Monthly Archives: July 2019

From Combat to Counseling: Service members, veterans and military family mental health

By Duane France July 14, 2019

 

This is the debut article of what is intended to be a monthly online column about counseling military-affiliated clients.

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Service members, veterans and their families face some unique challenges both during and after military service. There’s the stuff that is widely known — deployments, constant moving, a regimented lifestyle — and then there’s the stuff that isn’t so well-known. This includes the experience of living in a mutually supportive community; a lack of individualism and getting used to relying on others while others rely on you; for veterans, a lack of purpose and meaning in post-military life; for family members, experiencing the aftermath of the military, because it’s a stressful job. No one is getting out of the military without a couple of dents in the fender.

Sometimes, the challenges faced by the military population turn into crisis. The high rate of suicide in the service members, veterans and their families (SMVF) community is well-known. Given a higher level of exposure to trauma, service members and veterans may be more likely to develop posttraumatic stress disorder and other psychological conditions. And with greater physical danger comes a higher risk of catastrophic injury, which comes with its own problems, including the need to adjust to a new reality.

This is where the counseling profession comes in. As clinical mental health professionals, we are uniquely qualified to help the SMVF population live the life that they desire and deserve. We look at mental health from a wellness perspective, not an illness perspective. People with a military background will reject the concept of “sickness” and “brokenness” because, to them, that’s equal to weakness. If someone approaches a service member, veteran or military family member with pity, as if they’re a broken-winged bird, there will probably be a bit of a confrontation.

I know, because I’m a member of this community.

Who am I?

I retired from the U.S. Army in 2014 after a 22-year career. After retiring, I took on a new mission to help my brothers and sisters in arms, and their families, adjust to the circumstances that put some of those dents in their fenders. After several years of clinical work, I realized that my lived experience combined with my clinical background could help others. Which is where this column comes in.

Over the coming months, I’ll be sharing some of my insights about the culture and character of the military. Even though the need is great, the counseling profession doesn’t include a lot of people like me — former service members who have become professional counselors. As a matter of fact, that is what brought me to the profession — a chance encounter at just the right time and someone saying exactly the right thing to someone who was open to hearing it.

I was not a mental health professional when I was in the Army. I was in logistics, which is the Army’s euphemistic way of describing supply and transportation. In 2007, knowing that I would eventually have to leave the military, I started going back to school while I was deployed to Iraq. I was looking for a degree with the least amount of math possible and came across an associate degree in counseling and applied psychology. I thought that might make me a better leader, and I was interested in psychology, so I figured why not?

Fast-forward nearly a year. My unit was redeploying from Iraq after 15 months, and we were participating in post-deployment reintegration sessions. We all went to a conference center at a local hotel, where we were presented with breakout sessions on not going too wild with our drinking, not being mean to the neighbors … that kind of thing.

One of the breakout sessions was led by a counselor from the local Vet Center. For those of you not familiar with Vet Centers, they are outpatient mental health clinics that are part of the Department of Veterans Affairs (VA) but separate from the main VA health care system. The counselors at the Vet Centers are typically veterans themselves, as was the case with this clinician. She introduced herself and said that she was a retired Air Force officer. I don’t remember much of what she talked about that day, but something she said struck me then and stays with me now: “By the way, if any of you are interested in psychology, consider a career in the mental health industry. There are not enough combat veterans in our field.”

That’s all it took. Up until that point, I had not considered becoming a mental health counselor. After that, I started on the path that I’m on now and, with the help of many mentors along the way, currently work as a counselor at a private outpatient clinic in Colorado Springs, Colorado, that primarily serves the military population.

What the counselor said that day was correct then, and it still holds true now: There are not enough veterans in the counseling career field serving others in the military population. At the same time, that truth does not minimize the need for mental health counseling for the military population. There are two solutions to this: Bring more veterans into the counseling profession, and help those clinicians in the counseling profession who are not veterans to understand more about the unique needs of the military population.

As professional counselors, we recognize the need to be culturally competent with whatever client populations we work. We can’t work with someone from another culture without knowing about that culture; the ACA Code of Ethics clearly identifies this.

In that sense, the military population is an entirely different culture. Anything that defines the characteristics of a culture — ways of dressing, language, conceptualization of the world — applies to the military. I often describe it this way: It’s as if I went to England to live for 22 years and then moved back to the United States. Sure we spoke the same general language in those two countries, but there were also significant cultural differences between them and, therefore, adjustments that I needed to make. That’s how service members and their families feel after military service.

So, the goals of this column will be:

  • To provide insights into the culture of military-affiliated clients
  • To support counselors who find themselves working with service members, veterans and their families
  • To answer questions (if you have any, feel free to drop me a line at duane@veteranmentalhealth.com)

Thank you for your willingness to serve the military-affiliated population and for your willingness to learn more. Your efforts are greatly appreciated

 

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Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at duane@veteranmentalhealth.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.

Voice of Experience: Giving away power

By Gregory K. Moffatt July 11, 2019

“Are you Dr. Moffatt?” a soft voice said as Antoine (not his real name) stepped into my office.

I nodded. He was a 20-something African American male. He explained that he had been arrested for assault. His court requirements included completing 12 counseling sessions for anger management. I quickly perused the copy of the court mandate Antoine had brought with him as he stood by respectfully.

“So, let me get the picture,” I said. “You got in a fight. A white guy arrested you. A white guy represented you in court, and a white guy sentenced you and sent you to see a white guy for 12 weeks. Is that about right?”

Antoine tried to stifle a smile but failed. “Yeah, that’s pretty much it,” he acknowledged.

“Well,” I said, “according to this court document, the only mandate is that we have to meet for 12 weeks. We can do whatever you want. We can talk about life, sports, or stare at the wall. Whatever you like. At the end of 12 weeks, assuming you show up, I’ll sign off. Or, if you like, we can work on what might have led to your arrest. If we do, then maybe I can learn something about you, and you can learn something about yourself and hopefully never see a jail cell again.”

When I tell that story to new clinicians, they argue that it would have been unethical to see Antoine for 12 weeks but not do therapy. We would have done therapy, but that isn’t the issue. The mandate didn’t require that I show progress or that the client cooperate. The document only required him to attend.

I’m not playing word games. Alcoholics Anonymous has done this since its inception. Individuals can attend, not say a word, be resistant, and they can show little or no progress or even relapse. Showing up is a giant step on the long road to recovery.

Predictably, mandated clients bring resistance with them. We have no power to force any of our clients to change. The wording of the court mandate allowed me to give away power from the get-go by stating the obvious: I couldn’t force Antoine to change or engage in therapy. (Be aware that some court mandates do require growth.)

I also gave Antoine power by stating something else that was obvious. He was nonwhite, and I was just another white man in a system in which he had no power. I gave him permission (power) not to trust me, and in so doing, ironically, I began to earn his trust.

Mandated counseling makes giving power to our clients especially challenging, and resistance is predictable. Because I’m white, I was pretty sure Antoine assumed that I wouldn’t understand him or his culture. He had no reason to trust me. If I had been in his shoes, I wouldn’t have trusted me either.

Giving away power is one of the things in our therapeutic tool boxes that can help us earn trust very quickly. My technique worked. Within minutes, Antoine was at least willing to give me a chance.

I do something similar with child clients because children are also mandated in a way. Guardians bring them to me — a stranger — often without even asking these children their thoughts about it.

But like Antoine, young children learn to trust me almost as soon as they cross my office threshold. I meet them at the door, welcome them in and say, “You can do about anything you want in here. If there is something you can’t do, I’ll tell you.”

Some children test me with a question such as, “Can I break something?”

“If you feel like you need to,” I reply.

I often watch them as they roam around my playroom, shooting occasional glances at me, seemingly waiting for me tell to them what they can’t do. Saying “no” is rarely necessary.

Antoine turned out to be one of my favorite adult clients. If I hadn’t given him power from the start, he probably still would have shown up and been respectful and cooperative. But growth may not have happened.

Instead, over our 12 weeks, he was fully engaged — starting with our very first session — and he grew tremendously. Several times I saw his eyes light up as he had epiphanies about his decision-making processes. He gained insight into his behavior and developed numerous coping and problem-solving strategies that make it unlikely he will ever see the inside of a courtroom again, at least as a defendant.

I still think about Antoine and his sly smile during our first meeting. Witnessing his growth was satisfying, and that is why I became a counselor in the first place. I doubt I would have ever earned his trust without giving him power from the beginning.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.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.

The pretend professional

By Jamie McNally July 9, 2019

W hen I served in the military, we would call cadence as we marched. Those call-and-response songs helped to build camaraderie amid challenge and established a rhythm that brought comfort and familiarity.

Similarly, in my role as a clinic manager, clinic director and site supervisor, I have heard an exasperated expression of uncertainty repeated by dozens of supervisees and interns — “I feel like I don’t know what I’m doing.” Those nine words have become as familiar and comforting to me as a cadence. In fact, the expression has transformed in my mind from something despondent into an indication of growth because self-doubt is a seemingly necessary step in the taxing process of professional development.

Doubt as part of development

I feel like I don’t know what I’m doing. I have come to recognize those words as a sign that the person speaking them understands the gravity of our profession and desperately wants to be able to help the clients in front of them, even if in that moment the person has little to no faith in their ability to do so. Although I empathize with the discomfort of that phase of development and growth, I also celebrate counselors-in-training’s awareness of their internal struggles and their willingness to confront the hard truth that the work we do is as intensely complicated as the human beings we’re called to help. As a supervisor, I’ve learned to cherish the opportunity to meet developing counselors in this place of doubt and help them understand — and even embrace — the normalcy of their insecurity and its role in our profession.

I feel confident in saying that we, as mental health professionals, have all been there — that place where our professional identity intertwines with the hesitancy embodied by those nine words: I feel like I don’t know what I’m doing. We so easily get lost within that phrase and the enormity of its implications.

What if I chose the wrong career?

How could I possibly start over in a different field after spending so much time and money on this one?

What if I cause harm to this client because I say the wrong thing? What if they find me out and tell people how awful I am?

In good company

Self-doubt is part of the human condition and can plague professionals in any field. The term impostor syndrome, coined in the late 1970s, encapsulates the idea that regardless of our accomplishments or skill, we can feel fraudulent in our own skin and fear being exposed as such. This fear becomes exacerbated in the counseling profession, where confronting the complexities of the human condition is a daily (OK, an hourly) requirement. In the face of such complicated realities, it is only natural to be uncertain about how to move forward and then to conclude that the confusion one feels is a sign of inadequacy.

During my own five-year supervisory journey, in which time I have trained more than 100 counselors, I can recall encountering two individuals who didn’t admit to having these struggles. Two. That means that, at best, in my small nonempirical sample, roughly 2% of the early career counseling professionals I have supervised have not vocalized doubts indicative of impostor syndrome.

Perhaps those two students just didn’t feel comfortable telling me about their difficulties, or maybe they were too fearful to disclose this truth to anyone, let alone their supervisor. It’s also possible that they truly never had experienced insecurity as a professional, in which case they were the enviable two who genuinely made their way through the early phase of their professional development unscathed. That would make them the exception, of course, and not the rule.

Diversity and discrimination

I find it critically important to also highlight that other aspects of our identities can influence how we experience impostor syndrome. For example, if a person has faced discrimination throughout his or her life, this can have a dramatic impact on the intensity of impostor syndrome’s doubts.

As a white person who has benefited from systemic privilege in certain ways, I may have an entirely different perspective on my accomplishments and credentials than does a colleague who acquired those credentials in the presence of prejudices against them. I therefore recognize that each person’s doubts and identity are affected in very different ways on the basis of cultural differences. For that reason, we cannot assume that impostor syndrome will affect each person similarly, and it is wise to self-reflect on how our personal experiences might mitigate or exacerbate our struggles with impostor syndrome.

Overcoming self-doubt

“I feel like I don’t know what I’m doing.” With this whispering refrain of insecurity in mind, the question now becomes, “How do I unbury myself from the weight of this doubt and find self-confidence?”

To answer this question, it helps to start thinking like a counselor because, let’s be honest, often we have to therapize ourselves and practice what we are preaching to our clients. Remind yourself of the difference between thoughts and feelings, and acknowledge that “I feel like I don’t know what I’m doing” is not actually reflective of a feeling. This gentle challenge reminds us to check in with ourselves and acknowledge the emotion we are actually experiencing, which is almost always the same for everyone: fear. Sometimes intense and paralyzing fear.

Having acknowledged that we are fearful, I find it helpful to then assess one’s perspective — why the fear is present — and test it against reality. This step can be made easier by recalling that all emotions have a purpose. Anxiety’s job is to prepare us for daunting or intimidating situations. Next, I find that a little rudimentary reframing, self-grace and reassurance make the process smoother.

Here are six important reminders to help you reframe your fear and self-doubt and reassure you that what you’re feeling is normal, all in an effort to combat impostor syndrome.

1) You already have the skills to overcome insecurity. Chances are that you experienced doubt before even enrolling in graduate school, yet you found a way to push through and find yourself face-to-face with actual clients. I would assert that simply by arriving at this stage of accomplishment, you have demonstrated the skills needed to overcome whatever doubts you may feel about your abilities as a professional. When a person’s doubts prevent them from even attempting to pursue their ambitions and career goals in the first place, I call this prodromal impostor syndrome. You found a way to get from prodromal to professional, so try to recall what helped you then and use those same skills to help you overcome your current obstacles.

2) You are in the top nine. Did you know that only about 9% of Americans have a master’s degree? That number will vary slightly depending on your source for statistics, but even so, let that number sink in: the top 9%. When it comes to educational and professional achievement, you are an outlier in the most positive sense. That doesn’t happen by accident or luck; you did that. Trust your knowledge and skills. You know what you’re doing.

3) Our normal is someone else’s goal. We often forget that our version of normal is not where a large number of people — including many of our clients — find themselves. That’s because we have worked so hard and long on our own garbage and made it past many of the obstacles that used to prevent us from being relationally healthy. Through that journey alone, we’ve developed skills and understanding that many of our clients just don’t possess yet or are unable to see in themselves. Sometimes by simply showing up and modeling hope and health, we are doing more for our clients in one hour than they are getting anywhere else in their week.

Sure, we all still have our own “stuff,” but we have to remember that we have earned advanced degrees and chosen a profession that, at its very core, is about achieving better emotional and mental health. You have the tools that clients desperately need. Meet them where they are and reassure them that such development takes time. Through a bit of work, they’ll get there too.

4) We don’t always get to see the results. Just because we shared the same moments in the session room with our clients does not mean that we shared the same reality. Our perceptions are often very different from those of our clients, and that is to be expected, because we’re very different people with very different backgrounds.

Strict adherence to a session agenda or a particular intervention is not a requisite for healing or progress. I have come to learn that during those times when I didn’t adhere to my initial plan for our time together or when I didn’t feel that I was a therapeutic master, my clients often felt differently and had takeaways that I wouldn’t have imagined. Our perfectionism is not reflective of our clients’ process. Our self-denigration is not reflective of their growth.

Additionally, we often work with clients who are only at the beginning of a very long journey toward healing and growth. As professionals, it is tempting to set goals or have expectations for our clients that are overly ambitious. Overcoming our own self-doubts often requires removing the pressure we put on ourselves to work unrealistic objectives.

It can help to try to remember that sometimes we are merely planting the initial seeds in clients’ lives and that these seeds will bloom only after clients have left therapy. We may never be aware of clients’ later successes even when we played a pivotal part in making those successes accessible. Learning to accept that results are not always visible to us can dramatically strengthen our ability to trust ourselves and our interventions.

5) See yourself in context. Having a title, a certification or a professional license doesn’t mean that we should compare ourselves (or our perceived shortcomings) to someone who has been doing this work for 40 years. I often see new professionals striving to be just like the counselors they look up to — those with decades of experience — even though they are so fresh out of graduate school that their degrees haven’t even arrived in the mail.

Measuring yourself against someone who is at such a drastically different level of professional development than you inevitably makes you feel like a fraud. It is important to see yourself in the context of your level of experience while remembering that even on day one, you bring value to clients and to the mental health field itself. Take time to celebrate that now and then — and rejoice that you will only move forward and improve from where you are now.

6) Mastery in mental health is a lifelong process. Confidence often coincides with mastery, and yet, in this field, mastery will always be elusive. As counselors, we do not get the advantage of clear-cut problems, let alone clear-cut solutions. Human beings will always be complex, meaning that our jobs will always be difficult.

It’s healthy to continuously strive to improve and learn more about one’s field; that mindset prevents complacency and arrogance. We can be skilled and competent and will always be privileged to do this work, but mastery is always an ongoing process. Being the “best” (as it may look or feel to most of us) isn’t a destination. Rather, it is an ongoing journey of humility and self-improvement that ultimately yields better client care.

The authentic professional

These six reminders can alleviate some of the uncomfortable symptoms of impostor syndrome. They can also highlight the need for us to accept the reality that some of those symptoms may always be present.

No matter what your background or where you are in your professional development, try to enjoy the thrill and uncertainty of this field’s learning curve. It helps to remember too that you are not alone. Your cohort and fellow professionals have experienced — and perhaps still are experiencing — the very same struggles as you.

It is likely that you will periodically allow that worrying impostor to enter your therapy office, but the trick is not letting it take control of the room. That impostor does not dictate your professional development. In fact, you can learn to accept the normalcy of those nine words — “I feel like I don’t know what I’m doing” — as a comforting cadence and an expected step in your professional growth process. Self-grace and compassion are vital. Remind yourself of your strengths and celebrate victories, no matter how small (or big) they may be. You are a lot better than you think you are, and yet, not as good as you can be. And that’s OK.

 

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Jamie McNally is a licensed professional counselor, a limited licensed psychologist, a certified HIPAA compliance officer, and the owner and clinic director of Sycamore Counseling Services (sycamorecc.com). Contact her at jamie.mcnally@sycamorecc.com.

 

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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.

Caring vs. carrying: A therapeutic review of empathy and boundaries

By Laura Sladky July 8, 2019

“When you hurt, I hurt.” Does this adage sound familiar? No doubt, it stems from a benevolent place, but it inherently reinforces poor boundaries and misses the heart of empathy entirely.

Instead of joining in on someone else’s experience (which is not entirely possible because we do not share the exact same experiences), empathy is more akin to “You’re hurt by this.”

Empathy recognizes the feelings in each experience, names them, and honors them by listening intently with an “as if” quality — listening to another person as if this situation were their own but without making it their own. Empathy honors another person’s experience without trying to take it from them by adding on, comparing, rescuing or minimizing. In short, empathy requires boundaries.

 

Empathy is not sympathy: Empathy is often misunderstood for sympathy. By definition, sympathy is expressing pity or sadness for someone else’s situation or misfortune. Furthermore, sympathy seems to have an unspoken “Thank goodness that didn’t happen to me” undertone by association.

Although it is appropriate to express sympathy in reference to a person’s genuine loss, sympathy misses the heart of empathy because it does not approach another’s experience with an “as if” quality. Offering “I’m sorry you’re in pain” often feels dismissive and does not foster the core conditions that encourage further discourse.

Empathy is not rescuing someone from his or her experience: “If I could, I would fix it for you.” As human beings, prosocial behavior dictates that we care for others. In learning of others’ strife or struggles, there is an inherent temptation to “fix” or help even when it is not necessary.

I work in an elementary school as a school counselor. I can confirm with certainty that parents spend so much time trying to help their children (for example, by bringing forgotten homework or a jacket in case their child gets cold) that they often rob these students of the opportunity to feel and learn. In the case of the forgotten homework, students are more likely to remember to turn it in on time in the future if they are allowed to feel the discomfort of not having it once. Repeatedly rescuing someone from their experience prevents the processes of acceptance, coping and moving on that are required to fully feel an experience.

Finally, rescuing someone from their experience rather than allowing them to experience natural consequences is the picture of poor boundary setting. Empathy allows for the full and complete exploration of thoughts, feelings and behaviors, with no intent to short-circuit the process simply because we cannot tolerate someone else’s pain.

Empathy does not minimize someone’s experience: Author and researcher Brené Brown maintains that no empathic response begins with “at least.” For example, if a friend discloses that they just received a cancer diagnosis, the temptation might be to immediately highlight the good in the situation rather than holding space for their feelings and experiences toward their current situation. (“At least you have a great doctor! At least you’re able to afford the health care!”)

There is certainly a time and a place to exercise positive cognition to influence feelings and subsequent behavior. It is essential to remember, however, that active listening is just that — listening, not adding on (“Let me tell you about my aunt who had cancer”) or minimizing (“At least …”). Empathy does not absorb or modify the worries, problems, sadness or experiences of others. Empathy is standing still inside a moment, caring for another and sharing their experience — without carrying their load exclusively.

 

The science of empathy

Research suggests that mirror neurons allow us to grasp the message of and accurately respond to others. These neurons help us understand the feelings of others more accurately and approximate their experience. For example, if I see someone laughing, my brain is primed to join in alongside them, noticing the crinkle around their eyes and the upturned corners of the mouth that indicate a genuine smile.

As social creatures, we are constantly scanning one another for biological markers associated with feelings. While mirror neurons help us adjust to another’s feelings, it is important to note that, if left unchecked, we can “take on” or linger in someone else’s feelings.

 

The need for boundaries

As counselor clinicians, it is necessary for us to maintain boundaries to center the work around the client’s needs, to monitor for transference and countertransference, to attune to our worldview and how it affects the way we work with clients, to uphold ethics and to prevent compassion fatigue.

One of my favorite professors once mused that in his work with clients confronting substance use disorders, he cared about his clients deeply, but not so much that he was unable to continue to do his job. At first, I was unclear about the meaning of his statement. Now I understand that his declaration of boundaries allowed him to recognize the importance of his work without absorbing his clients’ challenges as his own to the point of burnout.

Empathy intersects boundaries in accurately understanding the experience of another without taking it on as our own. Enter the importance of self-care.

 

Final thoughts:

Author Glennon Doyle suggests, “Pain is just a traveling professor. When pain knocks on the door — wise ones breathe deep and say, ‘Come in. Sit down with me. And don’t leave until you’ve taught me what I need to know.’”

Empathy does not require pain or sorrow to be present. Rather, empathy is present whenever two individuals are together. In the fine-tuning of our responses to the thoughts, feelings and experiences of others, we are more in tune with ourselves and can better serve our clients.

 

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Laura Sladky is a licensed professional counselor intern and licensed chemical dependency counselor who currently works as a school counselor in Dallas, Texas. Contact her at l.perry09@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.

 

 

Facilitating support groups for caregivers

By Brooke B. Collison

The 40 million adults in the U.S. identified as caregivers often find themselves overwhelmed, lonely and depressed. They provide care on a part-time or full-time basis for individuals — usually family members — who, because of health or other reasons, need assistance with activities of daily living. Facilitated groups can provide a nonjudgmental framework for caregivers to find understanding and support from others who are in similar situations. Support groups can be self-sustaining, but they function best when a professional counselor or trained facilitator assists group members with their processing.

A gentle but convincing nudge from my spouse started my volunteer work as the facilitator of a caregiver support group six years ago. I continue to serve caregivers in that role today. My experience as a facilitator has allowed me to make a contribution in my retirement, and I encourage other counselors to explore the same possibility.

Enormous variability exists in caregiving situations, but common among them are conditions that are of high concern in aging populations: dementia, Alzheimer’s disease, chronic illness and other age-related deterioration. The three individuals my wife pointed out to me in church that Sunday morning had become full-time caregivers of spouses with Alzheimer’s disease. My spouse said to me, “They need a group. You should do something.”

The first group started with a direct invitation from me: “Would you like to get together with some other caregivers to have a place to talk?” I was met with quick affirmative responses from two of the three people I approached, and they were soon joined by a few others who heard something was beginning. Over time, the group grew to a dozen members, with some joining and some leaving as caregiving situations changed.

Nine deaths of care receivers occurred during the first three years before the caregivers decided to dissolve the group, having worked through the stresses and strains of caregiving, as well as the agonies and life-change issues of death. Among the caregivers in that first group were spouses, adult children, relatives of care receivers, and an employee of a care center. Although the medical and physical issues of care receivers were varied, the issues of being a caregiver seemed universal.

The support group was probably therapeutic, but it was not therapy. Although I have been a licensed counselor, I was the facilitator for the group, not the therapist. People entered the group voluntarily, and there was no contract that described my behaviors, philosophy or approach. I had retired as a counselor educator and did not renew my counseling license. So, I would clarify to new members that my role was to facilitate the discussions in the group. I also stated that I had no expertise in any of the medical issues being experienced by the care receivers. I explained that, as the facilitator, I would help manage the discussion, ask questions to clarify issues and, if I felt it necessary, remind members of the few general ground rules they had established for themselves: Treat personal situations and conversations with respect, don’t dominate, listen, and accept another person’s feelings and emotions as legitimate.

I do have a philosophy about support groups. I believe that most of these groups can develop to a point where they can manage their own issues and in-group communication. However, I saw part of my role as being somewhat protective of vulnerabilities among group members. If a member expressed strong feelings that might be contrary to the beliefs of another member, I would monitor critical responses. For example, if a caregiver expressed anger at a spouse or partner — “He makes me so mad when he …” — I would listen for the “You shouldn’t feel that way” response. This seldom happened, but when caregivers are living by the “in sickness and in health” vow they took at the beginning of their marriages, they can have a set of values that discourage anger toward or criticism of a spouse.

My belief is that the primary value of caregiver support groups is to provide a place where caregivers can give voice to stressful experiences, strong feelings and personal frustrations in the company of others who, ideally, give verbal and head-nod agreement with the issue rather than criticism or value-laden responses that only make these difficult feelings intensify. In short, caregiver support groups should provide what most people in the caregiver’s larger circle cannot give — authentic empathic understanding.

There have been times during the life of caregiver groups when I moved from the role of facilitator to member. I became a caregiver when my spouse broke her hip when we were traveling out of state, resulting in surgery and several months of recovery. At one session, I moved from “my spot” in the circle to a different chair and announced, “I’m a member today, not the facilitator.”

I proceeded to share an experience in which I had become quite upset over a huge mix-up in communication with my spouse that had left each of us very angry with the other. At the time, I saw our inability to clearly communicate — both in sending clear statements and in not understanding statements — as a scary image of what our future might become as we grew older. The communication mix-up, which became funny in time and with perspective, loomed at the time as a grim picture of a possible future. Members of the support group heard my story, shared their similar concerns, and accepted my worries. When I shared the same episode with other friends, it drew none of the same empathic understanding.

In a second major block of time in the same support group, I became more member than facilitator after my spouse was diagnosed with an untreatable brain cancer and lived only three more months. I remained in the group as a member, and another person took up the facilitator role very effectively.

Several kinds of support groups can be found in most communities. I prefer a noncurricular support group. In these groups, discussion topics emerge from the issues that caregivers bring to the sessions rather than from a predetermined agenda. Many support groups, especially those established for a fixed number of sessions, operate from a curricular base — sometimes even with a textbook — and have specific topics identified for each session. Other support groups may become more instructional in format. I believe the noncurricular support group provides the best opportunity for members to talk about the critical concerns and issues they have in the caregiver role and to find the greatest empathic understanding among a small group of people who share somewhat similar life situations.

Caregiver issues

In the caregiver support groups I have facilitated, members have raised a broad range of issues, including:

  • Loneliness
  • Depression
  • Role reversal
  • Becoming an advocate for the care receiver’s medical and social needs
  • Preparing for the care receiver’s death
  • Money/estate issues
  • Sexuality
  • Respite
  • Handling inappropriate questions and responses from others
  • Lack of patience
  • Anger
  • Relationship changes
  • Asking for, accepting, giving and refusing help
  • Decision-making for self and others
  • Concerns for their own health
  • Conflict with parents/siblings
  • Change in social supports
  • Moving the care receiver to a care facility and being an advocate for
    them there

I will comment on a few of these issues more specifically to demonstrate the value of a noncurricular caregiver support group.

Loneliness characterizes the lives of most caregivers to a certain degree and becomes extreme for some. Becoming a caregiver means that a person’s world changes. Day-to-day employment, recreational and social activities no longer exist for that person in the same way. In cases in which the care receiver’s dementia or other cognitive dysfunction begins to increase, the caregiver discovers that the person, although still physically present, begins to disappear. Loneliness becomes a way of life, as the years of sharing spirited discussions each morning over newspapers and coffee turn into coffee and silence. It isn’t uncommon in a support group to hear someone say, “She’s/He’s just not there.” The support group becomes a loneliness antidote for many members.

Depression is another common topic in caregiver support groups. More than a third of long-term caregivers experience depression, according to surveys reported by AARP. Caregivers might not use the word “depression” as they talk, but the behaviors and emotions they discuss often reflect that condition. In several group sessions, after a member has talked about depressed status, I have heard other members respond along the following lines: “I was feeling that way after my wife was at home for two months, and my physician labeled it as depression. I’m still on a prescription for antidepressants, and I think it’s perfectly OK to be on the pill.”

Role reversal happens in some fashion for nearly all caregivers who have had a long relationship with the care receiver. Couples who have been together for years and have fallen into clear divisions of responsibility around money management, food preparation, driving, decision-making and other tasks will discover that either physical or mental limitations force role changes. For example, the partner who never wrote a check finds that checks, credit cards, bills, tax preparation and all other money matters now fall under their domain. The person’s reaction to this can be either positive or negative. Being the fiscal manager may give the partner feelings of responsibility and control that they have not had before, or it can be experienced as an overwhelming burden that leaves the person feeling totally incompetent. Discussion of the effects of role reversals can be quite revealing to self and to others. If one partner who seldom drove the car because the other partner was extremely critical is now forced to become the driver — only to discover that the criticism from the nondriving care receiver only increases — relationship stress will multiply.

Lack of patience has been voiced by nearly every caregiver with whom I have had a group experience. As the person they care for starts to slow down physically or as their daily living abilities begin to disappear, caregivers see their daily load increasing, leaving them with less and less time to manage everything that needs to be done. Caregivers will often say their lack of patience is mixed with anger, even when they know it takes the care receiver longer to do nearly everything or that tasks and functions are forgotten or items misplaced. “It now takes 45 minutes to get from the house to the car, and I can feel my anger increasing with every minute. It makes us late for every appointment, and I have to start earlier and earlier for everything we do.” This statement brought unanimous head-nod agreement from an entire group. The discussion shifted to the resulting feelings of anger and loss, then moved into individual strategies for handling impatience and increased time requirements.

Becoming an advocate is a role that some people relish and others avoid. Caregivers are generally thrust into the role of patient advocate with the medical system, the care facility complex, and their surrounding social system in general. Frequent support group discussions have begun with a member telling their story of the previous week’s battle with some element of the complex that serves their care receiver. Sometimes these stories are ones of frustration, feelings of helplessness and lack of needed information. At other times, the story might emerge as a powerful feeling of accomplishment: “Yesterday, I met with the administrator of the assisted-living facility and demanded more attention to medication schedules.” These are moments for groups to celebrate, especially when caregivers who describe themselves as hesitant to challenge authority relate successful actions on behalf of their care receiver. Sometimes, when a discouraging episode has been shared, other members have related to the same issue or provided inside information gleaned from their own trying times. Some have even volunteered to accompany the caregiver to the next appointment.

Respite is labeled by experts as one of the most essential elements of caregiver health. As a topic in a support group, discussions frequently focus on how time away, or relief or respite care, would be appreciated. Simultaneously, caregivers will talk about how respite or any form of time away is impossible. This is frequently tied to the personal belief that the caregiver is the only person who can or should fulfill the task of giving care.

Help becomes a common discussion topic in one of several forms: Where do I get help? How do I ask for help? How do I turn down help? Embedded in many of these discussions are personal core values about what giving or receiving help really means. It is one of those topics where it would be easy for a facilitator to slip over into a therapist role. When caregivers describe how it is essential that they be the one who does everything and how impossible it is for them to accept help with any of their caregiver duties, the natural tendency of the trained therapist is to probe or confront or interpret in order to explore parental and other messages about help. It is also one of those situations in which group members may step in with their own illustrations of what help means, where their core values about help came from, and how their beliefs about help either facilitate or inhibit their functioning as caregivers. In staying away from my therapist tendencies to remain a facilitator, there are times when I can smile later and say to myself, “The group is doing what a good group does; they don’t need me to be the therapist.”

Information needs are high when someone first takes on the caregiver role. In early stages, they may be bombarded with pamphlets from their physician about specific diseases, friends may tell them about books to read, and technologically informed caregivers may search the web for sources. New caregivers are often directed to information support groups; medical facilities may offer groups for individuals with similarly named conditions. I find these groups helpful during the early information-gathering times, but their helpfulness diminishes when the caregiver gets deeper into the caregiving experience and discovers that information is important but not enough. It is more valuable for the caregiver to have a place where they can say, “My life is slipping away, and I don’t know what my future will be,” with six or seven people nodding in agreement. Then one of them says, “Yes, some days I don’t have anything that resembles my life before.”

Other issues common in support groups include concerns about money because long-term illness is expensive. If other family members are involved, conflict with siblings or other relatives is inevitably a cause of stress for the caregiver. Sexuality is usually discussed in the group relative to hygiene and physical care by others, but on more than one occasion, caregivers have dug in to issues of appropriate and inappropriate sexual behavior in care facilities. In a support group, caregivers may find an environment where they can talk about impending death, even anticipating relief when it comes. Often, caregivers will agonize over the decision to place their loved one in a care facility, then have additional agony with second thoughts and regret after the decision has been made, even though the decision will be described as “the right thing to do.”

Support group procedures

I believe the best way to create a caregiver support group is by invitation. Within any group of older people, it is likely that some will be serving as caregivers. Over time, that number will increase. (AARP provides good summaries of this trend at its website, aarp.org; the organization’s reports and resources are easily accessible by typing “caregiver” in the search field.) Posting announcements of a caregiver support group will attract a few people, but many people are reluctant to attend without a direct invitation.

Support groups function best when there are enough people present for good discussion but not so many as to restrict individual participation. My ideal numbers range from eight to 12 participants. I have worked with both larger and smaller groups that seemed effective, however.

Groups have a beginning and an end and can be announced as such. The open-ended entry and exit group can go on for years; facilitators need to be clear about what they are agreeing to do when they begin a group with no clear end. Ending a group and then resuming later with the same members can be effective. This can also serve to ease the transition of new members in and old members out if they choose to leave. I strongly encourage some kind of summary or ceremony when group members depart. Likewise, I urge groups that decide to end to develop a concluding summary and ceremony.

Caregiver groups, by the very nature of what brings people to the group, will morph into grief groups. In my experience, people generally wish to remain with their caregiver group rather than shift to a separate grief recovery group because of the close relationships they have formed and the comfort that comes from being with people who know their story. As group membership begins to reflect more people whose care receiver has died, it does make it more difficult for new members to join.

Volunteer versus paid facilitation is an issue for many counselors. My participation is as a volunteer. In my community, support groups exist that are tied to medical or service agencies in which the facilitator might be a paid employee. There might be instances in which insurance would cover the cost of an ongoing support group, but this is not as likely for an open-ended group as it is for a fixed-length program.

Counselors in private practice could offer support groups for which members would compensate the facilitator. Under those circumstances, members could enter the group in the same way they would enter counseling sessions — with a contractual understanding of the role of the counselor who is operating with a prescribed set of ethics and an appropriate license.

I believe it is important for group facilitators to have a person they can go to regularly to discuss issues that arise for them in the facilitation role. In the same way that we expect counselors to have clinical supervision, facilitators need to seek this support. I get this through occasional coffee sessions with a friend who is a clinician.

I urge counselors to find or to create support groups that make use of the facilitation skills that counselors possess. Caregivers in their communities will be the beneficiaries. The service meets a critical need, and the satisfaction that facilitators will experience is beyond measure.

 

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I’d like to thank Bob Lewis and all the other caregivers over the years who have taught me what I know about support groups. I appreciate the stories and feelings they have shared and for the support they have given each other in such meaningful ways.

 

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Brooke B. Collison is an emeritus professor of counselor education at Oregon State University. He is a fellow and a past president of the American Counseling Association. For the past several years, he has served as a facilitator for caregiver support groups as a volunteer activity in his retirement. Contact him at BBCollison@comcast.net.

 

 

Letters to the editor: ct@counseling.org

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

 

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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.