful interventions are always important. Some clients may have a hard time identifying any strengths. They may be so wounded that it would make such an approach a hard sell. What we must do as clinicians is be patient, empathize and continue to provide strength-focused reframes whenever possible. This dance requires sensitivity on the part of practitioners. With a focus on clients’ current needs and an eye toward positive coping, we can help our clients to move forward in their journeys.

We would be remiss if we didn’t discuss the fact that we share the journeys of our clients in very real ways. Any clinician who has worked with these issues has been warned of the dangers of vicarious trauma — the potential that, as clinicians, we can experience disturbance as a result of just listening to the experiences of our clients. The result of such exposure can be as mild as thinking too much about a client or as severe as full-blown PTSD symptoms.

But there is an upside. If we can be disturbed by our clients’ disturbance, then we can also grow from watching our clients grow. Vicarious posttraumatic growth is a burgeoning area of study that suggests we can experience the same kind of fundamental shifts in positive thinking that our clients may undergo just by watching them do it. What a great side effect of a salutogenic approach to our work.

It seems that every day there are terrible, traumatic things reported in the news. There are mass shootings, natural disasters, horrific accidents and incidents of community violence. It seems that each day creates a new Mark. If we were to focus on the pathology of Mark’s experience and the bad in the world, he — and we — may never choose to venture out again.

Mark didn’t choose that path, however. He eventually chose to be a phoenix. He decided to rise up from the ashes of his own experience. It wasn’t an easy process. A great deal of emotional pain was involved. He had to let go of a significant amount of anger and blame. He had to come to understand that all of his experiences, all of his suffering, all of his trauma, did not define him. Mark came to know that all of those things made him tough. They made him compassionate toward others. They made him a survivor who had the skills to fly as high as he wanted to go. Mark chose flight. Watching him fly was beautiful.

 

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

Debra G. Hyatt-Burkhart is an assistant professor in the counselor education program at Duquesne University in Pittsburgh. With more than 25 years as a practicing clinician, her work focuses on positive approaches to clinical supervision and treating trauma. Contact her at hyattburkhartd@duq.edu.

Eric W. Owens is an assistant professor and graduate program coordinator at West Chester University of Pennsylvania. He has worked in higher education, K-12 and clinical settings for 20 years. His work focuses on strength-based approaches to trauma treatment and crisis intervention. Contact him at eowens@wcupa.edu.

Letters to the editor: ct@counseling.org

Validating the quarter-life crisis

By Lynne Shallcross April 22, 2016

More than a decade ago in the song “Why Georgia,” musician John Mayer put words to a phenomenon that many 20-somethings sense all too well.

“I rent a room and I fill the spaces with/ Wood in places to make it feel like home/ But all I feel’s alone/ It might be a quarter-life crisis/ Or just the stirring in my soul/ Either way I wonder sometimes/ About the outcome/ Of a still verdictless life/ Am I living it right?”

Despite its inclusion in a hit pop song, the quarter-life crisis isn’t always taken seriously by society at large. “Nobody questions the midlife crisis,” points out Cyrus Williams, an associate professor in the Branding-Images_quarter-lifeSchool of Psychology and Counseling at Regent University, but the same isn’t always true of the quarter-life crisis, which Williams defines as a period of significant life and career transitions for young adults between the ages of roughly 22 and 30.

“As a culture, we all think that age 25 is the best stage of your life — these folks are happy, they’re doing everything they want and it’s a great time of life,” says Williams, an American Counseling Association member who has been studying and speaking about the quarter-life crisis for more than five years.

In the counseling session, however, the quarter-life crisis — a developmental time period of potentially high anxiety — needs to be given the same level of respect and attention as the midlife crisis rather than being dismissed out of hand, Williams says. “We really need to acknowledge and not minimize this time period,” he emphasizes.

Decisions, decisions, decisions

In their early 20s, many young adults are graduating from college and find themselves faced with a deluge of life transitions, Williams explains. There are choices and changes swirling around them in almost every major area of life.

They are deciding where to live, whether moving to their own apartment (or a shared living space) in a new city or back into their parents’ home. They want to pursue a career but sometimes find themselves stuck in entry-level jobs that don’t pay their bills or student loans. They wonder whether they should already be in a committed relationship headed toward marriage and a family. They question whether and how they will develop new friendships while hanging on to old ones from their high school or college days.

All of those issues can lead to feelings of anxiety, fear, instability and an existential crisis of “Who am I?” Williams says. “There are too many choices, too many decisions to make, and it’s scary,” he says.

This time in life can also dredge up self-doubt, says Melissa Nelson, a doctoral candidate in counselor education and supervision at Regent University who has been researching the quarter-life crisis with Williams. For example, some young adults might see that a peer has landed a successful job and become financially stable and start wondering why they haven’t been able to follow the same timetable. This can make young adults question themselves, their decisions and their abilities, says Nelson, a member of ACA. “Did I major in the right thing? Is there something wrong with me?”

It isn’t uncommon for clients in their 20s to present in the counseling session with feelings of depression and anxiety, says Katherine Hermann, an assistant professor in the Department of Counselor Education at the University of Louisiana at Lafayette. The idea of leaving a close-knit community, whether the town where someone grew up or the circle of friends an individual developed at college, can be isolating, says Hermann, who has presented on transitions in adulthood. The search for a romantic partner can also feel isolating and provoke anxiety, she points out.

Young adults in this stage may also feel a sense of betrayal, Williams says. Many of these individuals have grown up being told by parents, teachers and others that if they follow the rules and check all the boxes they’re instructed to, life will work out as it is supposed to. When things don’t fall into place that seamlessly, Williams says, these young adults feel lied to.

In such cases, Williams says, it can be helpful if counselors talk through those feelings of betrayal with clients, allowing them to express why things feel unfair and then working together to move forward past those feelings.

All of the anxious feelings that are normally experienced at this time of life can be exacerbated by social media, Williams adds. For instance, on Facebook and Instagram, people tend to post messages and photos documenting only their best experiences, which doesn’t translate to a realistic account of life. “That is one of the things that other generations didn’t have to deal with,” Williams says. “They [didn’t] have to have this in their face every day of ‘Wow, my friend is having a great life and I’m not.’”

Nelson agrees. It is easy for people in this stage of life to get caught up in comparing themselves to peers who post photos or messages related to career success, romantic adventures or starting a family. “What does that mean for an individual who doesn’t have those things yet?” Nelson asks.

One key is for counselors to talk with these clients about how social media rarely shows the day-to-day reality of people’s lives, Williams says. That simple action can help young adults begin to put things in the proper perspective, he adds.

Keep your ‘therapeutic antennae up’

With all those choices and transitions hurtling toward young adults in rapid succession, how can counselors help most? “I wish there was a magic answer,” says Hermann, a member of ACA. Short of that, developing a strong therapeutic relationship is perhaps most important, she says, along with gathering and attempting to understand the perspective of the client as much as possible.

“I think having your therapeutic antennae up is one of the most important things,” says Hermann, who adds that the client’s presenting problem isn’t always the real problem. Get to know these clients and work on the issues they present with, she says, but also be open and attentive to exploring other issues of which they may not even be aware.

Counselors should also know that these clients aren’t afraid to walk through your door, Williams says. “This generation is not like generations in the past,” he explains. “There’s not a stigma involved in mental health issues [with them]. They’ll come in to your office and they’re like, ‘Listen, I’m stressed out, I’m anxious. I need some help.’”

In return, Williams says that he stands ready to help these clients identify what they are experiencing. He specifically uses the term quarter-life crisis with young adult clients because he says it is empowering for them to hear a phrase that defines their experience. “It’s liberating for them,” Williams says. “They’re like, ‘Holy crap. OK. I get it. This is what I’m going through right now.’ So normalizing this is very important.”

Nelson agrees, adding that 20-somethings are reading magazine articles and self-help books on this topic as a way of finding support and normalizing their experience. “If we as counselors and therapists don’t do the same in normalizing this and recognizing this,” Nelson says, “then we’re not providing the comprehensive services that we need [to].”

Even if career counseling is not a counselor’s specialty, being well-versed in career counseling topics is imperative when working with these clients, Nelson says, because career issues are intricately tied to many other areas of life, from identity to finances to relationships. For example, Nelson says, paying for a house or paying for child care is tied to family and partner relationships, but it is also dependent on career decisions. That means that even if a counselor doesn’t specialize in career or academic counseling, it is critical to have a basic understanding of those areas of counseling, she says.

On the flip side, Nelson says, career counselors might have young adult clients come in for help writing résumés, only to discover that their parents are pressuring them to create the “perfect” résumé in order to find the “perfect” job. Or perhaps a counselor working with a couple in premarital counseling might find that one member of the couple is struggling with career and financial worries. Nelson suggests that counselors try to look holistically at everything going on in these clients’ lives.

Williams points out that, of course, not every 20-something is going to experience a full-blown “crisis.” But the potential is there for these various life transitions to lead to crisis if young adults don’t have the coping skills and supports in place to weather changes in a healthy way, he says.

Counselors would be wise to do assessments with these clients at the outset of counseling, Williams says, especially to help determine whether they might be experiencing clinical depression or anxiety. Then, he says, counselors should hear these clients out and try to understand where they’re coming from.

Williams often explores existential questions such as “Who am I?” and “What do I want to do with my life?” with clients in this age group. He also reminds these clients that the answer to what they want to do with their lives doesn’t necessarily have to be related to their jobs; a job can pay the bills without necessarily “satisfying” or defining every aspect of the person. Williams prefers a holistic perspective, asking clients to think about what things in life make them happy, bring them meaning and help them make sense of the world.

No one right approach

When working with clients on quarter-life crisis issues, Williams suggests that practitioners remember to keep the counseling brief. Although these clients tend to be more willing than generations past to seek out counseling, they also generally want a faster route to a solution, not years of sessions, he observes.

“They come to counseling, but they don’t stay in counseling,” Williams says. Brief, solution-focused and existential approaches are often the best alternatives with these clients, he says. At the same time, many young adult clients aren’t afraid of doing work toward arriving at the solution, he adds, so counselors shouldn’t hesitate to suggest books for them to read, questions for them to ponder or other homework for them to do between sessions.

When deciding which interventions to use with these clients, Nelson suggests that counselors familiarize themselves with the literature on evidence-based practices related to life transitions, such as the school-to-work transition or the transition of becoming a family. Because the quarter-life crisis is a newer area of study that hasn’t yet been extensively researched, Nelson says it is hard to pronounce whether one counseling approach would be more effective than another. She believes almost any evidence-based approach can be effective with these clients, although she tends to lean toward existential-based approaches.

Williams came up with an intervention that he calls the “NEEDS” approach. The “N” stands for normalize, which all three counselors interviewed for this article highly recommend trying to do with clients confronting a quarter-life crisis.

The first “E” stands for empower. Williams says counselors can do this by arming these clients with anything from books to YouTube videos that will help them feel less alone and more confident that what they are experiencing is real.

The second “E” stands for taking an existentially focused approach. Williams says this involves helping clients explore who they are, what their calling is and the “why” behind it. For example, if young adult clients are focused on landing a particular job or moving out of their parents’ house, Williams will ask them to examine the “why” behind those desires.

The “D” stands for a developmental approach, in which Williams encourages clients to explore the “long continuum” of their lives, and also the decision-making skills that are required at this time in life. The decisions that 20-somethings make can have consequences that extend into their later years, he points out. For example, some young adults make the decision to run up their credit card debt so they can rush to move out of their parents’ home, while others decide to get married and have children before they are truly ready.

The “S” stands for screening and assessment, which Williams says is a must in determining whether clients are experiencing a normal transition or if their experience has crossed over into crisis mode.

Prevention where possible

Although counselors must be prepared to help 20-somethings who already find themselves in the midst of a quarter-life crisis, Nelson says practitioners should be thinking with a preventive mindset whenever possible. For example, she says, counselors who work with college students can help those students better prepare for what lies ahead by engaging them in exercises to build their self-esteem and raising their awareness of the challenging decisions and transitions that might pop up in the near future.

University counseling centers might be able to offer graduating students continued career counseling services until they land jobs, Nelson says. If such services aren’t feasible, she suggests that college counselors ensure that their clients who are graduating leave the school equipped with referral sources. She encourages college counselors to add website resources for recent graduates “who are feeling the heat of the quarter-life crisis.”

Nelson says counselors must do what they can to arm graduating students with the tools they need before they actually need them. “Getting the information out there and the resources out there before it becomes a problem is really important,” she says.

In preparing to work with clients on issues related to the quarter-life crisis, Nelson says it is crucial for counselors to be aware of changing cultural dynamics. For example, she says, counselors should understand how social media can further complicate life transitions for young adults and how changes in unemployment rates and student loan rates can have “very real implications” during an already frightening time period for 20-somethings.

Counselors who desire to work with young adult clients should read more about this generation, Williams says. Understand what makes them culturally unique, what is significant to them and what has shaped their lives. Among the resources that Williams suggests is the 2001 book Quarterlife Crisis: The Unique Challenges of Life in Your Twenties by Alexandra Robbins and Abby Wilner.

“Cultural shifts of parenting style and expectations are one of the greatest mitigating factors in understanding millennials,” Williams says. “Concepts such as positive reinforcement rather than punishment, or self-esteem building rather than tough love, became popular during the millennials’ formative years. Millennials were revered by parents and sheltered from the world, developing unrealistic expectations of self and never learning skills necessary for survival in the ‘real world.’ Often they have been sheltered so much that they have not been allowed to learn to survive on
their own.”

“In addition to the confounding dynamics such as parental influence, millennials have come to age during a period of significant corporate downsizing, unemployment, underemployment and outsourcing,” Williams continues. “The estimated unemployment rates for young adults are more than double that of overall unemployment rates. As a result, young adults face increased financial stressors, often resulting in an inability to pay student loans, save for retirement or maintain independent living. It is estimated that approximately 44 percent of recent college graduates are currently experiencing underemployment, working in fields and positions in which they are overqualified. Like many other generations, work is a crucial aspect of one’s identity and expression of self. Consequently, when employment aspirations and ideals are not met, crises of personal identity may result.”

Hermann agrees. “Understanding the culture of this population will be important to sustained treatment success,” she says. “I think a systemic perspective is very important, and understanding the individual within [his or her] environment, especially as it pertains to relationships — family of origin, intimate, social, professional — is imperative to treatment.”

Hermann recommends two journals published by ACA divisions to counselors who might be working with this population. One is Adultspan Journal (published by the Association for Adult Development and Aging), which includes topics relevant to young adults. The other is the Journal of Creativity in Mental Health (published by the Association for Creativity in Counseling) “because of the innovative, therapeutic applications that engage and challenge clients to think differently,” she says.

Expert wisdom

To help counselors better prepare to work with clients undergoing a quarter-life crisis, Counseling Today asked these experts to weigh in with their best advice and guidance. Here are their top tips.

  • Don’t minimize the quarter-life crisis, Nelson says. “Far too often, that’s one of the reasons that an individual is there [in counseling] in the first place.” In many cases, parents, peers or co-workers have minimized what these 20-somethings are experiencing, which only ends up increasing the pressure on them, Nelson says.
  • Do focus on wellness, decision-making and the future, Williams says, not pathology.
  • Don’t make assumptions, Hermann says. “Every client has a different past and goals for the future. Focus on the individual,” she says. Although counselors develop models and frameworks to understand patterns, “every person is a unique human,” Hermann reminds her colleagues.
  • Do your research, Nelson says. Become aware of factors outside of your counseling specialty or area of practice that may be affecting young adults. “Awareness is half the battle,” she says.
  • Do make it clear to these clients that this is short-term counseling, Williams says, “because you lose Generation Y if you are going to ask them to come back for 15 sessions. They really need to see the end from the beginning.”
  • Don’t rely solely on clinical intuition, Williams adds. “I love the fact that we are intuitive, but we have instruments and science out there that can help us,” he says.
  • Do consider group therapy. “If you are working in a setting that has the ability to utilize group therapy and group counseling interventions, I would say go for it,” Nelson says. “I think that group counseling can really help that process of normalizing the crisis [and] developing a support network for individuals beyond their counselors.”
  • Do take the time to explore the individual’s relationships, including family relationships, intimate relationships, friendships and work relationships, Hermann says. “This exploration will give counselors an understanding of the individual and also the depth and capacity of [his or her] support group. In addition, so many of the changes that occur during this developmental period are connected to changes in relationships, so having a complete understanding of the relational aspects of an individual can be helpful in understanding and focusing a treatment plan.”
  • Do encourage these clients to address their relationship with their parents, Williams says. It is a relationship that has likely changed now that these young adults are in their 20s, but it is a relationship and an influence that has long been paramount to them, he says.
  • Do normalize the crisis, Nelson says. Point clients toward books or other resources to help them recognize that they are not alone in experiencing these struggles and challenges.
  • Do explore identity development with clients, Hermann says. What is meaningful to them, and how do they create meaning?
  • Do give these clients resources, books to read and homework to do, Williams says. They are typically used to being on the computer and doing research, so they are likely to engage in the homework related to their own counseling, he says.
  • Do ask questions and then address any issues that become apparent from the answers, Nelson says. “Is it stressful to pay your student loans each month? Is it stressful to be pressured by your parents to be married and to have children, and how are you dealing with that?” Nelson suggests asking. “I don’t think that counselors need to be afraid and shy away from addressing the quarter-life crisis.”

 

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To contact the individuals interviewed for this article, email:

 

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

Letters to the editor: ct@counseling.org

Fertile grounds for bullying

By Laurie Meyers April 21, 2016

Bullying isn’t just for kids anymore. In the past 10 to 15 years, recognition has grown that bullying goes beyond taunts in the schoolyard. Adults can encounter it at work, “traditional” bullying is now enhanced and magnified by online or cyberbullying, and those who identify as lesbian, gay, bisexual, Branding-Images_bullytransgender or queer (LGBTQ) can experience it at any age just for being who they are.

“Bullying and interpersonal violence are tragic experiences that far too many people undergo every day,” says American Counseling Association President Thelma Duffey, who has shined a spotlight on anti-bullying/interpersonal violence efforts as one of her main presidential initiatives. “People can be hurt in such devastating ways when they are bullied, and counselors are in prime positions to help.”

But to be effective, counselors need to increase their understanding of bullying in all of its forms.

Trouble in the schoolyard

The first place many people experience bullying is, of course, at school, and school bullying remains a complex problem. Researchers say putting an end to bullying and ultimately preventing it requires the involvement of everyone in the system, including not just teachers, counselors and students, but also staff such as janitors and bus drivers. Even without a comprehensive anti-bullying program in place, however, there are many steps school counselors can take to help those who are being bullied.

Although any student can face bullying, those perceived to be somehow “different” and, critically, viewed as easy targets most often find themselves in the crosshairs, says JoLynn Carney, an associate professor of counselor education at Penn State whose research focuses on bullying.

“Abusers of all ages seem to have an uncanny sense of who can defend themselves and who may be unable to self-defend,” she explains. “Youth who are isolated — meaning few to no friends — are often targeted. They may have poor social skills … or other qualities not valued in the peer social network such as disability, different sexual orientation, different religion/culture or socioeconomic background. Even just being the new kid can be the characteristic that has the person being targeted. Kids who are highly anxious by nature or depressed also often seem to be the students who are bullied.”

Regardless of the reason behind the bullying, being a target is very isolating. A first step for counselors to take is to listen to and to act as advocates for students who are being bullied to reduce their sense of isolation, says Carney, a member of ACA. But she cautions that counselors must not give the impression that students are passive participants in solving the bullying problem. “The worst thing I’ve seen done over the years is to inadvertently teach kids that the adults in the situation have to handle this, which yields a sense of helplessness in the targets,” Carney explains.

Instead, counselors should work with students who are being bullied to help them understand the situation they are facing and what actions they might take to change it, she says. “Actions for targets are meant to change the dynamics of the situation by changing the target’s conceptualization of the situation and the target’s actions before, during or after the situation,” she says.

Carney says counselors should focus on problem-solving, helping bullied students to:

  • Increase connections to others who can provide immediate or follow-up support. Counselors can help bullied students make connections in multiple ways.

“Whether elementary, middle or high school, the counselors know their students; they know the students they can count on who have the social skills and the empathy to be peer mentors [to the student being bullied],” Carney explains. “They also know about the groups of students — like what club could the target student join to form bonds, and so forth. The bridging the school counselor can do often makes a huge difference. Honestly, I’ve had students or parents tell me in clinical settings that having that one friend saved their child’s life.”

The more friends and support from others the student has, the less vulnerable the bullied student will be.

  • Change some aspect of their behavior so that they are less “predictable” for their abusers, thereby reducing the abusers’ confidence that bullying will produce the desired effect. Taking away the desired result can help shift the power imbalance that is inherent in all bullying situations. For example, students who are being bullied can work on reacting in a different manner or even simply changing their body language. Those who are bullied often display a classic posture — slumped shoulders, head down, perhaps crying. Shifting that submissive posture to a posture in which the body is held more upright sends a different message to all concerned — the abuser, the target and any bystanders.
  • Learn appropriate physical, verbal and social assertiveness. Having a sense of assertiveness allows bullying targets to understand their own power and influence in the situation.

Carney says it is also crucial for counselors to show students who are being bullied how, where and when to seek support when necessary. “Working clinically with targets and their families, I’ve helped with the smallest of shifts that [would] seem inconsequential but have yielded good results, such as helping the person being bullied [not to] see themselves as the ‘victim,’ [which is] a disempowering … view of the self,” she explains. “Instead, helping them see themselves as simply the current ‘target’ of an abuser brings a sense of empowerment because anyone can be a target, and it’s not an internalized sense of negative self-worth. Helping the student see themselves differently can make a big difference in the ability to make the changes to end the abuse.”

Those who are being bullied don’t always ask for help or talk in great detail about what they are experiencing, so Carney has identified several red flags that might indicate that a student has become a target. These include:

  • Changes in behavior such as not wanting to go to school or avoiding other social situations such as birthday parties or school trips.
  • Changes in eating habits such as consistently saying they’re not hungry or skipping meals at school (which might be the result of not wanting to face bullying behavior in the cafeteria) or even engaging in binge eating as a source of comfort.
  • Self-destructive behaviors such as running away and serious talk about (or even an attempt at) suicide.
  • Changes in physical symptoms such as frequent headaches or stomachaches, frequently feeling ill, trouble sleeping or an increase in nightmares.
  • Changes in academic performance such as slipping grades or a lack of interest in classes that the student used to enjoy.
  • Changes in emotional state such as feeling helpless, hopeless, depressed, highly anxious or worthless.

Students who are being physically bullied may also have injuries that can’t be explained or damaged personal objects such as clothes and electronic devices.

Carney believes that if bullying is to be fully addressed, a school culture must be developed that doesn’t tolerate bullying behavior. She and her colleague and fellow researcher Richard Hazler, a professor of counselor education at Penn State, are currently part of the research and implementation team for a major anti-bullying initiative called Project TEAM, which former school counselor Lindsey Covert created based on a framework she developed as a graduate student at Penn State. Covert had success implementing the program and then collaborated with another school counselor, Lisa Dibernardo, to expand the program in the Stafford Township School District in New Jersey.

Covert is the director of the program, which is now part of the College of Education at Penn State. Carney says the curriculum, which she and Hazler are currently implementing in several grade schools, teaches students to focus on the importance of teamwork and leadership in their daily lives. It emphasizes helping others, the concept of positive change, problem-solving and conflict resolution, resilience and leadership.

Individual school counselors can help prevent bullying by conducting professional development trainings that educate teachers, school staff and administrators about the behavioral indicators of bullying and victimization, says Rebecca Newgent, a professor of counselor education at Western Illinois University–Quad Cities. “Bullying can take on several forms, such as physical, verbal and relational bullying,” explains Newgent, an ACA member who researches school bullying and children who are at risk. “Signs that school personnel might notice in regard to physical bullying are hitting, pushing and kicking. Signs for verbal bullying typically include calling the other student names, threatening other students or teasing other students. Relational bullying is somewhat harder to recognize, but some typical behaviors include leaving other students out of activities, not talking to other students and telling rumors about other students.”

School counselors should also emphasize the importance of all school personnel teaching children to demonstrate empathy for the bullied classmate by imagining what the student might be feeling, says Newgent, a member of the Association for Counselor Education and Supervision, a division of ACA. Children should also be encouraged to report bullying and helped to understand that this differs from “tattling,” she continues. “Consistent support and encouragement from teachers and school counselors can reinforce this [reporting] behavior,” she says.

Newgent also urges counselors to reach out to parents via newsletters and parent workshops to engage them in anti-bullying efforts. “Counselors can help parents to work with their children on increasing social skills and assertiveness,” she says. “Parents can help ensure that the family environment is one where the child feels safe and understood.”

Workplace bullying

Bullying isn’t confined to childhood or adolescence. Adults can experience bullying too, particularly in the workplace. Bullying in the workplace involves less obvious behavior than does school bullying and can be almost intangible, says Jessi Eden Brown, a licensed professional counselor and licensed mental health counselor with a private practice in Seattle.

“Bullying in the workplace is a form of psychological violence,” says Brown, who also coaches targets of workplace bullying through the Workplace Bullying Institute (WBI), an organization that studies and attempts to prevent abusive conduct at work. “Although popular media theatrically portray the workplace bully as a volatile, verbally abusive jerk, in actuality, the behaviors tend to be more subtle, insidious and persistent.”

Instead of shoving and name-calling, Brown says, workplace bullying includes behavior such as:

  • Stealing credit for others’ work
  • Assigning undue blame
  • Using public and humiliating criticism
  • Threatening job loss or punishment
  • Denying access to critical resources
  • Applying unrealistic workloads or deadlines
  • Engaging in destructive rumors and gossip
  • Endeavoring to turn others against a person
  • Making deliberate attempts to sabotage someone’s work or professional reputation

“It’s the fact that these behaviors are repeated again and again that makes them so damaging for the target,” she explains. “The cumulative effects and prolonged exposure to stress exact a staggering toll on the overall health of the bullied individual.”

What’s more, those bullied in the workplace often stand alone, Brown notes. “While the motivating factors may be similar between workplace bullying and childhood bullying, the consequences for the bully and the target are unmistakably different,” she says. “In childhood bullying, the institution — the school — stands firmly and publicly against the abuse. Teachers, staff, students and administrators are thoroughly trained on how to recognize and address the behavior. Students are given safe avenues for reporting bullying. Identified bullies are confronted by figures of authority and influence — teachers, administrators, groups of peers, parents. When the system works as intended, there are consequences for the bully, as well as resources and support for the target.”

Brown continues, “In the workplace, bullying receives far less attention and focus. Management may fail to appropriately label the bully’s behavior as being abusive, especially if it doesn’t violate the law. Some employers recognize the problem and still choose to turn a blind eye. And even worse, there are some companies that actively encourage ‘weeding out the weak,’ whereby successful bullies are rewarded with promotions, bonuses, extravagant gifts and other incentives. After counseling and coaching more than 3,000 targets of workplace bullying over the years, believe me, I’ve heard it all.”

The consequences can be devastating. “There is a significant body of research linking workplace bullying to physical, mental, social and economic health harm for the bullied target,” Brown notes. “Hundreds of empirical studies have linked repeated exposure to stress, including stress originating from emotional and psychological sources, to severe physical ailments, such as cardiovascular disease, gastrointestinal problems, immunological impairment, diabetes, adverse neurological changes, disorders of the skin, higher levels of cortisol leading to organ damage, musculoskeletal pain and disorders, and more.”

Workplace bullying has also been linked to panic disorder, generalized anxiety disorder, major depression, substance abuse and posttraumatic stress disorder, Brown continues.

Brown began specializing in counseling clients who have experienced workplace bullying after going through the experience herself in two different positions. “Both times were painful and deeply confusing,” she says. “I seriously considered leaving the counseling profession after the second experience.”

However, a friend who was doing web design for WBI introduced her to psychologists Gary and Ruth Namie, the founders and directors of the institute. The Namies were looking for a professional coach and offered Brown the job. As she worked with those who had been bullied, she began to integrate her experiences into her private counseling practice.

“The vast majority of my clients present as capable, accomplished professionals with a documented history of success in the workplace,” she says. “At some point in their careers, they encounter the bully and everything changes. Under constant attack, belittled and sabotaged, the once-competent, assured worker may begin to question her abilities and role at work. She tries everything she can think of to remedy the problem but finds few working solutions. Mounting stress starts to take its toll and spills over into other areas of life. Throughout this process, many targets fall victim to self-blame. Deep confusion, shame, anger and exhaustion are common at this stage. … This seems to be when most clients discover my services.”

Brown says the first step toward helping clients who are being bullied is to identify what they are experiencing — workplace bullying and psychological violence. Naming the behavior helps clients frame and externalize their experiences by realizing that they are not creating or imagining the problem, she explains.

“Encouraging the client to prioritize [his or her] health comes next,” Brown says. “Working closely with other health care providers is essential in situations where the individual’s health has been severely compromised.”

“It is imperative that the counselor promote the client’s self-care and turn attention toward enhancing [his or her] social support network,” she continues. “This may mean helping the client figure out a way to take time off from work, teaching new coping skills and encouraging time spent with loved ones — time that is deliberately not focused on recounting the situation at work.”

“Targeted workers may choose to file formal or informal complaints to unions, the EEOC [Equal Employment Opportunity Commission], the bully’s boss, ethics hotlines or professional boards,” Brown says. “Although there is no legal protection against bullying in the United States, some workers find grounds for harassment, discrimination, constructive discharge, intentional infliction of emotional distress, wrongful termination or other legal claims.”

According to Brown, WBI research indicates that once targeted by workplace bullying, there is a 77.7 percent likelihood that the individual will lose his or her job due to resignation (voluntary or forced) or termination. A 2014 study conducted by WBI found that 60 percent of bullied workers were women and that men were more than twice as likely as women to act as bullies (69 percent versus 31 percent). However, when women exhibited bullying behavior, they were also more likely to bully other women — 68 percent of female bullies’ targets were also female.

Counselors can help clients who experience workplace bullying to consider their options, starting with whether to stay in their current job or leave. “Many targeted workers choose to transfer or quit just to escape the abuse,” Brown says. “The decision to leave on one’s own terms can be empowering and frequently results in better emotional health than being fired or laid off due to the bullying.”

Brown believes that counselors are in a unique position to help those who are bullied at work. “First, and most importantly, we can believe them when they tell us about the mistreatment at work,” she says. The stress and exhaustion that targets of workplace bullying endure are often isolating and paralyzing, Brown points out, adding that it is generally the bully’s goal to disempower the target.

“Even when they do speak up, targets of workplace bullying tell me that their employers, family and friends often do not believe them or understand their level of distress,” she says. “As counselors, we can listen to their story, convey a sense of belief and offer a distinctly different response than the target has received thus far. … Do not blame the client for the abuse [he or she is] experiencing.”

In most cases, Brown says, the target has done nothing to deserve the mistreatment; the bully chooses the target, timing and tactics, and the targeted individual may have very little control or influence over these factors. The responsibility to stop the abusive behavior ultimately rests with the employer. In these instances, just teaching clients to be more assertive or to stand up to the bully is not the answer, Brown emphasizes.

Cyberbullying: Virtual environment, real bullies

Bullying is presumably as old as the human race, but one thing about the dynamics of bullying has changed dramatically during the past 10 to 15 years. Online, anyone can bully anybody anywhere, from next door to halfway across the world. Cyberbullying is often used to enhance the “traditional” bullying tactics that are taking place in a school or workplace, but it can also serve as a standalone method of harassment.

“Cyberbullying can take place via email, text, instant messaging, social media or any other digital form of communication or information dissemination,” Brown explains. “It may manifest as harassment, impersonation, defamation, stalking, manipulation, denigration or other types of abuse.”

Unfortunately, even people who might never consider participating in traditional bullying behaviors are often tempted by the anonymity of cyberbullying. “When people get on [an electronic] device, normal roles of civil interaction somehow become less relevant,” says Sheri Bauman, author of the book Cyberbullying: What Counselors Need to Know, which is published by ACA.

People who previously were afraid of getting caught for bullying or didn’t want to accept responsibility for their actions now feel free to indulge their baser instincts online, she says. “[They think], ‘I can be as nasty as I want to be; no one knows who I am.’ They don’t have to censor themselves and don’t have to follow social rules,” explains Bauman, a professor and director of the counseling degree program at the University of Arizona.

Researchers don’t know exactly why anonymity has this effect, but Bauman, an ACA member, speculates that it may in part be because online interaction doesn’t quite feel real.

Janet Froeschle Hicks, a licensed professional counselor and certified school counselor in Texas, posits a similar explanation. “Not being face to face with a person makes it easier to dissociate and reduce empathy,” she says. “Technology also gives the false impression that the person on the other end is an ‘object’ rather than a person.”

Young people appear particularly adept at cyberbullying, Hicks says. “Youth participate in cyberbullying several ways. They impersonate one another by stealing passwords, create fake social media pages and send cruel messages anonymously. Often they create pages for another person without that person’s knowledge. This is very damaging because several others can be harmed with one posting.”

“For example, Student A creates a page for Student B without Student B’s knowledge. Student A then uses Student B’s fake page to bully Student C. When this happens, Student C is now upset with Student B, and Student B has no idea what has happened. Rumors about others, gossip, humiliating pictures and rude comments can be posted by Student A on this fake page,” explains Hicks, a professor of counselor education at Texas Tech University whose research focuses on cyberbullying, social aggression and school, child and family counseling.

Many students also participate in a practice known as “sub-tweeting” on Twitter. “Anonymous tweeters comment on others’ tweets without identifying themselves,” Hicks says. “This means rude anonymous messages appear in the midst of a conversation.”

Cyberbullies can use a wide array of methods — from texting to social media to digital pictures — to torment their targets online. As a result, Hicks says, those who have been bullied may develop a fear of technology. “Since we live in an age where students need technology to complete homework, apply for college admission and succeed at a future job, it is important to teach that technology can be safe,” she emphasizes. “I teach parents and youth to use privacy controls, not to share confidential information and to avoid negative conversations [online].”

Although adolescents are typically assumed to be both the culprits behind and the targets of cyberbullying, experts say this isn’t always the case. Adults may be targeted as part of a workplace bullying campaign, a neighborhood grudge or simply at random.

Brown urges her clients to think about ways they can minimize the potential of being bullied. “I encourage my clients to be intentional about their online presence and reputation by actively reflecting upon the image they want to portray,” she explains. “What skills, attributes and experiences are important to highlight? Where do you want your information to appear? Who is likely to find and use your information based on how and what you choose to share? What are you most concerned about regarding your online persona? By exploring questions like these, [clients form] a picture and a plan of how they want to manage their online information.”

Brown also advises clients to thoroughly search their own names on the Internet to find out what information — or misinformation — is already out there about them. “I recommend they set up a Google Alert for their own name and any related identifying key terms. Using myself as an example, I’d set an alert for ‘Jessi Eden Brown,’ ‘workplace bullying counselor,’ ‘professional coach workplace bullying,’ etc. This way, I increase my chances of catching any references made to my name or professional identity. The more I know, the better able I will be to respond to online attacks.”

After clients have identified the details of their online presence, Brown talks with them about how to respond to damaging content and minimize future problems. For example, she advises clients to periodically review the privacy settings on their social media and web-based accounts. “For those being actively cyberbullied, it is wise to lock down all privacy settings or, in some cases, to delete or suspend accounts altogether to give the bully fewer points of access to the target,” she says.

Bauman, who is also a member of the American School Counselor Association, a division of ACA, says that given the prevalence of cyberbullying, counselors need to educate themselves about all social media and related online platforms so they can knowledgeably discuss the issue if a client brings it up.

No walking away

It’s certainly not an ideal option, but if all else fails, those who are bullied at school or work might be able to switch schools or change jobs. At the very least, those who are cyberbullied can choose to reduce their online presence or temporarily go offline. Simply being able to leave a bullying situation can provide precious relief.

But for those who are being bullied because of their sexual or gender identification, there is no walking away. “LGBTQ individuals are bullied in all facets of their lives,” says Tonya Hammer, an assistant professor of counseling at Oklahoma State University-Tulsa whose research interests include both bullying and the intersection of gender and sexual orientation. “We are socialized as a society to bully or reject that which is perceived as different. Unfortunately, it permeates so much of our daily lives.”

LGBTQ individuals usually start facing bullying behavior at a young age, regardless of whether the individual is already “out,” says Hammer, who adds that most bullying prevention efforts don’t start until middle or high school. By that time, according to the National School Climate Survey by the Gay, Lesbian and Straight Education Network (GLSEN), a majority of LGBTQ students are routinely hearing anti-LGBTQ language and experiencing victimization and discrimination at school.

The 2013 survey — the latest year for which statistics are available — found that of the 7,898 students between the ages of 13–21 who participated in the study, 55.5 percent felt unsafe at school because of their sexual orientation, while 37.8 percent felt unsafe because of their gender identity. In addition, 71.4 percent of LGBTQ students heard the word “gay” used in a negative way frequently or often at school; 64.5 percent heard homophobic remarks frequently or often; and 56.4 reported hearing negative remarks about gender expression (for example, not acting “masculine” enough) frequently or often.

Distressingly, 51.4 percent of the survey respondents reported hearing homophobic remarks from their teachers or other school staff, and 55.5 percent reported hearing negative remarks about gender expression from teachers or other school staff.

The effects of this widespread bullying are significant, says Hammer, who presented a session on LGBTQ bullying across the life span at the 2016 American Counseling Association Conference & Expo in Montréal. “Bullying results in feelings of shame and humiliation, which can lead to isolation, lack of emotional regulation [and] violence against self or others,” she notes. Hammer adds that it also increases dropout rates and negatively affects academic performance.

Although counselors cannot completely stop school bullying single-handedly, they can provide a refuge for LGBTQ students to feel supported and accepted, says Hammer, president-elect of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling, a division of ACA. “Counselors can create a safe space by a variety of means. It can be as simple as displaying an HRC [Human Rights Campaign] equal sign [the organization’s logo] in their office or a small rainbow flag somewhere. I know that sounds minor,” she says, “but small symbols can signify something to students.”

Hammer says counselors can also reach out to students who may be subject to bullying, but she emphasizes that counselors should not address sexual/affectional or gender identity unless the student brings it up. Instead, counselors could start by letting the student know that they have noticed a change in the student’s behavior that they think might be connected to bullying.

“You can also [just] ask them if everything is OK and if they need someone to talk with,” says Hammer, who during her time as a board member of the Houston GLSEN chapter trained school personnel in Texas using GLSEN’s anti-bullying program. “Sometimes it is also simply providing a space for them. When working with counselors or librarians, we often suggest creating an actual physical space in their office where students can come and just hang out. Make the space feel inclusive in the way you decorate it and in the material that you provide for them to read or occupy their time with.”

“Also understand that the students may still be questioning their sexual/affectional orientation or gender identity or expression and need people who they can confide in while doing this. Furthermore, their parents may not be that safe space,” Hammer says. “Give them time to feel comfortable and to trust you so that they will open up about what is going on with regard to the bullying and also about their sexual/affectional orientation or gender identity and expression.”

Hammer also cautions counselors not to assume that a student is gay simply because he or she is perceived as being gay. “The most important thing is the relationship,” she emphasizes. “Listen to them with respect and treat them with dignity, not as if they are abnormal. Let them know that they matter to you, to their family and to the world.”

Because eliminating bullying requires altering a school’s culture, counselors can also help students by offering schoolwide education on LGBTQ issues or sponsoring formation of gay–straight alliance groups, Hammer says. Additionally there are awareness activities counselors can help organize such as No Name-Calling Week, Ally Week and Day of Silence, in which silence is used to protest the silencing of LGBTQ people due to harassment, bias and abuse.

Workplace bullying based on sexual/affectional orientation or gender identification is also still very common, Hammer says. In fact, according to HRC, of the LGBTQ Americans who have experienced discrimination, 47 percent reported experiencing it in the workplace. To add insult to injury, HRC reports that only 19 states and the District of Columbia explicitly prohibit workplace discrimination based on sexual orientation or gender identity. A 2009 HRC study found that 51 percent of LGBTQ workers hid their identities from most or all of their co-workers. Strikingly, the report found that younger workers were even more likely to hide: Only 5 percent of LGBTQ employees ages 18–24 said they were completely open at work, compared with 20 percent of older workers.

Unfortunately, leaving a hostile working environment and finding another job isn’t always possible — regardless of sexual or gender identity. And given the extent of bullying that LGBTQ workers face, leaving one job for another is far from being a surefire solution to the problem.

“Sometimes it is a matter of helping people to develop support systems outside of work that can help them to address the hardships of their daily life at work,” Hammer says. “If possible, it is our responsibility as counselors to help advocate for our clients. If legal resources are available, we help connect our clients to those resources. Organizations like HRC, the Southern Poverty Law Center and the ACLU [American Civil Liberties Union] can help in some situations, but not all. We can also connect them with career counselors or agencies that can help them see if there are options for them to change jobs or careers.”

Hammer also believes counselors have a responsibility to help lobby to change laws that make it legal for people to be fired because of their sexual orientation or gender identity.

“LGBTQQI clients, like all clients, want to know that they matter and that they are important,” Hammer says. “The therapeutic relationship may be the first and only relationship in which they experience that, and it may be the only place where they can truly be all of who they are. Providing that space and time for them to do that may empower them to be able to do it with other relationships in their life as well. You can help them to understand that they are worth [having] healthy growth-fostering relationships and provide them with the skills and resources to develop those relationships.”

 

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To contact the people interviewed for this article, email:

 

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Additional resources

For those who would like to learn more about the topics addressed in this article, the American Counseling Association offers the following resources:

Books (counseling.org/bookstore)

  • School Counselors Share Their Favorite Classroom Guidance Activities: A Guide to Choosing, Planning, Conducting, and Processing edited by Janice DeLucia-Waack, Meghan Mercurio, Faith Colvin, Sarah Korta, Katherine Maertin, Eric Martin, and Lily Zawadski
  • Youth at Risk: A Prevention Resource for Counselors Teachers and Parents, sixth edition, edited by David Capuzzi and Douglas R. Gross
  • Casebook for Counseling Lesbian, Gay, Bisexual, and Transgender Persons and Their Families edited by Sari H. Dworkin and Mark Pope
  • Cyberbullying: What Counselors Need to Know by Sheri Bauman

DVDs

  • Working With Perpetrators and Targets of Cyberbullying presented by Sheri Bauman
  • Bullying in Schools: Six Methods of Intervention presented by Ken Rigby

Webinars (counseling.org/continuing-education/webinars)

  • “Children and Trauma” with Kimberly N. Frazier (part of the ACA Trauma Webinar Series)
  • “Counseling School and College Students” with Richard Joseph Behun, Julie A. Cerrito and Eric W. Owens (part of the ACA Trauma Webinar Series)

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

VISTAS Online articles (counseling.org/knowledge-center/vistas)

  • “Anger Management for Adolescents: A Creative Group Counseling Approach,” Carolyn O’Lenic and John F. Arman
  • “BEST Buddiez: A Programmatic Innovation in Early Child Mental Health Treatment for Physically Aggressive Preschool Children,” Rita J. Terrago
  • “Brief Solution-Focused Counseling With Young People and School Problems,” John Murphy
  • “Domestic Violence and Children,” Laurie Vargas, Jason Cataldo, and Shannon Disckson
  • “Making the Change From Elementary to Middle School,” Laura M. Hill and Jerry A. Mobley
  • “Solution-Focused Counseling in Schools,” John J. Murphy
  • “The School Counselor’s Role in Easing Students’ Transition From Elementary to Middle School,” Matthew Mayberry
  • “Empowering LGBT Teens: A School-Based Advocacy Program,” Matthew J. Mims, David D. Hof, Julie A. Dinsmore, and Laura Wielechowski
  • “School Climate Perception: Examining Differences Between School Counselors and Victims of Cyberbullying,” Megan M. Day, Lindsay R. Jarvis, Charmaine D. Caldwell, and Teddi J. Cunningham
  • “School Counseling for Systemic Change: Bullying and Suicide Prevention for LGBTQ Youth,” Jeffry L. Moe, Elsa Sota Leggett and Dilani Perera-Diltz
  • “School Shootings and Student Mental Health: Role of the School Counselor in Mitigating Violence,” Allison Paolini
  • “Sexually Active and Sexually Questioning Students: The Role of School Counselors,” Vaughn Millner and Amy W. Upton
  • “The Bullying Project,” Le’Ann L. Solmonson
  • “The Impact of Attendance at a LGBTQIA Conference on School Counselors’ and Other Educators’ Beliefs and Behaviors,” Aaron Iffland and Trish Hatch
  • “Using the Reflecting As If Intervention to Reduce Bullying Behaviors,” Gerald A. Juhnke, Brenna A. Juhnke, Richard E. Watts, Kenneth M. Coll, and Noreal F. Armstrong

 

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

Letters to the editor: ct@counseling.org