Monthly Archives: March 2019

Building a kinder and braver world

By Bethany Bray March 13, 2019

When Cynthia Germanotta discusses how complicated and misunderstood mental illness can be, she speaks from a place of knowing because her family has lived the reality. Germanotta is the mother of two daughters, the oldest of which, Stefani — better known as Oscar and Grammy Award-winning artist Lady Gaga — is open about her struggles with posttraumatic stress disorder, depression and anxiety.

“My husband and I tried our best (and still do!) to be deeply loving and attentive parents, who made sure we had regular family dinners and spent hours talking with our children. But, for all of that communication, we still didn’t really understand exactly what they needed sometimes,” Germanotta wrote in a candid essay last year. “Like many parents, I didn’t know the difference between normal adolescent development and a mental health issue that needed to be addressed, not just waited out. I mistook the depression and anxiety my children were experiencing for the average, if unpleasant, moodiness we all associate with teenagers.”

Cynthia Germanotta

Together, Germanotta and Lady Gaga work to combat the stigma and misunderstanding that often surround mental health issues through the Born This Way Foundation, a nonprofit they co-founded in 2012. Germanotta will speak about mental health and the work of the foundation during her keynote address at the American Counseling Association’s 2019 Conference & Expo in New Orleans later this month.

Through research and youth-focused outreach programs, the Born This Way Foundation works to disseminate information and resources about mental health and help-seeking. Its mission is to “support the wellness of young people and empower them to create a kinder and braver world.”

Counselors, Germanotta asserts, have an important role to play in achieving that goal. She recently shared her thoughts in an email interview with CT Online.

 

Q+A: Cynthia Germanotta, president of the Born This Way Foundation

 

Part of the mission of your foundation is to empower young people to “create a kinder and braver world.” From your perspective, what part do professional counselors have to play in that mission? What do you want them to know?

Building a kinder, braver world takes everyone — including (and especially) counselors. As adults who care about and work with young people, counselors can and do help young people understand how to be kind to themselves, how to cope with the challenges that life will throw their way, and how to take care of their own well-being while they’re busy changing the world.

To us, being brave isn’t something you just have the will to do; it’s something you have to learn how to do and be taught the skills for, and counselors can help young people do that. Counselors are a vital part of the support system that we need to foster for young people so that they are able to lead healthy lives themselves and to build the communities they hope to live and thrive in.

 

What would you share with counselors — from the perspective of a nonpractitioner — about making the decision to seek help for mental health issues or helping a loved one make that decision? How can a practitioner support parents and families in making that decision easier and less associated with shame or stigma?

When you’re struggling with your mental health, asking for help is one of the toughest, bravest and kindest things you can do and, for so many, shame and stigma make these conversations even harder. If that’s going to change (and my team works every day to ensure that it does) we have to normalize discussions of mental health, turning it from something that’s only talked about in moments of crisis to just another regular topic of conversation.

Practitioners can help the people they work with, and their loved ones, learn strategies for talking about mental health, equipping them with the skills they need to communicate about an important part of their lives.

 

What motivated you to accept this speaking engagement to address thousands of professional counselors?

My daughter would be the first one to say, we can’t do this work alone. Fostering the wellness of young people takes all of us working together.

Counselors are such a crucial part of the fabric that surrounds and supports young people, so I was honored to be invited to speak to the American Counseling Association and have the opportunity to not only share our work at Born This Way Foundation, but to hear from (and learn from) this amazing group of practitioners.

 

What can American Counseling Association members expect from your keynote? What might you talk about?

I’m so looking forward to sharing a bit about Born This Way Foundation — why my daughter and I decided to found it, what our mission is and how we’re working toward our goal of building a kinder and braver world, including a couple of new programs we’ve excited to be working on this year.

I’m also excited to share what we’re hearing from young people themselves about mental health. We invest heavily in listening to youth in formal and informal situations, in person, online and through our extensive research. We’ve learned so much through this process, and we have some important insights we’re looking forward to sharing, including the results of our latest round of research where we collected data from more than 2,000 youth about how they perceive their own mental wellness [and] their access to key resources.

 

How have you seen the mental health landscape in the U.S. change since you started the Born This Way Foundation in 2012? Are things changing for the better?

Over the past seven years, we’ve seen real momentum around both the willingness to discuss mental health and the urgency of the challenges that so many young people face. We certainly have a long way to go, but I truly believe we’re starting to move the needle.

There are so many examples of the progress being made on mental health — public figures starting to talk about it, global advocates organizing around it, governments starting to invest in it, schools starting to prioritize it, and so much more.

And, as always, I’m inspired by young people who are so much further ahead on this issue than I think we sometimes give them credit for. In the research we’ve done, about 9 out of 10 young people have consistently said mental health is an important priority. There’s still work to do, but that’s a great foundation to build on.

 

After seven years of working on mental health and the foundation’s youth-focused initiatives, what gives you hope?

Young people give me hope. The youth that we have had the privilege to meet and work with throughout the years are so inspiring, demonstrating time and time again just how innovative, brave and resilient they are.

Young people already recognize mental health as a priority and have the desire and determination to change how society views and treats this fundamental part of our lives. Their bravery and enthusiasm make me excited for the future they will build, and [we are] committed to fostering their leadership and well-being.

 

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Hear Cynthia Germanotta’s keynote talk Friday, March 29, at 9 a.m. at the 2019 ACA Conference & Expo in New Orleans. Find out more at counseling.org/conference.

 

Find out more about the Born This Way Foundation at bornthisway.foundation

 

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In her own words

Read more about Germanotta’s perspective and experience through two articles she has written:

 

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

 

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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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.

The caregiving conundrum

By Tia Amdurer March 12, 2019

The branch of therapy that deals with anticipated loss due to death is a specialization that often gets overlooked. As a counselor who works with anticipatory grief and has five years’ experience in a hospice bereavement office, I have found that primary caregivers usually need guidance and support but don’t ask for it until they are completely overwhelmed. Counseling for end-of-life caregiving is very much an area in which good therapists can make the difference. 

Current Medicare standards for hospice do not cover the cost of a bereavement specialist for family members of a dying patient. Unless the family or caregiver seeks an outside therapist, chaplains and social workers affiliated with assisted living facilities or hospices become the de facto mental health experts, juggling family dynamics, anticipatory grief, medical regulations, spiritual concerns and the patient’s care plan.

Caregivers: The unsung heroes

Whether end-of-life care is being given in a home or a facility, caregivers can grow overwhelmed by the physical and emotional toll of their responsibilities. They may start showing signs of anticipatory grief, including mourning the loss of their role and relationship and fearing the future. This can be coupled with anger at the isolation and abandonment by others, bitterness at the exhaustion, frustration at the never-ending demands, shame for wishing caregiving were over already (which would mean the patient’s demise), helplessness at being unsure about what they should be doing and sadness at the way that time is running out.

In my book Take My Hand: The Caregiver’s Journey, Chris Renaud-Cogswell offered written reflections on her emotional overload with caregiving responsibilities: “I’m so jealous of all of you who enjoy your parents’ company and treasure the time you have with them. When do I get past the ‘I can’t believe this is my life,’ regretful, resentful stage? I have never used the F-word as much as I do since my mother moved in.”

Guilt seems to be the emotion that rises to the surface most often for caregivers. Even in the most “functional” homes, the intensity of caregiving can be enormous. For example, a spouse may not be capable of doing everything but still feels responsible for the care of his or her sick partner. Conversely, partners in good health may feel weighed down by the extreme change in their role and lifestyle. Adult children who are working or raising kids themselves can feel put upon to do more and angry that their time is so limited. Those caring for an elder may find old childhood resentments bubbling up. Relatives who might like to visit don’t know how to help. Asking for help triggers additional feelings of guilt and frustration among caregivers.

As grief counselors, we listen to recitations based on a lifetime of behaviors and try to help put boundaries in place. We validate and remind clients that they are doing the best they can under trying circumstances. Caregivers may struggle with the history of a poor relationship with the patient. These interpersonal dynamics are likely to continue being problematic. For many families, a storybook resolution or a full sense of forgiveness might be difficult to achieve.

One middle-aged man paid a daily visit to his dying father, who had a long history of being abusive and battling alcoholism. Despite the visits lasting for four or five hours, the man refused to interact with his father. Instead, he sat in a chair, played games on his phone and felt guilty. A daughter who had been constantly rejected by her narcissistic mother reacted by directing her frustration at staff for any minor infractions, fearing that her mother, who was dying, would deride her for her own lack of attention. In another case, an adult daughter wanted to scream at her mom for never asking for what she needed, acting out passive-aggressive patterns and playing the “martyr.” The daughter hated the nagging person she was becoming.

Caregiving can be a long journey, so, as counselors, we must explain the necessity of self-care for the caregiver. Even among caregivers who are fully engaged with their sick loved ones and content with their position, emotional exhaustion takes a toll. Whether dealing with a loved one’s personality changes or the loss of that person’s physical abilities or mental acuity, being on call as the “responsible adult” is draining. Caregiving can run the gamut of emotions and experiences, from boring to terrifying.

Self-care for caregivers includes asking for help, making schedules, sleeping, taking time alone, exercising, seeing friends, checking out support groups, praying, laughing, journaling, connecting through social media and, of course, learning to accept help. By presenting family members, friends, faith organizations or neighbors with specific ways to help, the caregiver is actually providing a service. Rather than viewing these “asks” as a burden to others, it can be reframed as an opportunity for others to do a good deed for the person who is dying.

A caregiver’s functions will depend on many variables. For instance, if the person who is dying is in a facility, the caregiver may be tasked with doing laundry, attending functions at the facility, visiting the sick loved one daily or weekly, finding coverage for meetings with facility staff to discuss behavior changes or concerns, driving the loved one to outside medical appointments, scheduling visits from friends and relatives, and maintaining a family home.

For at-home caregivers, responsibilities might include adjusting for safety precautions around the home. This might involve installing grab bars, removing throw rugs and acquiring nonslip mats, having a working fire extinguisher, checking that the water heater thermostat is set below 120 degrees Fahrenheit and preparing for durable medical equipment (such as commodes, hospital beds and oxygen tanks/cylinders). In addition, these caregivers typically shoulder the responsibility for being available to drive the person to appointments as necessary, finding coverage when away from the home and providing meals that are dietarily different.

Counselors should remind clients who have caregiver responsibilities that friends or relatives might be able to visit or engage in crafts or music with a sick loved one, thus allowing the caregiver some time off. To ward off burnout, caregivers need respite.

Thus we arrive at the conundrum of respite: “If I go away for a few days, what if my loved one dies? How will I live with the guilt?”

There are two scenarios at the end of life: One, the loved one dies when someone is with them and, two, he or she dies when no one is there. Caregivers often worry that their loved one might be alone when they die. Some hospices can provide 11th-hour care, during which volunteers can sit at bedside if the family wishes.

My experience in hospice has been that some patients follow a definitive trajectory in their decline, whereas others follow an indeterminate timeline, making a family’s desire to be bedside at the last breath fraught with uncertainty. Although many cultures encourage “vigiling” at the deathbed, there is an unknown: Does the patient want the family there? Some individuals need to be alone when they die and will release from this life only when the family or a specific person leaves. The speculation about why this happens is endless, but it may help alleviate family guilt to use the metaphor of a group coming to a bridge together, but because only the dying individual may cross that bridge, he or she will do it alone. 

Family dynamics

As counselors, we should encourage caregivers to see that a document such as Five Wishes (fivewishes.org) is completed while the elder is mentally competent. This document serves as a directive about how the patient wishes to be cared for at the end of life. It is a binding document like a living will. In considering end-of-life protocols, all adults should be encouraged to write down their wishes so that these are known in advance.

During a crisis or major upset in a family system, different personality traits come to the fore. Family members who aren’t the primary caregiver might assume many roles at the end of life: the Swooper, the Know-It-All, the Call-Me-If-You-Need-Me sibling, the I-Don’t-Know-Anything-About-Dying-Elders family member … All the family roles are intensified. Folks who have a personal need to make amends come crashing in. The Golden Child comes back for a weekend and questions everything that’s been done.

Renaud-Cogswell shared her experience in Take My Hand: “Mom was diagnosed with lymphoma a week and a half ago. The hospice team began coming to care for her at our house shortly thereafter. Brother wants to take mom to lunch. Incredulous, I tell him she is sick, she has lymphoma, and that he could bring lunch here. He brings lunch. He doesn’t, however, bring lunch for me. Not something I should be overly surprised by, but I am hurt nonetheless. Then brother asks Mom if she would like to move into his empty townhouse. (Alone.) Then he and his girlfriend begin telling her all the positives about moving in there. I say, ‘She’s sick. She needs 24-hour care.’ Brother says, ‘Since I kicked my renters out, I need the money.’

“Loudly enough for them to hear, but soft enough so that Mom doesn’t, I hiss, ‘She’s dying!’ Then what do you suppose this brother asks our mother? ‘Can I borrow $500?’ (Who asks their dying mother for money???) And do you know what? She gives it to him! This was yesterday. I ran from the minute my feet hit the floor in the morning till my head hit the pillow at midnight last night. I need to sit down and have a good cry, but today, I’m afraid, will be just as busy.”

There are additional complications that must be addressed when “helpers” come. For caregivers, it is a frustrating and delicate struggle between wanting support and allowing helpers to make mistakes while visiting. The strain of feeling that no one else can do the caregiving correctly is immense. Caregivers should establish safety rules that are nonnegotiable — for example, the parent cannot go out without oxygen, medications must be administered on time, hospice will be called if the elder falls.

Grief counselor David Maes created a template (see below) that can be used when conflict arises between family members. The template helps ensure that during a family meeting, the identified patient remains the center of attention. Family members respond to prompts written in the appropriate boxes. Other concerns are written outside the square in list format.

Start by asking the existential questions (the upper left-hand box): What is meaningful for the patient? Before the illness, what was the person’s worldview? How did he or she move through life? What was the essence of who they were? Next, move to the upper right-hand box, which deals with patient preferences. Ask what the person likes related to music, food, art, reading, nature, hobbies, etc.

The lower left-hand box deals with the illness: How is the diagnosis and prognosis affecting the loved one’s personality, behavior, likes and worldview? What gets in the way of who they are? Finally, list the resources: How is the family going to work together? What’s the plan of care? Who is responsible for what?

Counselors might need to remind family members that past relationship dynamics should have little bearing on the here-and-now focus of the discussion. The question to ask is, “Whose death is this anyway?”

Another protocol, from Susan Silk and Barry Goldman, is called Ring Theory (see tinyurl.com/RingTheory). In this exercise, the center circle is the patient, the subsequent circle is the primary caregiver and concentric circles can identify others who are less involved with daily care. The idea is that only comfort can go inward while the difficult emotions go outward. Family members and friends can offer unconditional love to each inner circle while finding their own support and a place to vent in extending circles. Each family member may find their own rings of support.

If end-of-life care is an area you are considering as a professional counselor, begin by learning about grief and bereavement. Alan Wolfelt’s comprehensive books are available through the Center for Loss & Life Transition (centerforloss.com). The Hospice Foundation of America also offers excellent webinars and books (hospicefoundation.org). There may be local support groups for caregivers in your area, and we should also be able to direct clients to resources such as the Alzheimer’s Association (alz.org) and AARP (aarp.org).

Competency in serving caregivers and families at the end of life involves a combination of approaches. We should be able to provide psychoeducation on dying and the needs of the dying. We should be competent listeners, validating and normalizing their experiences while encouraging life review and memory making. We can offer facilitation for family discussions. We can help our clients with boundaries, rituals and support groups. Finally, we can encourage the caregiver to engage in self-care, including therapy.

 

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Tia Amdurer is a licensed professional counselor and national certified counselor with a private practice, Heartfelt Healing Counseling, in Lakewood, Colorado, that specializes in grief, loss, life transitions and trauma. She is the author of Take My Hand: The Caregiver’s Journey, which was published last year (TakeMyHandJourney.com). Contact her at tiaamdurer@gmail.com.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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.

The Counseling Connoisseur: Cultivating silence in a noisy world

By Cheryl Fisher March 11, 2019

Silence is about rediscovering, through pausing, the things that bring us joy –  Erling Kagge

In an attempt to reboot, my husband and I packed up our fur family and spent a week at the beach over the Christmas holiday. We got up each morning and trekked the shoreline immersing ourselves in the feel of the fresh salt air, the crash of the ocean waves and the caw of the seagulls flying overhead. We walked miles and miles each day — often in companionable silence with our cell phones off and tucked away in back pockets. Every now and then we would stop, plop down on the cool, damp sand and just be in silence.

Noise does not simply refer to sound, it includes the busyness of both internal and external environments. The constant need to “do” something and the aversion to boredom prevent the opportunity to relax the body and the mind. While technology has certainly contributed to the “skim, scan, scroll” processing of our world, it has also generated the technostress afforded by constant availability. Therefore, it is important to recognize the value of cultivating a practice of silence.

The Benefits of Silence

According to a study published in the March 2015 issue of the journal Brain Structure and Function, preliminary research on mice indicates that  as little as two hours of silence may promote brain cell growth by strengthening the hippocampus and improving memory. Additionally, some research has found that cultivating just moments of silence can lower blood pressure and heart rate, and improve relaxation and sleep even better than listening to soothing music.

Ways to Cultivate Silence

  1. Early morning moments: Invite intentional silence into your morning. Curl up in a blanket and sit in the dark allowing your eyes to focus slowly. Take a few moments to gaze at the sunrise, or inhale the fresh morning air. Ease into your day grounded and calm.
  2. Thankful mealtimes: Use the first few seconds prior to eating to close your eyes, take a deep breath and take a moment to appreciate your meal. Attending to your meal in this manner will not only provide you with a nice transition from your busy morning but welcome a more pleasant dining experience.
  3. Breathe: Throughout our busy days, we often forget about breath. We become complacent that the next breath will come without effort or thought. Take a moment to turn your attention to your breath. Are you taking full, deep cleansing breaths? Or do you inhale wisps of air? Take time to breathe.
  4. Meeting preludes: Begin your meetings at work with a five- minute practice of silence. This will allow the transition from work to the meeting agenda at hand. You and your co-workers will begin the meeting focused and ready to tackle the work.
  5. Media fast: Intentionally unplug for thirty minutes, an hour, a day. No cheating! No devices. A colleague of mine has initiated Unplugged Sundays, where she and her family members put away devices and spend time interacting as a family.
  6. Brisk walk in nature: Nature provides endless opportunities to soothe and refresh. Take a 15-minute walk around the block or on a nearby trail. When I work from home, I schedule a couple brief walks with my dogs to clear the clutter from my brain.
  7. Bedtime brain purge: Prior to bedtime, take a moment to purge all of the worries of the day. Lists of things left undone. Ruminations of concerns. Simply let them go long enough to prepare for slumber. You can use a journal to quickly write down your thoughts or just say them all out loud — quickly.
  8. Gratitude: I love to end my day with a gratitude list. I crawl into my comfy bed and immediately acknowledge the comforts of my home, my bed, my full tummy and the loving companions (my dogs and hubby) who share my life.
  9. Meditation practice: Consider beginning a meditation practice. A 20 minute practice morning, midday, or evening can promote calm focus to the day.
  10. Silent retreat: If you find that you crave longer jaunts with silence, consider participating in a silent retreat. Many retreat houses offer formal or informal retreats. Additionally, you may choose from group or individual silent retreats. I regularly schedule overnight escapes to the beach by myself to just reboot. I return ready to take on life’s challenges.

 

Modern-day living is accompanied by a cacophony of external noise and internal concerns. Our bodies and minds cannot sustain the ongoing level of stimulation without disease or disorder. Apparently, silence is golden, and it is imperative to make time for silence in our noisy lives. As counselors, we are trained to listen and sometimes we just need to unplug, retreat and refresh.

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.

 

 

 

 

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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.

Parent-child interaction therapy for ADHD and anxiety disorders

By Donna Mac March 6, 2019

When one hears the term “parent-child interaction therapy” (PCIT), it might be assumed the therapy’s purpose is solely for that specific use — i.e., for parents to use with their children. However, this couldn’t be further from the truth. In fact, PCIT can be used in therapy sessions, then the therapist can teach the child’s teacher how to use PCIT in the school environment and, of course, the therapist can teach parents how to use these skills at home and in community settings, all in an effort to coordinate and synchronize treatment across settings.

Sheila M. Eyberg developed PCIT in the 1970s out of the University of Florida. It was built from multiple theories of child development, including attachment, parenting styles and social learning. In the past, PCIT was intended mostly for children 2 to 7 years old with disruptive emotional disorders and behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder. The purpose of PCIT was to work on rapport building and to enhance the relationship between the child and parent, for the child to develop more intrinsic motivation to comply and for the parent to develop more positive feelings toward the child — a cycle that can then be positively repetitive.

In addition to disruptive disorders, PCIT also seems to help children with anxiety disorders. In particular, there is research demonstrating its efficacy with the anxiety disorder of selective mutism. Therefore, clinicians have also begun using it for social anxiety disorder, social phobia, school phobia and agoraphobia. In school and community settings, PCIT is used as an antecedent intervention that helps shape the environment to create an emotionally safe space for these types of anxiety disorders to be more effectively managed. (It should also be noted that PCIT can be used to treat ADHD and anxiety beyond age 7 with simple modifications.)

The goal of this therapy is to produce more prosocial behaviors, regardless of the diagnosis. For example, with anxiety disorders that specifically manifest as a fear of being around people or communicating with others, the goal is for the child to be less inhibited and avoidant. The child’s symptoms might include struggling to leave the home, averting eye contact, displaying a shrinking body posture and having frozen reactions, both in terms of a lack of verbal response and a lack of body movement (think of a “deer in the headlights” appearance). The goal in such cases is to help these children manage their symptoms so they can present in a socially expected manner.

On the other hand, children with ADHD can present as too disinhibited, demonstrating hyperactive, impulsive, incessant and intrusive behaviors, so the goal is to adjust those behaviors to be more inhibited.

Subsequently, the PCIT goal for both of these populations is to produce more desired social behaviors, which will lead to better social outcomes, thus perpetuating the cycle in a positive manner. When children receive positive social feedback, they are likely to keep using these skills in an effort to continue engaging in positive interactions.

Addressing self-esteem

PCIT is a relationship-enhancing therapeutic technique. The concepts from this therapy that I use with children who have either ADHD or avoidant anxiety disorders revolve around Eyberg’s child-directed interaction (CDI) and PRIDE skills. CDI and PRIDE go hand in hand and, when combined, have been shown to build rapport with the other person and build confidence and self-esteem within the child (in an effort to manage both disruptive and anxious-avoidant behaviors). If a child feels comfortable with a certain relationship, that child may feel more valued, worthy and confident and have stronger self-esteem. As a result, the child will be less anxious, better able to manage disruptive impulses and more likely to use expected social skills.

Children with ADHD often struggle with their self-esteem because of the amount of negative feedback they tend to receive on a daily (or more frequent) basis: “Don’t touch everything in this store.” “Stop asking me if we can go to the pool.” “Leave your sister alone.” “Why can’t you just behave?” Yet if a child receives positive feedback versus corrective feedback in an approximate ratio of 4-to-1, the child will be more likely to comply with the directive to “stop asking that question,” to “leave your sister alone,” etc.

Children with the avoidant types of anxiety disorders also struggle with self-esteem because of the negative judgments they assume and perceive that others are making about them. When these children receive praise, it helps them feel less anxious. In turn, when their brains are stabilized, they are more able to use their actual abstract counseling strategies (such as cognitive behavior therapy, or CBT) on themselves to manage their anxiety and actually “leave the house,” “maintain eye contact,” “use complete sentences” (rather than one-word answers), etc.

In therapy, PCIT can be used as a stand-alone treatment, but I recommend combining it with other therapeutic treatments such as operant conditioning, exposure therapy and CBT. Of course, the use of CBT will depend on the age of the child and whether his or her brain is developed enough to process abstract counseling strategies. Children don’t usually possess this ability until age 7 or 8. It should be noted that use of these treatment techniques (alone or in combination) does not guarantee success or an absence of symptoms.

Implementing PCIT with CDI and PRIDE

Some professionals refer to CDI as “child chooses.” Regardless of the terminology, during this portion of PCIT, no directives are to be given to the child and no questions are to be asked until CDI has been used for at least three minutes. This allows the child to feel positive about himself or herself because nobody is giving directions to correct something that the child was “doing wrong” upon entering a room or during a new transition.

When children feel positively about themselves, they are more likely to comply later down the line. Therefore, it should be noted that CDI is not a time to criticize. CDI means that the child will choose something to do without any adult direction. The adult (whether that is the counselor, the parent or the teacher) is to observe what the child does and give the child physical space if the adult’s presence seems to agitate or increase anxiety in the child. After at least three minutes of CDI, the adult uses PRIDE skills (verbal interaction from the adult) when the child seems more emotionally regulated. PRIDE is an acronym that directs the adult to offer the child labeled praise, reflection, imitation, description and excitement/enjoyment (in the adult’s voice).

As a real-life example, let’s say that “Alison” is in homeroom at school first thing in the morning. At the therapeutic school in which I work, this is where the students meet in the mornings to get any homework lists, eat healthy food, use coping skills, check in with their teachers and therapists, and practice socializing with peers appropriately. CDI is used immediately upon students’ arrival.

In this case, Alison puts her backpack on the floor upon entering the room, then goes to sit at her desk (her backpack is not where it is supposed to be, plus it is open, with its contents falling out). When Alison enters the classroom for the first time, it is time for CDI, so the teacher is not to direct her to move the backpack, at least for a few more minutes. (If your first interaction involved someone telling you to correct something, think about how you would feel.)

At her desk, Alison eats an apple, and then a peer asks Alison for a piece of paper. Alison silently gives her peer the paper, without offering any eye contact, and then gets up to throw away the apple she just finished eating. She then remembers to get her assignment notebook out of her desk. Even though Alison’s backpack is open on the floor with papers, food and more disorganized contents spilling out, the teacher doesn’t direct her to do anything until after offering Alison the full array of PRIDE skills:

  • Praise: Praise appropriate behavior. This should be specific labeled praise about what is positive. In this case, it could be any number of things: “Alison, thanks for sharing your paper with Sarah. You are so helpful” or “Thanks for throwing away that apple in the garbage. You are very responsible” or “You remembered to get out your assignment notebook. You have a great memory!” This labeled praise includes helpers to build confidence in Alison related to both her IQ and her EQ (emotional intelligence), therefore lessening her anxiety and helping her manage her impulsivity.
  • Reflect: Reflect appropriate talk. This means the adult reflects back what the child says to them. For example, when Alison is done with her assignment notebook, she asks the teacher, “When is the fire drill?” The teacher is to reflect the main concept of the question. In this case, the teacher might say, “I am glad you want to know when the fire drill is so you can be prepared. That is very responsible of you. It is at 9.” Reflection is key to letting children know you are really listening to them. And if someone is listening to them, then they feel valued, understood, worthy and accepted, lessening their anxiety and raising their self-esteem. In this case, the teacher also offered more labeled praise about Alison being prepared and responsible.
  • Imitate: Imitate appropriate social behaviors. If Alison takes out paper and colored pencils to draw as a “quiet coping” skill during the appropriate time, the teacher takes note of how to imitate this same concept down the line. “Your drawing just reminded me of something, Alison. When all of the homeroom students have arrived, we can all play that drawing game we played a few weeks ago. Would you be willing to lead the game since you really understood it last time and are such a talented artist?” This lets Alison perceive that she is worthy because she was doing something that the teacher also wants to do (artwork). This serves to lessen Alison’s anxiety. It also helps her realize that she can in fact be a leader herself, increasing her self-confidence.
  • Describe: This is the time to give behavioral descriptions. Simply describe what the child is doing, which shows the child that someone is both attending to them and giving approval of their actions. This serves to increase the child’s confidence and decrease anxiety. For example, the teacher might tell Alison, “You’re drawing a sports car with a mountain in the distance. That looks fast and powerful yet peaceful at the same time. That’s pretty impressive and creative that you’re able to capture all of that in one picture.” This description also includes more labeled praise pointing out that Alison is creative.
  • Excitement/enjoyment: Demonstrate excitement in your voice, which is key to attending skills. This strengthens the relationship with the child and allows the child to experience many positive feelings. This also increases the chances the child will comply when you give a corrective direction.

It should be noted that some people with anxiety fear receiving positive praise in front of other people. If this is the case, adjustments can be made to the treatment technique.

In Alison’s case, all of the PRIDE letters were used, and she received even more than the allotted three minutes of CDI time. Alison’s CDI time included getting to choose to eat her apple, asking her fire drill question and taking out paper to draw a picture. Once CDI and PRIDE have been used, the teacher can move to adult-directed interaction, in which the teacher can finally:

  • Ask questions: “Alison, do you have your math assignment from last night?”
  • Direct some peer interaction (such as getting the students together for the drawing game referenced earlier).
  • Give instructions (such as addressing that backpack issue): “Alison, it would help us out if you could close your backpack and put it in your locker. I would hate for anything of yours to get lost or for someone to get hurt tripping on it.” When Alison complies with that direction, the teacher can follow up with more labeled praise: “Thanks for following directions.” One caveat: Never say, “Thanks for listening.” There is a big difference between someone “listening” and someone “following directions.”

Other considerations

The CDI/PRIDE skills/adult-directed interaction combination should be used in the child’s home continuously, at play dates in others’ homes, at school and community activities and, of course, in the therapy office. PRIDE continues to be a way of communication, so it doesn’t stop when the conversation gets going.

In the therapy office, once emotional regulation has been established with the combination of CDI/PRIDE/adult-directed interaction, the counselor can move to reminding the child of the operant conditioning plan, then work on CBT skills or exposure skills to continue building strategies to manage impulsivity or anxiety.

If children’s ADHD symptoms are impairing their social and educational functioning with significant intensity, frequency and chronicity, it is also likely that a psychiatrist will prescribe a stimulant medication. ADHD is a genetically based, neurobiological disorder that affects many parts of the brain. Medication can touch parts of this, especially when it comes to dopamine and norepinephrine disruptions, but it can’t adjust everything. Even for the parts of the brain that can be medicated, medication doesn’t guarantee an absence of symptoms. That is why it is crucial to continue using therapeutic techniques as antecedent management and counseling strategies to help children function in their different environments.

In terms of anxiety, for those suffering impairment in their social and educational settings on an intense, frequent and chronic level, the first line of medication will likely be a selective serotonin reuptake inhibitor (SSRI). This is because the main area of the brain affected is serotonin (in addition to anxiety affecting norepinephrine, glutamate and the limbic system structures of the hippocampus, hypothalamus and amygdala). Again, however, an SSRI will not guarantee an absence of symptoms, which is why therapeutic techniques, exposures and counseling strategies remain key.

 

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For more examples of how the attending skills of CDI, PRIDE and others related to PCIT can be used in school settings, home situations and community/recreation settings, please reference my two books: Toddlers & ADHD and Suffering in Silence: Breaking Through Selective Mutism.

 

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Donna Mac is a licensed clinical professional counselor in her 12th year working for AMITA Health in one of its therapeutic day school locations. Previously, she was a teacher in both regular and special education settings. She has three daughters, including identical 9-year-old twins diagnosed with ADHD hyperactive/impulsive presentation and selective mutism anxiety. Contact her at donnamac0211@gmail.com or through her websites: toddlersandadhd.com and breakingthroughselectivemutism.com.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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.

Counseling individuals of African descent

By Malik Aqueel Raheem and Kimberly A. Hart March 5, 2019

In 1963, James Baldwin wrote that to be Black and relatively conscious is to be in a state of rage almost all the time. The historical record of people of African descent is filled with triumphs and trials. The great empires and kingdoms of Africa, including Egypt, Mali and the Moors, experienced vast triumphs. Records of tremendous successes, such as those led by Mansa Musa, Hannibal, Queen Nana Yaa Asantewa, Shaka Zulu and Amenhotep IV, demonstrate the great history of people of African descent prior to the trans-Atlantic slave trade and colonization.

The trans-Atlantic slave trade had a unique impact on Africa and on individuals of African descent. Historians report that Brazil was one of the last governments to make slavery illegal in the Americas, in 1888. However, long after slavery formally ended in the United States — in 1865 with ratification of the 13th Amendment — the psychosocial oppression of people of African descent continued. For the next 100 years, Black codes and Jim Crow laws were influential in creating a second-class citizenship for people of African descent. In 1964, the Civil Rights Act was signed, appearing to offer the full promise of freedom, but the civil right for freedom remained existent in theory only. A separate existence dominated by institutional racism — highlighted by such laws and policies as redlining, the federal crime bill of 1994 and the school-to-prison pipeline — was the actualized manifestation of post-slavery experience for many individuals of African descent.

In 1991, the movie Boyz N the Hood included an opening scene of four young males of African descent walking through the neighborhood of South-Central Los Angeles. This could have been any urban area in America during the height of the crack epidemic and the infamous “war on drugs.” One of the four young men shows his peers the remains of a dead body among the weeds of an empty lot. Similar scenes have transpired regularly across the United States and throughout the African diaspora. It stands as one example of the trauma being experienced in many urban areas and inner cities today.

The crises of institutionalized racism, race-based oppression and racial trauma are significant aspects of the intersectionality of individuals of African descent. Counselors need to understand the meaning and impact of this intersectionality on the students and clients they counsel. Understanding the core constructs of historical and complex crisis and trauma for individuals of African descent who present in counseling is an essential phase for developing counselor efficacy.

Definitions

The information presented in this article can be understood and discussed using the definitions that follow. Scholars such as Derrick Bell, Patricia Williams, Kimberlé Williams Crenshaw and Mari Matsuda have contributed to critical race theory. According to the theory, racism has three levels: institutional, individual and internalized. Racism is to be understood as discrimination, marginalization or oppression inequitably inflicted upon individuals identified as belonging to a socially constructed racial category. Racism requires the combination of prejudice, power, access and privilege. For an individual to be racist, he or she must have access to an element of power and privilege to oppress the group being prejudicially discriminated against.

In the 2007 article “Racial microaggressions in everyday life,” Derald Wing Sue and colleagues defined racial microaggressions. Racial microaggressions are brief and commonplace verbal, behavioral or environmental indignities that are used, unintentionally or intentionally, to communicate hostile, derogatory or negative racial slights and insults to the targeted person or group based on their socially constructed racial category.

In 2003, William Smith coined the phrase racial battle fatigue. The term captures the psychological attrition that people of color experience in their daily encounters as they try to deflect racial insults, stereotypes and discrimination. Racial battle fatigue is the cumulative debilitating effect of being on guard against attacks about or because of one’s socially constructed racial category. It is also a theoretical framework for examining social-emotional-psychological stress responses such as frustration, anger, exhaustion, physical avoidance, psychological withdrawal, acceptance of racial stereotypes, and verbal, nonverbal or physical fighting back related to the experience of racism and racial microaggressions in acute episodes or chronic intervals.

Culture is a collective constellation of behavioral norms, values, spirituality, traditions, history, language and unique variables such as food, music, dance and clothing that guide and influence a people’s cognitive and affective complexity. This in turn determines their behavioral response to life circumstances. Culture frequently is identified by ethnic populations. However, the concept of culture is not restricted by ethnic groupings. Microcultural norms influence the unique intersectionality experiences of microcommunities and individuals within identified cultural groups.

Intersectionality is a term coined by Crenshaw in 1989. It is used to recognize systemic influences on individual identity, positionality, access and experience narratives. The primary influence on Crenshaw’s discussion of intersectionality was the exclusion of differential narratives of women of African descent during the feminist movement in the United States. Intersectionality is used in identification of nonmajority sociopolitical experiences that were suppressed by individuals operating from racist and heterosexist sociopolitical majority narratives. Intersectionality is understood to encompass microcultural influences such as religious diversity, nation of origin diversity, gender expression diversity, sexual orientation diversity, ethnic diversity and generational diversity.

White supremacy is the belief and practice that individuals who racially identify as White are superior to all other races, especially to people of African descent or Black people. Within this belief system, people of Whiteness and White culture are considered rightful dominators in dictating normalcy and social policies. Neely Fuller said, “If you do not understand White supremacy, what it is and how it works, everything else you think you understand will confuse you.” The supremacy of Whiteness, like racial categorization, is a sociocultural myth. Nevertheless, these constructs influence trauma.

Trauma is defined as an emotional response to distressing or life-threatening events. Traumatic events overwhelm a person’s ability to cope, leaving the person fearful of injury, mutilation or death. Trauma has affective, cognitive and behavioral influences on human development and functioning. Some trauma is communal in that a collective of individuals sharing some community or temporal space connection is affected by a single traumatic event (e.g., the trans-Atlantic slave trade). Individual trauma affects one individual at one point in time. Complex trauma is identified by compound experiences (i.e., more than one traumatic event is experienced before the healing of a previous trauma or serves to restimulate a traumatic response to a distressing event that was previously managed). Trauma can manifest through vicarious experiences, transgenerational events or the experience of persistent adverse events that may not have been traumatic in isolation. There are different types of trauma and levels of traumatic responses. Trauma is individualized on the basis of perceptions of events and the person’s ability to cope in the present moment of the crisis.

Race-related trauma

A multicultural assessment of problematic behavior for people of African descent should not be limited to a description of mental and emotional deficits or to observations of atypical externalized behaviors. An accurate multicultural assessment must include responses to psychosocial and environmental conditions in which the observed behavior might be a normative and rational response. Behavioral pathology of people of African descent can be a consequence of ecological systems rather than intrapsychological deficits.

Racism is a psychological disease; racism is pathology cultivated through transgenerational neglect, and it has negative influences on perpetrators of racism, victims of racism and racism survivors. Unfortunately, as individuals in society have refused treatment for so long, people of African descent have continued to experience overt and covert culture-deteriorating suffering and trauma as the result of being targets of racism. Racism is both extremely common and extremely complex. Racism is entrenched in societal history, institutions and policies, with the exerted supremacy of Whiteness perpetrated and perpetuated as a societal norm.

Racism is pathology of power marked by ignorance. In 2013, racism scholar and healing racism advocate Lee Mun Wah described the privilege of numbness as an outcome of racism that is experienced by individuals of Whiteness. The privilege of numbness is a paradoxical term used to articulate the adverse impact of racism that influences the ability of individuals of Whiteness to perpetuate racism. Privilege in this equation of racism is one’s positionality of normativity. This privilege is the gift of psychological and emotional numbness resulting in not having to think about:

  • The construct of race or racism
  • How racism is oppressive
  • How complicit and explicit racists are advantaged in direct relationship to the oppressive trauma of individuals of African descent

This article focuses on direct counseling for individuals of African descent. However, it should be noted that healing the trauma of racism needs to include healing the numbness of racists. In general, this includes individuals of Whiteness within institutions of Whiteness reallocating their forcibly gained and complicity perpetuated power that has been used for oppressing individuals through policies and institutional norms.

Individuals of African descent commonly experience racial microaggressions. Racial microaggressions are communications of assumptions, including assumptions of intellectual inferiority, assumptions of criminality, assumed superiority of White values and culture, and assumed universality of the Black experience. People of African descent experience unrelenting forms of direct, vicarious and institutional oppression, marginalization, discrimination and microaggressions. Many of these incidents manifest as hypersurveillance, stigmatization, provocative irritations and recurrent indignities, and people of African descent experience these microaggressions daily. Microaggressive events can accumulate and compound into experiences of racial battle fatigue and race-based trauma, some of which is experienced by a collective group of individuals during the same time period.

Community-experienced trauma

One example of community trauma is the economic devastation in communities of people of African descent resulting from periods of deindustrialization in many urban areas. The convergence of deindustrialization and racial desegregation created losses in vital social and economic capital among communities of African descent. Increases in unemployment and underemployment quickly snowballed into lost wealth and concentrated poverty within communities of African descent.

Although deindustrialization was not targeted racism, the intersection of racism was a compounding factor in the unfortunate and traumatic impact on communities of African descent. Within this atmosphere of community poverty and a reduction in already sparse resources, a dynamic and traumatic upsurge of violence, drugs and institutionalized mass incarceration was also experienced in many of these communities.

Another example of community trauma is manifested through interpersonal violence and economic deprivation within communities of African descent. Men of African descent are the primary targets of this trauma. Nonetheless, women and children of African descent are also exposed to violence in the streets, violence in the schools and violence in the homes. The violence experienced within communities of African descent is a multifaceted intersection of trauma. Structural and institutional racism and oppression have created pandemic conditions of poverty and violence in these communities. By oppressive design, these communities have been deprived access to develop viable, legal and consistent wealth-producing economic avenues. Racist, oppressive and marginalized social structures have translated into drug, sex and weapons trafficking becoming the most consistently accessible sources of economic survival for communities of African descent.

Men of African descent

Men of African descent are disproportionately represented among both perpetrators and victims of violent crimes. According to the National Center for Health Statistics in 2017, men of African descent were nine times more likely than White men to be victims of homicide. Historically, men of African descent were (and continue to be) feared as a threat to the status quo of White supremacy. This social fear remains cloaked in racial stereotypes today. Stereotypically, men of African descent are prejudicially viewed as intimidating, scary and dangerous.

Educational disparities have created a cultural experience known as the school-to-prison pipeline within communities of African descent. The school-to-prison pipeline refers to policies and practices that push children at risk for school failure and civic disengagement due to poverty and marginalization out of the classroom and into the juvenile and criminal justice systems. Current policies such as “zero tolerance” in disciplinary actions have resulted in more suspensions, expulsions and even arrests by law enforcement officers who are typically assigned to schools in areas that are predominantly populated by people of African descent. Students of African descent are six times more likely than White students to be affected by such policies.

Women of African descent

Multigenerational and transgenerational trauma — in the form of coercive segregation of female/male units during slavery, lynchings, sexual violence, murder and intimate partner violence in different forms — have historically been a part of life for women of African descent.

It was previously documented that women on average made 71 cents to every dollar that men made; in comparison, women of color made 65 cents. Reports in 2018 included a marginal increase, with women in America making an average of 80 cents for every dollar that men made. However, that average included a decrease for women of African descent, who received only 63 cents per dollar that men made.

Violence perpetrated by men who are usually their community partners is one of the leading causes of death among women of African descent. A complicated lack of protection from men who were their life mates was a strategy that slave owners and post-slavery oppressors used to dismantle communities of African descent. This also prolonged trauma responses within these communities.

Another part of the marginalization and trauma for women of African descent involves their social image. Within literature and media, Black women are often stereotyped as one of four archetypes: Jezebel, Mammy, Matriarch and Sapphire. Jezebel is characterized as a woman who uses her sexuality as a weapon. Although these women do not necessarily engage in sexual relations, they utilize the lure of sexual possibility and overt sexual innuendo to navigate access and fulfillment of their life desires. Mammy is the woman primarily observed in roles of upkeeping other households; historically, she was the maintainer of a White family’s home and children. The Matriarch is the head of household of the Black family. Also called Medea or big momma, these woman provide protection, wisdom, connection, gospel and community history to the family.

Traditional family structures within communities of African descent include extended family units that are seamlessly interwoven into the family concept. The Matriarch was often the oldest living woman in the family unit, whereas Sapphires were usually women who had an aggressive attitude toward men. These woman were full-hearted and physically strong. They often worked to match men in traditionally male roles, which is often portrayed as an emasculation of their male counterparts. Sapphires are also portrayed as lacking maternal drive and striving for individual equality to the point of pushing men away. The strength and community utility of these archetypes are frequently ignored, whereas exoticism and exploitation of these stereotypes are perpetuated as a means of ongoing marginalization of women of African descent.

Counseling approaches and interventions

As individuals of African descent experience various adversities, crises and traumas related to racism and cultural discrimination on individual, community and generational levels, counselors can offer supports for healing trauma. Counselors must be aware of this history and the current sociopolitical institutions that traumatize and retraumatize individuals of African descent before healing work can begin.

Postmodern, humanistic and cognitive approaches have proved to be efficacious for counseling people of African descent. Other approaches are also being used with this population, however. For example, an African-centered psychological approach has been created as an alternative paradigm. This approach is grounded in traditional African spiritual philosophy but can easily be adapted for the specific religion/spirituality of the person of African descent. Because counseling is a sacred and spiritual relationship between the counselor and the client, it is important that the foundation of the therapeutic relationship be built on authenticity, trust and respect. Important interventions for counseling individuals of African descent include a focus on identity congruence, invitation for repair and the use of spiritual or religious connections salient to the individual or community.

Identity congruence: Culturally competent counselors need to be knowledgeable and sensitive to ethnic and racial issues. Ethnic identity is an aspect of a person’s social identity and self-concept derived from knowledge of their membership in a social group and the value and emotional significance they attach to that membership. Racial identity is one’s psychological response to one’s race. Racial identity reflects the extent to which the person identifies with a particular racial or ethnic group, the person’s self-perceptions because of their identified race and how that identification influences perceptions, emotions and behaviors toward people from other racial/ethnic groups.

Invitation for repair: Multicultural competence principles are rooted in internal awareness and critical reflexivity. Counselors must be aware of their biases and sociopolitical blind spots that might affect the therapeutic relationship. Multiculturally therapeutic relationships can be established using invitation for repair, as described by Malik Aqueel Raheem, Charles Myers and Scott Wickman in 2015.

Invitation for repair is acknowledging that overt and possibly covert differences in experiences exist between the mental health professional and the client. The invitation involves requesting that the client correct the counselor if the client feels that the counselor is not connecting or does not have empathy for the client’s intersectionality. Multicultural social justice principles exhort counselors to become more active advocates in addressing the institutional and environmental factors that influence client distress and trauma.

Spirituality and religion: A protective factor for many people of African descent is their connection between spirituality and psychological well-being. Research has shown that people of African descent are able to regulate and resolve distress through the practice of their spirituality or religious beliefs. Counselors should inquire about and create intervention opportunities that infuse these religious or spiritual norms. This approach will help to develop and maintain therapeutic alliance and efficacious therapeutic outcomes.

According to John Dillard, spirituality is a view of an individual’s place in the universe or a personal inclination or desire for a relationship with a transcendent power or God. Religion is an organized social means through which people express spiritual beliefs. Spirituality and religion do not necessarily have positive correlations for people of African descent. Spirituality can be experienced independent of religious contexts, and not all religions promote spirituality as part of their practices. However, many individuals of African descent are simultaneously religious and spiritual.

A majority of people of African descent identify as Christian from various religious microcultures of Christianity. There is also a movement toward infusing traditional African spirituality into some of their Christian practices. In addition, many in the African diaspora were from West African, and it is estimated that 30 percent of these Africans who were brought to the Americas were Muslim. In Islam, Sufism is the more mystical aspect of the religion. It is believed that the spiritual aspect of Sufism helps the Muslim to have a deeper and stronger connection with Allah (God). In 2018, scenes from the movie Black Panther depicted visitations to the “ancestral plane.” While in the ancestral plane, individuals could discuss issues with their ancestors. The belief that ancestors are ever-present and guiding forces is common among individuals of African descent. The tradition of libations (the ritual pouring of a liquid or other element to honor ancestors) or the West African practices of Vodun (more commonly known as Voodoo in the United States) may also be relevant for some clients of African descent.

Summary

As counselors work with individuals of African descent, acknowledgment of racism and oppressive structures that influence clients’ trauma experiences and trauma responses is vital to building therapeutic alliance. Interventions such as invitation for repair are most effective when used in the present moment of a psychological, affective or behavioral injury to the individual or the therapeutic relationship. Humanistic counseling approaches, including validation and implementation of relevant spiritual or religious practices, have also been shown to be effective for working with individuals of African descent.

 

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

Malik Aqueel Raheem has more than 10 years of clinical experience and seven years as a professional counselor educator at California State University, Fresno. Contact him at malik2xl@gmail.com.

Kimberly A. Hart focuses on multicultural inclusion as an area of counseling practice, counselor preparation and research. She provides presentations and training on mental health and intersectionality. Contact her at hartkimberly27@gmail.com.

 

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.