Monthly Archives: January 2018

CEO’s Message: In support of LGBTQ youth and professional school counselors

Richard Yep January 31, 2018

Richard Yep, ACA CEO

Later this month, ACA will once again be a co-presenting sponsor (along with the National Education Association) of the Human Rights Campaign Foundation’s Time to Thrive Conference. ACA has been a supporter every year that this event has been conducted. It is the only conference I know of where national professional associations, state-level advocates and LGBTQ teens and young adults come together for three days of workshops, discussion and networking. 

ACA has taken pride in its support of Time to Thrive, and I am grateful for our members and leaders who have presented and shared their knowledge of how best to help clients and students from the LGBTQ community. In addition to the high-quality presentations from our ACA members, I am so impressed by the eloquence and advocacy of the LGBTQ teens and young adults who also present. They tell their stories not to earn sympathy but rather so that we can all become better advocates.

Sometimes, I wish that those who seek to marginalize LGBTQ youth and dismiss their concerns would attend this conference. Without question, those who attend leave with more compassion for and knowledge about the issues facing young LGBTQ people.

As an outgrowth of ACA’s support of Time to Thrive, we also partnered with the Human Rights Campaign Foundation this past year to develop five webinars for professional counselors to use regarding the career readiness and preparation of LGBTQ young adults. Professional counselors who take these webinars and work with LGBTQ students and clients will enhance their skills and gain critical insights, with a specific focus on youth and young adults who navigate college and career readiness issues. These webinars, funded through a grant from the PepsiCo Foundation, provide continuing education credit and are provided at no cost to ACA members. More information is available at aca.digitellinc.com/aca/pages/hrccourse.

Professional counselors who work in school settings are key to helping LGBTQ youth. Creating safe spaces, providing an anti-bullying environment and working toward elimination of the discrimination that these youth face are well within the scope of professional school counselors. For those of you who work in K-12 school settings, thank you for all that you do to ensure safe, empowering and caring environments for all students. With February including National School Counseling Week (Feb. 5-9), I hope that you will participate and take pride in your profession.

Many of you may know that the American School Counselor Association created National School Counseling Week many years ago. Although I think professional school counselors should be celebrated every week of the year, this is the one designated time that we ask you to let your communities know about the good work being done in school counseling. I encourage practitioners and school counselor educators to celebrate and promote National School Counseling Week and this important group of counselors. For more information about how best to promote National School Counseling Week, go to ASCA’s website at www.schoolcounselor.org/school-counselors-members/about-asca-(1)/national-school-counseling-week.

Also, don’t forget that April is Counseling Awareness Month. Visit the ACA website at counseling.org for more information and resources. This is a special year because we will be holding the ACA Conference & Expo in Atlanta (April 26-29) during the time that we are celebrating Counseling Awareness Month. That has not occurred in many years. During this time in our history when the advocacy of professional counselors is needed more than ever at local, state and national levels, I think it is fate that more than 4,000 professional counselors will be gathering to network, learn and get reenergized for the work they face in 2018.

As always, I look forward to receiving your comments, questions and thoughts. Feel free to call me at 800-347-6647 ext.  231 or email me at ryep@counseling.org. You can also follow me on Twitter: @Richyep. Be well.

 

 

From the president: Love, is love, is love …

Gerard Lawson

Gerard Lawson, ACA’s 66th president

February brings us a couple of fun holidays, including Groundhog Day (a personal favorite) and a few presidential birthdays. But the stores have been preparing us for St. Valentine’s Day since the day after Christmas (seriously). Aside from the blatant commercialism, it is nice to have a holiday devoted to love.

In February, I also get to attend the Time to Thrive Conference put on by the Human Rights Campaign Foundation in partnership with the American Counseling Association and the National Education Association. ACA has been a co-presenting partner of Time to Thrive since its inception, and this conference serves as an opportunity for individuals who work with LGBTQ youth to learn new skills and become better advocates. It is also an opportunity for youth advocates to learn how to be agents of change in their own communities. That is an incredibly powerful process to be a part of.

I have been struck over and over by the importance of advocacy in our profession, and here are young people who have discovered that importance even before finishing high school (or middle school in some cases). They are often part of Gay-Straight Alliance or similar organizations in their schools. These groups of students have banded together not because of their own affectional orientations but because they believe to their core that people should be able to love whomever they love. They believe simply that love should be available to everyone.

I’ve also met pastors who are earnest in their desire to be better allies. They have told me that their faith is rooted in love, and when they found themselves standing between two people who had dedicated their lives to each other, they had to reexamine how they understood their faith. In essence, when they found themselves opposing love, they knew they were out of step with what they believed.

I am very proud of the position that ACA has taken to actively oppose the practices known as conversion therapy or reparative therapy and other sexual orientation change efforts. Scientific evidence tells us that those practices do not work, and courts have also ruled them to be fraudulent because they do not work. The ACA Governing Council closed out 2017 with a reaffirmation that sexual orientation change efforts are a violation of the ACA Code of Ethics and, in fact, violate several specific sections (go to counseling.org/about-us/leadership/meeting-minutes and click on “Resolutions”). And that has been true of our ethics code for decades.

Part of that is an understanding that when people finally take the brave step of seeking the assistance of a counselor, we want them to feel affirmed and supported, not judged or rejected. Part of it is a belief that the practice of counseling must be rooted in empirical evidence that what we offer to clients is efficacious. Part of it is rooted in the fundamental belief that we meet our clients where they are and help them to achieve their goals. Mostly, though, this position is based on the bedrock position that we will do no harm to our clients.

As our profession has grown, we have become clearer about the damage that can be done to clients when we try to impose our values on them, but the foundation of our beliefs is very much the same as that of those youth advocates whom I mentioned earlier. Our clients have a right to love, and we have the responsibility and the privilege to support them.

 

 

Talking through the pain

By Laurie Meyers January 30, 2018

By the time the 43-year-old man, a victim of an industrial accident, limped into American Counseling Association member David Engstrom’s office, he’d been experiencing lower back pain for 10 years and taking OxyContin for six. The client, whose pain was written in the grimace on his face as he sat down, was a referral from a local orthopedic surgeon, who was concerned about the man’s rapidly increasing tolerance to the drug.

“He often took twice the prescribed dose, and the effect on his pain was diminishing,” says Engstrom, a health psychologist who works in integrated care centers.

The man’s story is, unfortunately, not unusual. According to the National Institutes of Health, 8 out of 10 adults will experience lower back pain at some point in their lives. As the more than 76 million baby boomers continue to age, many of them will increasingly face the aches and pains that come with chronic health issues. And as professional counselors are aware, mental health issues such as depression, anxiety and addiction can also cause or heighten physical pain.

Those who suffer from chronic pain are often in desperate need of some succor, but in many cases, prescription drug treatments or surgery may be ineffective or undesirable. Fortunately, professional counselors can often help provide some relief.

Treating chronic pain

At first, the client had only one question for Engstrom: “I’m not crazy, so why am I here?”

Although the man’s physician did not think that the pain was all in the man’s head, it is not uncommon for sufferers of chronic pain to encounter skepticism about what they are experiencing. “It was important … to defuse the idea that I might think he was imagining his pain,” Engstrom says. “So I [told him] that I accepted that his pain was real and that all pain is experienced from both body and mind. I told him that we would be a team and work on this together.”

Engstrom and the client worked together for five months. As they followed the treatment plan, the man’s physician slowly eased him off of the OxyContin.

Engstrom began by teaching the client relaxation exercises such as progressive muscle relaxation. “When in pain, the natural inclination of the body is to contract muscles,” Engstrom explains. “In the long term, this reduces blood flow to the painful area and slows the healing process. Contracted muscles can be a direct source of pain.”

Engstrom also began using biofeedback to promote further relaxation. In biofeedback sessions, sensors are attached to the body and connected to a monitoring device that measures bodily functions such as breathing, perspiration, skin temperature, blood pressure, muscle tension and heartbeat.

“When you relax, clear your mind and breathe deeply, your breathing slows and your heart rate dips correspondingly,” Engstrom explains. “As the signals change on the monitors, you begin to learn how to consciously control body functions that are normally unconscious. For many clients, this sense of control can be a powerful, liberating experience.”

As Engstrom’s client learned to control his responses, he began reporting a decrease in pain following the relaxation exercises.

Engstrom also used cognitive behavior therapy (CBT) methods, including asking the man to keep a daily journal recording his pain level at different times of the day, along with his activity and mood. Through the journal, the man started recognizing that his pain level wasn’t constant. Instead, it varied and was influenced by what he was doing and thinking at the time.

Engstrom highly recommends CBT for pain treatment because it helps provide pain relief in several ways. “First, it changes the way people view their pain,” he says. “CBT can change the thoughts, emotions and behaviors related to pain, improve coping strategies and put the discomfort in a better context. You recognize that the pain interferes less with your quality of life and, therefore, you can function better.”

In this case, the client was trapped by thoughts that “the pain will never go away” and “I’ll end up a cripple,” Engstrom says. He and the client worked on CBT exercises for several months, keeping track of and questioning the validity of such negative future thoughts. They also practiced substituting more helpful thoughts, including “I will take each day as it comes” and “I will focus on doing the best I can today.”

Chronic pain often engenders a sense of helplessness among those who experience it, Engstrom says, so CBT also helps by producing a problem-solving mindset. When clients take action, they typically feel more in control of their pain, he says.

CBT also fosters new coping skills, giving clients tools that they can use in other parts of their lives. “The tactics a client learns for pain control can help with other problems they may encounter in the future, such as depression, anxiety or stress,” Engstrom says.

Because clients can engage in CBT exercises on their own, it also fosters a sense of autonomy. Engstrom often gives clients worksheets or book chapters to review at home, allowing them to practice controlling their pain independently.

Engstrom notes that CBT can also change the physical response in the brain that makes pain worse. “Pain causes stress, and stress affects pain-control chemicals in the brain, such as norepinephrine and serotonin,” he explains. “By reducing arousal that impacts these chemicals, the body’s natural pain-relief responses may become more powerful.”

Although Engstrom acknowledges that he could not completely banish the discomfort his client felt, he was able to lessen both the sensation and perception of the man’s pain and give him tools to better manage it.

Taking away pain’s power

Mindfulness is another powerful tool for lessening the perception of pain, says licensed professional counselor (LPC) Russ Curtis, co-leader of ACA’s Interest Network for Integrated Care.

Mindfulness teaches the art of awareness without judgment, meaning that we are aware of our thoughts and feelings but can choose the ones we focus on, Curtis continues. He gives an example of how a client might learn to regard pain: “This is pain. Pain is a sensation. And sensations tend to ebb and flow and may eventually subside, even if just for a little while. I’ll breathe and get back to doing what is meaningful to me.”

Engstrom agrees. Unlike traditional painkillers, mindfulness is not intended to dull or eliminate the pain. Instead, when managing pain through the use of mindfulness-based practices, the goal is to change clients’ perception of the pain so that they suffer less, he explains.

“Suffering is not always related to pain,” Engstrom continues. “A big unsolved puzzle is how some clients can tolerate a great deal of pain without suffering, while others suffer with relatively smaller degrees of pain.”

According to Engstrom, the way that people experience pain is related not just to its intensity but also to other variables. Some of these variable include:

  • Emotional state: “I am angry that I am feeling this way.”
  • Beliefs about pain: “This pain means there’s something seriously wrong with me.”
  • Expectations: “These painkillers aren’t going to work.”
  • Environment: “I don’t have anyone to talk to about how I feel.”

By helping people separate the physical sensation of pain from its other less tangible factors, mindfulness can reduce the suffering associated with pain, even if it is not possible to lessen its severity, Engstrom says.

According to Engstrom, mindfulness may also improve the psychological experience of pain by:

  • Decreasing repetitive thinking and reactivity
  • Increasing a sense of acceptance of unpleasant sensations
  • Improving emotional flexibility
  • Reducing rumination and avoidant behaviors
  • Increasing a sense of acceptance of the present moment
  • Increasing the relaxation response and decreasing stress

Curtis, an associate professor of counseling at Western Carolina University in North Carolina, suggests acceptance and commitment therapy (ACT) as another technique to help guide clients’ focus away from their pain.

“ACT can help people revisit what their true values are, whether it’s being of service, having a great family life or creating art,” he notes. Encouraging clients to identify and pursue what is most important to them helps ensure that despite the pain they feel, they are still engaging in the things that give their lives meaning and not waiting for a cure before moving forward, Curtis explains.

Teamwork and support

In helping clients confront chronic pain, Curtis says, counselors should not forget their most effective weapon — the therapeutic relationship. Because living with chronic pain can be very isolating, simply sitting with clients and listening to their stories with empathy is very powerful, he says.

Counselors have the opportunity to provide the validation and support that clients with chronic pain may not be getting from the other people in their lives, says Christopher Yadron, an LPC and former private practitioner who specialized in pain management and substance abuse treatment. The sense of shame that often accompanies the experience of chronic pain can add to clients’ isolation, he says. According to Yadron, who is currently an administrator at the Betty Ford Center in Rancho Mirage, California, clients with chronic pain often fear that others will question the legitimacy of their pain — for instance, whether it is truly “bad enough” for them to need extended time off from work or to miss social occasions.

Curtis says it is important for counselors to ensure that these clients understand that the therapeutic relationship is collaborative and equal. That means that rather than simply throwing out solutions, counselors need to truly listen to these clients. This includes asking them what other methods of pain relief they have tried — such as supplements, over-the-counter painkillers, physical therapy, yoga or swimming — and what worked best for them, Curtis says.

The U.S. health care system has led many people to believe that there is a pill or surgery for every ailment, Curtis observes. This makes the provision of psychoeducation essential for clients with chronic pain. “Let them know there’s no magic bullet,” he says. Instead, he advises that counselors help clients see that relief will be incremental and that it will be delivered via multiple techniques, usually in conjunction with a team of other health professionals such as physicians and physical therapists.

Curtis, Yadron and Engstrom all agree that counselors should work in conjunction with clients’ other health care providers when trying to address the issue of chronic pain. Ultimately, however, it may be up to the counselor to put the “whole picture” together.

A 60-something female client with severe depression was referred to Engstrom from a pain clinic, where she had been diagnosed and treated for fibromyalgia. After an assessment, Engstrom could see that the woman’s depression was related to continuing pain, combined with social isolation and poor sleep patterns. The woman was unemployed, lived alone and spent most of her day worrying about whether her pain would get any better. Some of her previous doctors had not believed that fibromyalgia was a real medical concern and thus simply had dismissed her as being lonely and depressed. Despite finally receiving treatment for her fibromyalgia, the woman was still in a lot of pain when she was referred to Engstrom.

Engstrom treated the woman’s depression with CBT and taught her to practice mindfulness through breathing exercises and being present. Addressing her mood and sleep problems played a crucial role in improving her pain (insomnia is common in fibromyalgia). By dismissing the woman’s fibromyalgia diagnosis, discounting the importance of mood and not even considering the quality of her sleep, multiple doctors had failed to treat her pain.

Engstrom points out that in this case and the case of his client with lower back pain, successful treatment hinged on cognitive and behavioral factors — manifestations of pain that medical professionals often overlook.

 

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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

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

A counselor looks at football

By Kevin Doyle January 29, 2018

I have been a lifelong football fan. I remember playing outside in the snow, emulating the National Football League (NFL) stars of the 1960s and then going inside to watch some of the fabled rivalries of the time, like the Kansas City Chiefs versus the Oakland Raiders. I grew up on Joe Namath’s Super Bowl guarantee, Franco Harris’s “Immaculate Reception,” and the undefeated Miami Dolphins team of 1972. My beloved Washington football franchise (yes, that name is a problem — but that is for another story) owned the 1980s (along with the San Francisco 49ers), and my brother and I sported Charley Taylor (42) and Larry Brown (43) jerseys in the previous decade. My two sons played the game at the high school level, both excelling and taking much from the experience. In short, I was raised on football in many ways.

All of these things will stay with me, but recent events have conspired to lead me to question of whether the sport in its current form is morally defensible. Recently, coverage of the death by suicide of former New England Patriots player, and convicted murderer, Aaron Hernandez, noted that his brain had advanced chronic traumatic encephalopathy (CTE), and a study published in 2017 in JAMA found evidence of CTE in 110 of 111 former NFL players.

Former NFL player Antwaan Randle El, a nine-year NFL veteran who is now in his late 30s, recently spoke out about his memory problems. He became the latest in a series of both high- and low-profile professional players known or alleged to have had serious brain issues possibly due to their football careers. This includes well-known players such as Junior Seau, Dave Duerson, Mike Webster and Frank Gifford.

The national discourse has been stirred by Steve Almond’s searing Against Football: One Fan’s Reluctant Manifesto; the film Concussion, based on the work of forensic pathologist Bennet Omalu and the work of Jeanne Marie Laskas in her article for GQ titled Game Brain; as well as pro football works such as Gregg Easterbrook’s The Game’s Not Over: In Defense of Football and Mark Edmundson’s Why Football Matters: My Education in the Game.

What, then, is the role of the professional counselor in this debate — or is there one? I submit that counselors in a variety of settings have a responsibility to be aware of this issue that is currently facing our culture, and there are several reasons why.

First, this appears to be a significant safety issue for a segment of our population, namely those individuals who have either played football in the past or are currently playing. No less an authority than the Mayo Clinic has reported that symptoms such as aggression, motor impairment, tremor, memory loss, irritability and focusing problems are associated with CTE.

If an adult male were to report symptoms such as these in counseling, it could be prudent to check to see if the client was once a football player. Referral for additional medical assessment could be an appropriate course of action, although currently, no effective treatments for CTE-related symptoms seem to be available. In fact, a definitive diagnosis cannot be made until tests of the brain can be conducted after an individual’s death.

For players currently involved in football, repeated concussions could be placing those individuals at increased risk and should be monitored. Most levels of play, including the NFL and NCAA, have put so-called “concussion protocols” in place to prevent players from continuing to play until they have received medical clearance. Although counselors would likely not play a leading role in these determinations, it would be advisable for counselors working on college campuses, with professional football players or even at lower levels (high school, middle school, youth football) to be aware of them and to support efforts to protect player safety.

Second, the question of whether to allow children to play football has become an emotional and sometimes conflict-ridden debate within families. Participation rates in both high school and youth football have widely been reported to be declining and show no signs of changing in the near future, according to numerous sources.

Counselors routinely work with children and families, and reaching a decision about whether a child should play football can be difficult. An informed decision must balance the potential safety concerns associated with the sport and the potential benefits of playing the sport, including physical activity and learning about teamwork and discipline. In some families, football is seen as a rite of passage — something that adolescent males (and, in some cases, females) engage in as part of the maturation process. In some cases, it may be the child who desperately wants to play, while the parents are warier. In other cases, parental pressure on a child to participate may be the driving issue. In either instance, a counselor, whether school-based or community-based, may be in a position to help the family make this decision. Knowledge of some of the relevant issues is essential to any effort to be of assistance.

Third is the reality that any societal issue can make its way into a counseling session. This is not to imply that we as counselors need to be experts on any and all social and societal issues. However, we do have a responsibility to be aware of burgeoning issues facing our culture and to be ready to discuss or address them —or at least to listen to our clients do so.

Many of us no doubt had clients with opinions about the most recent presidential election. Their thoughts naturally made their way into counseling sessions. Our own personal feelings aside, we had a responsibility as counselors to listen, to consider our clients feelings and opinions, and to ponder what role, if any, these thoughts contributed to the stressors they were facing. Likewise, we must strive as counselors to stay informed about myriad issues of relevance to our clients. Societal question such as same-sex marriage, health care, immigration and employment barriers for those with criminal convictions, to name a few, play out in our clients’ lives on a daily basis.

Granted, the issue of football may pale in comparison to some of these, but we have a responsibility nonetheless to pay attention, to inform ourselves and to monitor the debate, because it may well come up in a counseling session with an individual or family. If we are unaware of this issue (or another one), we may need to do further research in between sessions or, in extreme cases, even consider referring our client to another provider with more knowledge of the issue he or she is facing.

Finally, there are social justice issues to be considered, consistent with the counseling profession’s recent emphasis in this area. One would have to have been living under the proverbial rock not to have noticed the emotional national dialogue around NFL players sitting or kneeling during the playing of the national anthem. Started by former San Francisco 49er quarterback Colin Kaepernick in 2016, this protest has spread to other players and teams and led to an increasingly hostile “conversation” about the form of the protest itself, overshadowing the issue of police brutality that Kaepernick sought to highlight.

The various authors I noted earlier identified numerous concerns more specifically related to football that are of a social justice nature. Approximately 68 percent of NFL players are African American, and the treatment of players has been criticized by some as evoking memories of slavery by the so-called “owners” of the franchises. Anyone who has ever watched the “meat market” known as the NFL Combine, which consists partly of athletes’ bodies being examined by prospective employers (owners), and which is now nationally televised, cannot help but notice this parallel. With the average NFL career lasting less than four years and contracts, even when lucrative, not being guaranteed in case of injury, discerning individuals can easily raise legitimate social justice questions.

In summary, a growing national conversation about football, its viability, its safety and its future is becoming difficult to ignore. Counselors at various levels and in various settings have a responsibility not only to be aware of this conversation, but also to consider its significance in relation to the clients with whom we work. Engaging in this conversation is consistent with current calls within the profession for social justice.

 

 

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Kevin Doyle is a licensed professional counselor in Virginia and an associate professor in the counselor education program at Longwood University. He has also coached youth, high school and adult sports for the past 30 years. Contact him at doyleks@longwood.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Food for thought

By Laurie Meyers January 25, 2018

With January now behind us, the annual barrage of diet and fitness commercials has started to fade. Many people who made New Year’s resolutions to lose weight or “get fit” have already labeled themselves failures for indulging on leftover holiday chocolate and not making it to the gym more than twice per week. Other determined warriors in the fight to attain the perfect size and shape may stick to their resolutions and lose the desired amount of weight, only to find that they’ve gained it all back (and then some) within six months. This cycle of dieting and weight loss, followed by weight gain, is a process that many Americans go through over and over again, often in search of an unattainable or unsustainable ideal.

“The primary message we get from popular culture is that our worth is based on our appearance and the ability to achieve a thin and beautiful cultural ideal,” says Laura H. Choate, editor of the book Eating Disorders and Obesity: A Counselor´s Guide to Treatment and Prevention, published by the American Counseling Association. “When individuals internalize this message — that they are only worthwhile or acceptable if they are able to achieve this ideal — they develop a negative body image, which can lead to dieting and disordered eating behaviors.”

According to the National Eating Disorders Association, in the United States, approximately 20 million women and 10 million men will struggle with a clinically significant eating disorder at some point in their lives. Experts say that many millions more will engage in disordered eating — patterns of behavior that resemble those of eating disorders but which do not meet clinical criteria. Symptoms of disordered eating may include chronic dieting, frequent weight fluctuations, extremely rigid and unhealthy food and exercise regimens, emotional eating and a preoccupation with food, body and weight issues that causes distress.

Ashamed to eat?

Licensed mental health counselor Tamara Duarte, a private practitioner in the Vancouver, Washington, area who specializes in treating women with eating disorders and body and food issues, says that we live in a culture that has normalized chronic dieting. She refers to this phenomenon as the “dieting roller coaster.”

Women come to Duarte, an ACA member, having spent years pingponging back and forth between restrictive diets and binge eating. After attempting to limit their consumption only to “good” food, these clients have typically fallen off of their diet wagon and ended up in a binge cycle, during which they eat all of the foods they consider “bad,” Duarte explains. Feeling guilty, the women go back to dieting and start the cycle all over again.

Duarte also sees clients who have gained weight as they have aged and want to get their former bodies back — even if it is through unhealthy means. “People come in and tell me that they used to have a restrictive eating disorder and wish they could go back to that time so that they could be thin,” Duarte says.

What all of these clients have in common is a sense of shame about food and their bodies, Duarte says. Fear of being or becoming fat is so prevalent in our society that this shame has become normalized, she says. The irony is that much of the research has found that dieting ultimately leads to weight gain, Duarte notes. Chronic dieting (even at a subclinical level) may even be harmful to the body, and Duarte and other eating disorder experts say that the benefit of weight loss through dieting is unclear.

Like many who study or treat disordered eating and eating disorders, Duarte wants to remove the stigma attached to different-sized bodies. “Fat is just an adjective,” she says.

Part of breaking free of disordered eating — and eating disorders — is learning body acceptance, Duarte says. “Helping a person to accept their body as is can be a very slow, complex process,” she admits.

“I read something posted on Instagram once that said, ‘You cannot obtain recovery while actively trying to change the size and shape of your body,’” Duarte continues. “I really liked that, and I introduce that very early on in the counseling process. Throughout counseling, we look at the beliefs the client has about their body and where those stem from. Typically, thoughts like ‘I’m ugly and unlovable in this body’ stem from society or family members. It’s interesting because none of my clients so far have thought others are unlovable because of their body size, so I question what makes them different. We also look at how screwed up society is for picking one body size as being beautiful and acceptable. With a recovering mind, they are able to recognize how erroneous these thoughts are.”

Duarte also asks clients to get rid of their scales. “Not relying on an arbitrary number to tell them whether they are ‘good’ or ‘bad’ frees them up to connect in with themselves to figure out how they are feeling,” she explains.

Intuitive eating and Health at Every Size

Duarte has personal experience both with eating disorders and the power of that “arbitrary number.” She had been in recovery for more than 10 years when she happened to gain about 45 pounds because of some medication she was taking. Uncomfortable in her new body size, Duarte was ready to put herself on a diet and workout regimen. But then she attended some seminars on intuitive eating, an approach created by dietitian Evelyn Tribole and nutrition therapist Elyse Resch, both of whom specialize in eating disorders. Intuitive eating rejects dieting. Instead, it advocates listening to the body’s signals of hunger and fullness and getting rid of the idea of “good” and “bad” foods, among other principles.

Duarte also learned about Health at Every Size (HAES), a program and social movement inspired by the book written by Linda Bacon, a nutrition professor and researcher. HAES advocates the acceptance of bodies of all sizes, rejects dieting and calls for addressing health concerns directly with healthy behaviors. Both intuitive eating and HAES also encourage physical activity in whatever form a person naturally enjoys.

“I immediately recognized the power of teaching IE [intuitive eating] and HAES to clients,” Duarte says. “Both HAES and IE teach that when you listen to your body and feed it what it wants, when it wants, how much it wants, your body will naturally go to its set point range — the weight range where it works optimally. HAES tells me that I am OK no matter what my body looks like and that I can love and accept it right now.”

After learning about intuitive eating and HAES, Duarte started following the principles found in each approach. “At that point, I had a laundry list of good foods and bad foods, so I did the work to incorporate my ‘bad’ foods back into my diet,” she says. “An incredible thing happened: As I allowed myself to want and have these foods, the power they used to hold went away. Pizza was pizza. In the past, I would not allow myself pizza, and if I did decide to allow it, I would eat like five pieces because it tasted so good and I was telling myself I wouldn’t have it again. When pizza became accessible, I realized I only wanted one or two slices, and then I was able to step away because I knew that the next time I wanted pizza — in 10 minutes or 10 days — I would be able to eat it.”

Duarte also realized that although she enjoyed going to the gym, the activity she loved best was going on walks with her dog. So, instead of carving out time to devote to workouts, she started spending more time walking her dog.

“I really enjoy my walks when I go on them, and I am kind to myself when life gets busy and I can’t or don’t want to fit them in,” she says. “I no longer berate myself because the walks are for self-care, not to manipulate the size and shape of my body. I enjoy the array of foods I eat. I love opening a menu and deciding based on what I want instead of what I ‘should have.’ I never thought I would have this kind of relationship with food or my body.”

For those who might wonder whether Duarte lost weight, she responds that it doesn’t matter because her body shape and size have no bearing on her happiness or success.

Combating body hatred

Knowing from personal experience that intuitive eating and HAES can be very effective, Duarte now incorporates the approaches into her counseling work. “Every single client that calls my office for a free consultation ends up telling me that what they want most from counseling is freedom,” she says. “Freedom from the eating disorder, the never-ending thoughts about weight and food, freedom from self-hatred. I know that HAES and IE [are huge pieces] of the puzzle when it comes to freedom.”

“I don’t have to tell my clients about my experience with HAES and IE,” she continues. “I just have it with me when I am helping to guide them through it. It influences the way I feel and think about my clients’ bodies as well. I do not hold judgments about people’s bodies because of what I have learned in my journey, and my clients know I don’t judge them. When I tell my clients that their body is acceptable no matter what it looks like, I mean it, and they know it.”

Duarte discusses how HAES and intuitive eating helped guide her treatment of a teenage client she calls “Sara,” who was restricting her food intake and using exercise and vomiting to purge. “Sara believed that her body was wrong and ugly because it didn’t look like her family members, who were taller and built leaner than she was,” Duarte says. “One of the first things I had Sara do was put her scale away in a place that she wouldn’t have easy access to.”

Duarte introduced Sara to intuitive eating and its philosophy that foods should neither be demonized nor celebrated. Sara was particularly resistant to this concept, but Duarte successfully encouraged Sara to slowly add “forbidden foods” back into her diet.

Duarte also used mindfulness to help Sara with her purging behavior. “We worked on mindfulness, so she was able to identify when the urge to purge was coming on,” Duarte says. “She would write down for me everything that she was thinking — why she wanted to purge and why she didn’t.”

The urges would usually pass, and over time, Sara was able to get through them by using tools she had learned in session. Duarte teaches all of her clients distraction and self-soothing skills drawn from dialectical behavior therapy. Examples of distraction activities include dancing to a favorite song, writing or drawing, calling or texting a friend and going for a walk or a drive. Self-soothing might involve clients taking a shower, painting their fingernails (an activity that Duarte says is great for people with bulimia because they can’t induce vomiting with wet nails) or giving themselves a foot massage.

With time — and the help of the tools she had learned — Sara no longer experienced urges to purge. It took awhile for Sara to grow comfortable with her body, but she began to enjoy the increasing sense of physical strength that came from no longer restricting her food intake, Duarte says. Over time, that physical feeling of strength also became psychological.

“She struggles from time to time with not liking how she looks, but she’s able to identify what’s really going on at those times,” Duarte says. “Typically, Sara is stressed or scared, and instead of feeling [that], she focuses on her body and her need to change it. [But now] she uses the tools we have worked on in session, and she feels her feelings effectively, and most often, the body hatred goes away too.”

Alternatives to emotional eating

Licensed professional counselor Rachael Parkins is a practitioner at the Bucks Eating Support Collaborative in Bucks County, Pennsylvania, where she currently runs a support and therapy group for emotional eating. The group meets weekly and serves as a place for women to share their challenges, support one another and get professional guidance from Parkins. Group members may be struggling with a variety of concerns, but food is their common method of coping with emotions and issues such as stress, insecurity, self-esteem and body image, Parkins explains. Most of the women are working with a dietitian, and group members also have access to an intuitive eating coach.

The goal of the group is to learn how to handle emotions in a healthy way by working on methods such as distress tolerance. Group participants identify distressing emotions, such as loneliness, and Parkins helps them identify alternative ways to cope with what they’re feeling. Sometimes, this can be as simple as group members going out of their way to be kind to themselves and practice self-care, such as putting on lotion or taking a bubble bath. Other methods are more concrete, such as journaling or completing a decatastrophizing worksheet. In that case, participants write down their worst thoughts, evaluate the worst-case scenario and the likelihood of it happening, and identify other possible outcomes.

Parkins also encourages group members to acknowledge the small victories they experience in pursuit of their personal goals by recording them in a log. For example, a group member might state a goal of practicing better self-care. For this particular group member, an action such as getting out of bed and taking a shower might represent a small victory. Another participant might want to stop procrastinating. Calling to set up a doctor’s visit could be a small victory, even if the group member doesn’t keep the appointment.

Parkins also helps group members break free of comparisons, both with other people and themselves. She explains that participants regularly hold themselves and how they look up not only to the perceived “successes” of others in their lives, but also to their own past selves. Parkins says it is not uncommon for group members to express a desire to go back in time to when they were thinner, even if it was a miserable point in their lives.

“They have this idea in their head that if they get to this size or number on the scale, that’s going to bring happiness,” she says. “Losing weight might be desirable, but as an emotional focus, it’s never enough. I’m helping people accept that losing weight is not the answer.”

Signs of a problem

Although not every client who diets is engaging in disordered eating, counselors should regularly assess for eating and body issues, says Choate, a professor of counselor education at Louisiana State University.

“We know that a large proportion of the population experiences problems related to eating and negative body image, so it is reasonable for counselors to assess for these issues with all of their clients,” she says. “Because clients with eating-related problems might come to counseling with other issues — depression, anxiety, relational problems — asking questions specifically related to eating patterns and body image is a good way to explore to see if these problems are contributing in any way to the client’s presenting issues.”

Choate suggests asking the following questions:

  • Is the disordered eating pattern causing problems in the person’s life?
  • Does the disordered eating pattern interfere with the person’s relationships with others? With the enjoyment of life activities? With completing daily routines?
  • Does the client’s weight, shape or appearance unduly influence self-esteem?
  • Does the client believe that she or he is less acceptable if weighing a few pounds more than in the past or, conversely, that she or he is more acceptable if weighing a few pounds less?

When assessing clients for signs of an eating disorder, Duarte says, it is essential that counselors not be misled by the stereotypical presentation of extreme thinness. The stigma attached to larger bodies often can obscure the reality that eating disorders may occur in people of all sizes, she says. In part because our society generally expects that people who do not fit into an idealized size range want and need to lose weight, counselors may be less likely scrutinize dieting behavior and weight loss in larger clients. Like Choate, Duarte believes that counselors should assess all clients for signs of disordered eating.

Choate also offers one final caution for counselors. “While there are some eating-related problems that might respond well to counseling alone, it is important to be aware that eating disorders are chronic, and anorexia in particular has the highest mortality rate of any psychiatric disorder. Treatment of these disorders requires specialized knowledge and training, and because eating disorders all involve a medical component, the involvement of a multidisciplinary treatment team is required. This would include, at minimum, a physician or medical professional, a dietitian and the counselor.”

 

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Defining eating disorders: Changes in diagnosis

Laura H. Choate notes that in the past, most individuals with eating disorders fell into the diagnostic criteria of eating disorders not otherwise specified (EDNOS), which led to changes in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

The criteria for anorexia nervosa and bulimia nervosa were expanded to include more people. Binge eating disorder was added as a stand-alone disorder (rather than remaining as previously listed as a subcategory under EDNOS). EDNOS was renamed “other specified feeding or eating disorder” and includes issues such as:

  • Atypical anorexia nervosa: All criteria for anorexia nervosa are met; despite significant weight loss, the individual’s weight is within or above the normal range.
  • Bulimia nervosa of low frequency or limited duration
  • Binge eating disorder of low frequency or limited duration
  • Purging disorder
  • Night eating syndrome

 

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Multicultural considerations

Although often perceived as a “white” problem, eating disorders and disordered eating do occur among women and men of color, says Regine Talleyrand, an American Counseling Association member whose research focuses on eating disorders among women of color.

“Counselors should be aware that women of color do experience concerns regarding beauty and body esteem,” she says. “[However], the traditional methods of evaluating these factors — weight, body parts, preoccupation with thin body ideals — may not capture the real body appearance concerns of all women of color.” Talleyrand, an associate professor and coordinator of the counseling and development program at George Mason University in Virginia, says that characteristics such as hair, skin color and facial features may be more relevant when evaluating body image in women of color.

In addition, high rates of obesity and binge eating among Latina and African American women highlight the need to look beyond “traditional” eating disorders such as anorexia and bulimia when working with women of color who struggle with eating, weight or body issues, Talleyrand says. Because African American and Latina women are even more likely than white women to display eating disorder symptoms at any size, counselors who are evaluating clients of color for disordered eating should also look beyond the stereotypical underweight image, she emphasizes.

Of course, the factors influencing the risk of eating disorders in all populations go beyond appearance. These factors are often culturally specific. In particular, racism and oppression may play a significant part in eating disorder risk among Latina and African American women, Talleyrand says. In fact, the development of eating disorder symptoms — particularly binge eating — has been linked to racism and oppression experienced by African American women, she adds.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Eating Disorders and Obesity: A Counselor´s Guide to Treatment and Prevention, edited by Laura H. Choate

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Anorexia Nervosa” by Shannon L. Karl

Journal articles (counseling.org/publications/counseling-journals)

  • “Special Section: Assessment, Prevention and Treatment of Eating Disorders: The Role of Professional Counselors,” Journal of Counseling & Development, July 2012

 

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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

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.