Monthly Archives: September 2019

The invisibility of infertility grief

By Tristan D. McBain September 30, 2019

In my work as an outpatient mental health counselor, I have encountered numerous clients over the years with stories about reproductive loss. Not only were these stories fraught with sadness and grief, but some of the individuals were still experiencing acute grief even several years later.

As I branched out into my role as a researcher during my doctoral study, these stories stayed with me. So, I began a line of inquiry on reproductive loss that started with infertility and the accompanying grief. Since then, my research on infertility and miscarriage grief has resulted in numerous professional conference presentations and guest lectures. The purpose of this article is to share information that I have learned about those with infertility and to provide methods for best practice in counseling with these clients.

Infertility is generally defined as a condition of the reproductive system that inhibits or prevents conception after at least one year of unprotected sexual intercourse. To account for the natural decline of fertility with age, the time frame is reduced to six months for women 35 and older. According to the Centers for Disease Control and Prevention (CDC), about 12% of women between the ages of 15 and 44 have “difficulty getting pregnant or carrying a pregnancy to term.” Infertility can affect both men and women, despite a common misconception that infertility is a woman’s condition. Infertility in men may be caused by testicular or ejaculatory dysfunction, hormonal disorders, or genetic disorders. In women, infertility may be caused by disrupted functioning of the ovaries (such as with polycystic ovary syndrome, a condition that prevents consistent ovulation), blocked fallopian tubes, or any uterine abnormalities (such as the presence of fibroids).

Infertility can be categorized into one of two subtypes. Primary infertility refers to when a woman has never birthed a child and thus has no biological children. Secondary infertility refers to when a woman experiences the inability to birth a child following the birth of at least one other child. Both forms of infertility produce a cyclical pattern of strong emotion that is often referred to as a “roller coaster.”

Medical interventions

A number of available interventions may be used to increase the chances of becoming pregnant. The best course of treatment will be different for each couple and may depend on considerations such as whether the infertility is male factor or female factor, the cost and availability of insurance coverage, and cultural customs or beliefs. Some couples decide that pursuing any kind of medical treatment is not the right course of action for them. For others, medical treatment may include any of the following interventions.

  • Medication may be prescribed to stimulate ovulation or follicle growth in the ovaries, increase the number of mature eggs produced by the ovaries, prevent premature ovulation, or prepare the uterus for an embryo transfer.
  • Surgery may be necessary, perhaps to clear out blocked fallopian tubes or to remove uterine fibroids.
  • Intrauterine insemination (IUI), also known as artificial insemination, is a procedure in which sperm are inserted directly into the woman’s uterus. The woman may or may not be taking medications to stimulate ovulation before the procedure.
  • Assisted reproductive technology (ART) refers to fertility treatments in which eggs and embryos are handled outside of the body. This excludes procedures in which only sperm are handled (e.g., IUI). The most common and effective ART procedure is in vitro fertilization (IVF).

Undergoing IVF treatment requires a strong physical, emotional and financial commitment. Generally, medications are prescribed to stimulate egg production and may include a series of self-administered injections. Eggs are removed from the ovary using a hollow needle, and the male partner is asked to produce a sperm sample (or a sperm donor may be used). The eggs and sperm are combined in a laboratory, and once fertilization has been confirmed, the fertilized eggs are considered embryos. About three to five days after fertilization, the embryos are placed into the woman’s uterus via a catheter in hopes of implantation. The CDC reports that women under the age of 35 have a 31% chance of conceiving and birthing a child with the use of ART; the chances are closer to 3% for women ages 43 and over.

The IVF process can be a highly emotional time for the woman and the couple, marked by moments of excitement, hope, disappointment or uncertainty. The IVF cycle may be canceled if certain problems develop along the way, such as having too few or no eggs to retrieve, the eggs failing to fertilize, or the embryos not developing normally. Any of these situations may produce a sense of loss for the woman or the couple. After the embryo transfer, it is generally recommended to wait 10-14 days before testing for pregnancy. In some circumstances, a chemical pregnancy takes place. This is when implantation happens that results in an initial positive result, but then the pregnancy does not progress. In other words, a very early miscarriage occurs.

This section on medical interventions is important to include because these interventions are part of the infertility experience and may affect the emotional or mental health of the client. This is true even for women and couples who choose to not pursue treatment; at the end of the day, a decision was made and they must cope with the implications of that choice. Professional clinical counselors who are knowledgeable about the available medical interventions will have better context for recognizing the myriad decisions that these clients face and the potential losses that may occur throughout the process.

The invisibility factor

Take a moment to think about the grief that occurred for you after the death of a loved one. The relationship you had with your loved one was probably clearly defined, and you have memories of that person to look back on. The loss is easily identified and articulated, not only by you but by others who were aware of the death. You most likely had many people express sympathy and give you their condolences, perhaps verbally or by sending flowers. You may have taken time off work for bereavement and attended a ritual such as a visitation ceremony, wake or funeral that helped to facilitate your grief. Your loss was likely recognized, acknowledged, validated and supported in a multitude of ways.

Now think about the losses associated with infertility. One of the major losses is that of the imagined or expected family. Women with primary infertility, who do not have biological children, face the loss of the entire life stage of parenting. This may include pregnancy, passing on family or holiday traditions, and passing on the genetic legacy or surname, plus the eventual loss of other life stages such as grandparenthood. Counselors should recognize that meaning is often attached to these losses which further compounds the pain. For example, not being able to experience pregnancy means that the woman is also excluded from cultural pregnancy milestones such as going to the first ultrasound visit, thinking of fun and exciting ways to announce the news to family and friends, participating in a baby shower, and throwing a gender reveal party. With infertility, the loss comes from an absence of something that has never been rather than the absence of something that used to be.

The stigmatization surrounding infertility contributes to an atmosphere of silence and invisibility. Infertility and its accompanying losses are not as outwardly visible and may not be well known or understood by others unless the woman discloses them herself. Many women who experience infertility feel a sense of failure or self-blame toward their bodies, and some may withdraw socially, isolate, or struggle with their identity and sense of self. The stigma surrounding infertility can make it difficult for women to reach out for support. As a result, they find themselves navigating the experience alone.

When a woman does talk openly about her infertility, other people may not respond in ways that are validating or compassionate, which may make the situation worse than if she hadn’t disclosed at all. For example, comments such as, “Just relax,” and, “Give it time,” minimize the woman’s pain and invalidate her grief. Asking, “Have you tried (fill in the blank)?” or “Have you considered adoption?” implies that the woman is not trying hard enough to find a solution or that what she has tried already is inadequate. Most of the women with infertility I have encountered over the years acknowledge that people generally mean well and offer such comments in an attempt to provide hope or to decrease their own feelings of discomfort when talking about infertility.

Facilitating the grieving process

Professional counselors have a responsibility to provide compassionate and competent mental health treatment. Each infertility journey is unique, and counseling interventions should be tailored to fit the individual needs of every client. Taking clients’ cultural, religious or spiritual backgrounds into consideration, several interventions may be used to effectively assist these clients through their grief.

  • Counselors, first and foremost, can be present and listen. Typically, this is what is missing when family members, friends, co-workers, doctors or strangers offer comments that end up being hurtful or invalidating to the person or couple experiencing infertility. We do not have to have the answers — even as counselors. Just be there.
  • Counselors can assist clients in articulating what they need from others around them. This may also incorporate methods for helping clients increase their assertiveness or self-confidence.
  • Counselors can help clients redefine their life expectations and conceptualizations of womanhood, family and mothering. This may also include processing how clients perceive lost embryos, chemical pregnancies or miscarriages to fit within the family unit.
  • Counselors can help clients manage the roller coaster of emotions and ongoing stress as they are trying to conceive, rather than focusing on finding closure. Closure usually implies resolution, which may not be possible with the prolonged nature of infertility and the treatment process.
  • Counselors can assist clients in developing their own rituals while trying to conceive, undergoing fertility treatment, or after making the decision to stop treatment. For example, a woman once told me that she threw a party after she and her husband decided to stop IVF treatments. The party signified taking control over their decision to remain child-free and served as a celebration of the effort it had taken to come that far. 
  • Counselors can explore appropriate methods of client self-care, including engaging in hobbies, participating in creative or social activities, and even taking breaks (as needed) from trying to conceive or pursuing medical treatment.
  • Counselors can connect clients with appropriate resources. It may be necessary to provide clients referrals to group counseling if they wish to connect with others who have similar stories, or to couples counseling if they are struggling in their relationships. In addition, location or cost can be barriers to clients obtaining the services that would work best for them, so counselors who are knowledgeable about online resources can provide these options. Collaborating with other health care professionals with whom the client is working can also provide more comprehensive treatment.

This is not, of course, an exhaustive list. Grief is a personal experience. Which methods are the best fit for your client should be explored in a therapeutic setting that considers both individual and cultural contexts.

What do counselors need to remember?

Imagine that you are working in a private practice when you meet a new client experiencing infertility. You are a master’s-level clinician and are fully licensed in your state. You have taken one class in your graduate program on grief and loss but have no further specialization or experience with infertility. The client has heard numerous comments, questions and suggestions throughout the years regarding her infertility. She is unsure of how counseling might help, but she feels the need to seek support.

This scenario, while general, is a realistic picture of a possible situation that any clinician could experience. As such, I will provide thoughts on what every counselor should keep in mind when it comes to the areas of infertility grief. I am not attempting to reinvent the wheel when it comes to essential counseling tools; rather, I am striving to provide context for effectively using these tools with clients affected by infertility.

>> Convey empathy and understanding. If I could share only one thing I have learned in my work with women affected by infertility, it would be that so many of them feel and believe that you cannot possibly understand what infertility is truly like unless you have been through it yourself. Many women have asserted to me that they just need someone willing to sit with them through the anguish. Counselors who are attempting to provide encouragement and hope may instead end up inadvertently dismissing their clients’ pain or minimizing their grief. It is also possible that counselors end up avoiding a deeper exploration of the experience completely because they do not know what to say. Do not underestimate your basic counseling skills when working with these clients. Acknowledge, reflect and empathize.

One way that counselors can suggest understanding is through the careful use of language. For instance, matching the client’s chosen language of “baby” or “child” is more appropriate (and accepting) than using the more medically correct terms of “embryo” or “fetus.” Language can also offer a reframe from a label of “an infertile woman” to “a woman affected by infertility.” This choice of words depersonalizes the condition and acknowledges that her identity is separate from the condition.

>> Become familiar with client issues related to infertility. Clients who talk about their infertility journey will use a variety of terms and acronyms. For example, you may have clients talk about the time they were “TTC,” which stands for trying to conceive. They may also mention medications, medical procedures or basic biological functions with the assumption that the counselor is generally informed on these topics. Although asking clarifying questions of clients can help paint a clearer picture of their experience, it is not the client’s job to educate the counselor. Take the initiative early in the working relationship with a new client to learn about infertility in areas in which you are deficient. That way, you will be able to understand the client’s journey and experience in greater context.

>> Validate the loss. The invisibility of infertility may cause some women to wonder whether their losses are real or valid. For example, I met a woman during my research who had elected to try IVF after three years of actively trying to conceive, and she gave birth to a healthy baby after just one round. Still, she felt a sense of loss over the fact that her memories of the conception did not entail a moment of passion and love, but rather recollections of shame and fear. She referred to her husband having to masturbate in isolation to provide the needed sperm sample and her experience of lying on a cold table waiting for the doctor to transfer the embryo. She did not feel that she could verbalize this sense of loss to others, however, because it might make her sound ungrateful. A counselor could validate the loss of the ideal conception story and help her articulate feeling both sad for that loss and grateful for her baby at the same time.

The invisibility of infertility also means that some women may not have the vocabulary to identify and articulate their losses. Women with primary infertility endure the losses of pregnancy, delivery, parenthood and eventual grandparenthood but may not be able to understand for themselves that they are mourning the loss of an anticipated and desired life stage. Counselors can assist clients with developing language for their losses if they are struggling to verbalize their grief.

>> Get comfortable. Discussions about infertility may overlap with other taboo topics such as sex, masturbation, miscarriage and abortion. Many of the women I have met who have been affected by infertility have had miscarriages along the way. This brings about an additional — but connected — situation of grief and loss. Talking about miscarriage can be difficult to do without also bringing up abortion, given overlapping language (e.g., spontaneous abortion) and medical procedures (e.g., dilation and curettage). These topics can be slippery territory for personal bias, but counselors should regulate their own reactions and practice reflection to maintain appropriate neutrality and support. Engaging in self-care can be particularly important when counseling those affected by infertility.

Challenging infertility stigma

More and more, childbearing is being viewed as a choice rather than a societal or marital expectation, yet not having children is still considered to be somewhat taboo. Women are socialized from a young age to prepare for eventual motherhood through childhood play that often fosters a nurturing and caretaking role. Other cultural narratives suggest that women have an ability and responsibility to control their fertility. This contributes to self-blame and shame when they are unable to conceive. Infertility is infrequently discussed publicly and thus carries a sort of social stigmatization. Counselors can contribute to destigmatizing infertility by normalizing conversations about infertility, challenges to conception, fertility treatments, and miscarriage.

Stories related to infertility gained widespread media attention throughout 2018. That March, a fertility clinic in Ohio experienced a technical malfunction that caused the destruction of more than 4,000 eggs and embryos, a loss that most certainly had potentially devastating implications for the affected families. Then, in August, a rare visual of the emotional and physical struggle of trying to conceive was captured in a photograph that went viral of a newborn baby surrounded by the 1,616 IVF needles that it took to conceive her. In the months that followed, actress Gabrielle Union opened up about her emotional fertility journey that included numerous miscarriages and surrogacy, and former first lady Michelle Obama revealed her story that included miscarriage and IVF to conceive her two daughters.

These stories bring visibility to infertility and normalize conversations about the challenges that can come with attempting to get pregnant. Counselors can contribute to destigmatization by engaging in discussions and posing curious but sensitive questions about how resources and support can be bolstered for affected women and couples.

Conclusion

Each infertility story is unique, and no one-size-fits-all solution exists when it comes to helping women and couples work through their infertility grief. Whereas an obvious loss from the death of a loved one usually includes rituals and social support, the invisibility of infertility makes it difficult to identify the losses, often leaving women affected by these losses to deal with them in silence and isolation. Counselors can help clients find the vocabulary to articulate the losses they are grieving, give voice to what they need from the people around them, and create ways to process their grief in a warm, nonjudgmental atmosphere.

 

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Tristan McBain is a licensed professional counselor and licensed marriage and family therapist. She is a recent graduate from the Counselor Education and Counseling Psychology Department at Western Michigan University in Kalamazoo. Contact her at tristanmcbain@gmail.com.

 

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

Letters to the editor: ct@counseling.org

 

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Related reading on this topic, from the Counseling Today archives: “Empty crib, broken heart

 

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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.

Fostering resiliency in families and caregivers of individuals with disabilities

By Mariagrazia Buttitta September 26, 2019

It was like the world had collapsed on me, or worse. The words pronounced by my eye specialist felt like a sudden punch to my stomach, leaving me bruised and gasping for air. My life seemed over, or so I thought when I received an eye diagnosis of cone dystrophy at age 14. To this very day, it is emotional to recall the impact that diagnosis had on me and the confused look on my parents’ faces as they heard, for the first time, phrases such as “legally blind” and “disability.”

We all stood there in complete shock. Our faces must have looked ghostly white, perhaps hoping this was a nightmare from which we would soon awake. Instead, we left the office feeling defeated and frightened of what my future would look like, literally. The following day, I gathered all the energy I had left and Googled “cone dystrophy,” learning that it affects roughly 1 out of every 30,000 individuals (according to the National Organization for Rare Disorders). That number did nothing to lift our spirits or morale. My family still feared for my future and, the truth is, so did I.

According to the World Health Organization, nearly 1.3 billion people have a form of vision impairment. Furthermore, the Centers for Disease Control and Prevention reports that 1 in 4 people in the United States lives with a form of disability. So, why did my parents and I feel alone at the time of my diagnosis?

 

Media portrayals of disabilities

Today, it is clear to me that both my cultural background and the way that the media portrays individuals with disabilities might have influenced how my family and I coped with this news.

Growing up in Sicily, I experienced firsthand how my culture viewed disabilities as a weakness. Generally, individuals with physical or mental disabilities were looked down on and were not provided with the same opportunities as other people were. For example, it was assumed that I — someone affected by an eye condition — had less to offer; therefore, I was discouraged from pursuing education. Being the first person in my family with a visible disability did not help us know how to move forward either.

In addition, the media seems to send mixed messages regarding individuals with disabilities. Most of us have compared ourselves with models on magazine covers or wished to be the next Jennifer Lopez or George Clooney. But rarely does our society associate beauty with a physical disability. How many times have you watched TV and noticed someone with a visible disability? GLAAD’s annual report on inclusion notes that less than 2% of the main characters on American TV shows have a disability. A 2015 “Sandy’s View” column for The Chicago Lighthouse website discussed both the positive and negative stereotypes used when representing disabilities in the media. Both stereotypes seem to be extreme — one representing these individuals as victims, and the other representing them as “exceptional” individuals with unrealistic powers.

It is no wonder that my family and I were uncertain about my future. We lacked the proper resources and role models that could have helped us combat some of the negative stereotypes. Despite this, we overcame tremendous obstacles. Having a physical disability did not limit my life, and the realities of my disability only made my parents stronger and more resilient. In addition, it made them more educated about disabilities and cognizant of what other families and caregivers might experience.

 

Accepting and moving forward

Admittedly, my diagnosis of cone dystrophy was life-changing, both for me and my parents. The families of individuals with disabilities may have a difficult time adjusting and can develop their own mental health problems as a result. A study by Juan J. Sola-Carmona and colleagues that looked at 61 parents of blind children found that anxiety is higher and well-being is lower among these parents compared with the general population (published in Frontiers in Psychology, 2016). In general, families with individuals who have a disability are at greater risk of developing psychological problems. However, if these families learn how to cope well, it can increase the strength of the family. Here are the top five things that helped my family and me at the time of my diagnosis:

1) Reaching acceptance: Learning to accept the diagnosis was one of the hardest things for all of us, and I can assure you that it didn’t happen overnight. Acceptance developed with time. Once we traveled to various specialists and knew there was nothing that could be done to cure my vision, we needed to figure out how to live with the diagnosis effectively. After reaching that point of acceptance, we were able to figure out how we would cope and move forward as a family.

2) Seeking professional help: I was a teenager at the time of my diagnosis. The diagnosis was devastating, and it took a negative toll on me. As I got older, I had no faith in my ability to be successful, and that led me to feel helpless and useless.

Counseling proved extremely beneficial to me, but that came later in my life, when I was in my 20s. Talking to someone was therapeutic. My parents were extremely supportive of me, but they were also emotionally impacted by witnessing my struggles. Therefore, it was nice to find a therapist with whom I could talk and share all my emotions without feeling the guilt of hurting anyone else.

Once I gained confidence in myself, it automatically made the process much easier on my parents. I was a happier person to be around. Seeking professional help can be equally effective for family members and caregivers, providing them the time and space to focus on themselves and their own experience.

3) Educating ourselves: We spent hours educating ourselves as a family about my eye condition. We looked at hundreds of websites, articles, journals and magazines. After gaining that understanding and knowledge, we could start educating others about my level of blindness, why I walk with a white cane, and why I have to wear sunglasses all the time.

4) Learning about resources: Neither my family nor I had any idea about the resources available to me. Through research, however, we came across various resources, including the Commission for the Blind. After joining, we learned about still other resources, such as the various tools and technologies that would help me navigate the world with confidence. The resources reassured my parents that I, too, could go to college, get a job, and live a life like people without disabilities.

5) Having role models: Despite the number of individuals with a disability, we can often feel alone or misunderstood. Over time, my family and I met other individuals who, despite being blind or having other forms of disability, managed to live a successful life. As a result, my family and I started to view disabilities differently. No longer did we view my disability as a barrier. More importantly, we learned that we were not alone. My dream of going to college would become a reality.

 

A counselor’s perspective on disabilities

Throughout my graduate studies in a clinical mental health counseling program, I took note of a significant gap in how professionals are trained to work with those impacted by a visible disability. So, from there, I was on a mission: I rolled up my sleeves and got to work.

First, I interviewed Judy Schwartzhoff, a licensed clinical social worker with more than 30 years of experience in the mental health field, to ask her point of view on this subject. I posed several questions to her, including “How competent do you feel working with individuals, families, and caregivers of those affected by a visible disability?” and “Do you feel there are enough trainings provided to help deal with these clients?”

Her response didn’t surprise me one bit: “As mental health practitioners, we are often trained to treat the  emotional side of things, but I agree that we could use more knowledge and training in this area. However, if we do come across the issue, we tend to overlook the disability and stick with the emotional problem because that’s what we are trained in. We continue to separate mental health issues from physical disabilities, but sometimes, the two go hand-in-hand. As professionals, we need to expose ourselves to a diverse population and become more inclusive and know how to deal with different abilities as well as be able to assist their families and caregivers.”

I walked out of the office feeling determined and ready to put my thoughts on paper. Having witnessed, firsthand, the impact this issue had on my parents, I had to bring light to this issue. I immediately asked myself, a soon-to-be mental health professional, a question: What can I do to ease some of the worries and anxieties surrounding individuals affected by a different ability and their families and caregivers?

 

What mental health practitioners need to know

The chances of working with clients who have a visible disability, or their families or caregivers, are high. The truth is, we all will experience a form of loss in physical functioning at one point or another. This could be as simple as experiencing hearing or vision loss as we age. Even so, mental health professionals may feel incompetent if they’re lacking the proper resources and knowledge regarding these clients’ needs.

The day of my diagnosis, I recall a sense of fear and worry hovering over me. My parents had similar feelings, but they also experienced other emotions such as disbelief, sadness and confusion. An article by Josephine Defini in VisionAware described how blindness really affects the entire family as a whole — and I believe this truth can easily be applied to any form of disability.

As mental health professionals, we must be cognizant that each member of the family (or caregiver) might be experiencing a different state of mind and level of acceptance. Therefore, each person may require additional time to process and cope with the diagnosis. As practitioners, we want to be cautious not to assume that all family members are dealing with the news in the same manner or that they are even ready to deal with it at all. As a recent graduate counseling intern, I’ll acknowledge that I catch myself wanting to fix clients’ problems right away. I need to remind myself that everyone has his or her own timeline for healing and processing.

What follows are my top five recommendations for mental health professionals:

1) Use a psychosocial assessment: A psychosocial assessment can be helpful to gather information about the level of acceptance, skills needed to cope, resources, and any other observations noted for the individuals and their families or caregivers (Defini). By gaining this insight, mental health professionals will have a better understanding of what services are needed. For example, when working with an individual who uses alcohol as a way of coping with their issues, co-occurring treatment can be offered. Understanding the client’s individual experience of a disability can reduce bias or assumptions.

2) Use person-first language: In a 2014 article for the American Counseling Association’s VISTAS, Susan Stuntzner and Michael T. Hartley suggested that counselors use person-first language and avoid using negative phrases that could make clients feel less empowered. This would include saying “person with a disability” rather than “disabled person,” for example. In addition, don’t jump to conclusions about how clients feel about their disability. For example, don’t assume that they feel any weaker or have lower quality of life because of the disability. Speaking from my own experience, I think that being open and asking your client to educate you is also important. Everyone deals with a disability in a different way. Ask your clients what they prefer, and do not assume anything.

3) Know your resources: As mental health professionals, it is fundamental to know the resources that can be most helpful to clients. For example, as Defini suggests, if someone is experiencing vision loss, be sure to know the proper state services or local community programs that are available, such as rehabilitation, vocational rehabilitation, or low vision services. As mental health professionals, it might be impossible to know all of the resources out there, but we can be knowledgeable about who might have that information. Listed at the bottom of this article are some resources that may be helpful to you and your clients. Don’t be afraid to seek out information about resources that are more specific to each client’s needs and location.

4) Understand the adjustment process: It is important for mental health professionals to understand their clients’ adjustment process, including awareness of when they found out about their disability and how they coped. If individuals or their families or caregivers are not yet ready to process anything, they might not be able to utilize available resources to the best of their ability. Depending on how well adjusted they feel, the treatment will vary. Specifically, if they just found out about the disability, counseling might need to focus on the grieving process rather than on finding services and moving forward. Additionally, understand the individual’s barriers and that of their caregivers or family members (Stuntzner and Hartley).

5) Know the proper techniques: Be competent and knowledgable about what techniques can assist your clients. Many techniques used center around self-compassion, forgiveness and resiliency (Stuntzner and Hartley). Family counseling may also be helpful to clients and their family members because it gives each individual the opportunity to be open about their needs with each other and the counselor. One intervention may be to have families engage in activities together (e.g., take a meditation class, go to dinner, see a movie, visit a museum) to keep the disability from overtaking their lives.

Mental health professionals shouldn’t be afraid to use their own judgment to see what their clients and clients’ family members or caregivers may need. Every person copes with a disability differently, and everyone is going to need different strategies, so get to know the needs of your clients and their families or caregivers.

 

Conclusion

I wish that I could go back in time and wipe clean the past — especially the day I received my diagnosis — to remove the fear and anxiety my parents felt. Sadly, I can’t. But as a recent graduate counseling student, career counselor intern, author, motivational speaker, and mental health and disability advocate, I aim to help decrease the pain and fear that others may experience. I plan to do this by educating individuals who have disabilities, as well as their families and caregivers, and by setting as example, because a disability does not have to define or determine our future or the future of our loved ones. As figure skater Scott Hamilton once said, “The only disability in life is a bad attitude.”

 

Resources

https://www.familyresourcenetwork.org/

https://nfb.org/

https://sites.ed.gov/idea/parents-families/

https://www.psychologytoday.com/us/groups

https://www.cdc.gov/ncbddd/developmentaldisabilities/links.html

rarediseases.org page on cone dystrophy

 

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Mariagrazia Buttitta is an author, motivational speaker, and mental health and disability advocate. She holds a master’s degree in counseling education from the College of New Jersey and is national certified counselor candidate. Contact her at buttitm1@tcnj.edu and through her website at embracingyourdifferences.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.

Finding strength in sensitivity

By Lindsey Phillips September 24, 2019

When Louisa Lombard, a licensed professional clinical counselor in private practice in California, worked as a school counselor, parents would sometimes come to her saying, “My child is so sensitive. I don’t know why he’s like this. Everything is such a big deal. I parent my children the same way. Why is he like this? His brother’s doing great in school and not throwing tantrums and crying. What’s wrong with this kid?”

In actuality, nothing was “wrong” with the child. What the parents didn’t know was that their child had an innate temperament trait referred to as sensory processing sensitivity. Approximately 20% of the population has this sensitivity trait and is categorized as a “highly sensitive person.” Narrow that focus to the therapeutic world, and closer to 50% of psychotherapy clients possess this trait, according to Elaine Aron, a pioneer in the field of sensitivity, in Psychotherapy and the Highly Sensitive Person.

People with this trait often look carefully before entering new situations or retreat from overwhelming ones. For this reason, they are sometimes mislabeled as being shy, when in fact, an estimated 30% of highly sensitive people are extraverted.

Because no one person’s experience is the same, Aron identified four basic characteristics of the highly sensitive person (also known as the DOES model):

  • Depth of processing
  • Overstimulation
  • Emotional responsiveness and empathy
  • Sensitivity to subtleties

Aron points out that the sensory processing sensitivity trait is a survival advantage in some situations because it allows individuals to process information more thoroughly and increases their responsiveness to the environment and social stimuli.

So, why do highly sensitive people — who have this survival advantage — make up roughly 50% of therapy clients? Julie Bjelland, a licensed psychotherapist in private practice in California, thinks the number is so high because highly sensitive people are a) more responsive to therapeutic work and self-help and b) more likely to have higher levels of stress, anxiety and depression.

Heather Smith, an assistant professor of human development counseling at Vanderbilt University, posits that because these individuals process deeply, they are more inclined to seek out answers and are drawn to counseling for its penetrating conversations. In addition, she says, these clients may have developed low self-esteem because of negative stereotypes about sensitivity, or they might want tools to help them navigate times when they feel more emotional intensity.   

Misdiagnosing a trait for a disorder

According to Erica Sawyer, an American Counseling Association member in private practice in Vancouver, Washington, misdiagnosis of the highly sensitive person often occurs because people aren’t aware that the trait exists or of the trait’s specific characteristics. The scientific name for the trait — sensory processing sensitivity — doesn’t help. The similarity in name between sensory processing sensitivity and sensory processing disorder often leads to confusion. But sensory processing sensitivity is a temperament trait, not a disorder. (Aron notes on The Highly Sensitive Person website, hsperson.com, that sensory processing disorder, on the other hand, is a neurological disorder involving the senses.)

As Lombard points out, most therapists receive limited training on temperaments. She first learned about sensory processing sensitivity after graduate school when her oldest daughter started showing signs of the trait, including being sensitive to noise, facial expressions and food. As Lombard learned more, she realized that she is also highly sensitive. She had long suspected that she had attention-deficit disorder because she had a hard time paying attention in her college classes if another student was kicking a desk in a rhythmic pattern behind her or if there was a bright light overhead in the room.

In fact, because highly sensitive people can get overwhelmed and overstimulated more easily when a lot is going on around them, they can commonly be misdiagnosed with attention-deficit/hyperactivity disorder (ADHD), Bjelland says. However, whereas a highly sensitive person is typically able to concentrate in the right environment — when at home in a quiet room, for example — someone with ADHD might not be, she explains.

One confusing aspect to the highly sensitive temperament is that it doesn’t necessarily produce problems in daily life other than overstimulation, says Smith, a licensed professional counselor and an ACA member. Thus, when clinicians hear about a client’s distress due to overstimulation, they can erroneously attribute it to symptoms of a disorder, she explains. To help prevent this, Smith recommends that counselors investigate whether a client’s issue (such as anxiety, stress or an inability to concentrate) decreases if he or she is no longer in an overstimulating environment. If the client’s issue is still present, then it might be a symptom of a disorder.

Smith also points out that counselors often rely on observable behaviors to indicate a possible symptom or disorder. However, depth of processing is not easily observable, she notes. To help counselors learn to identify this characteristic, Smith describes some cues: Highly sensitive people think more about the meaning of life. If in an environment where they are not overstimulated and their ideas are valued, they have the ability to describe all facets of a problem and generate potential prevention steps or solutions — often before others realize there is a problem. They are observers, not the ones to jump into action. They often don’t make decisions quickly. When they speak, it seems as though they have grasped the insight or concept quickly, in large part because they have been thinking about all of these connections for most of their lives.

One tool that can help counselors assess for sensory processing sensitivity is Aron’s 27-item self-test (see hsperson.com/test/highly-sensitive-test). Smith, Julie Sriken and Bradley Erford analyzed the strength of this scale and found it to be a valid screening instrument that counselors can use in their practices (see “Clinical and Research Utility of the Highly Sensitive Person Scale” published in the Journal of Mental Health Counseling.) Smith presented on this topic at the ACA 2019 Conference.

However, to avoid labeling, Smith cautions counselors against placing too great an emphasis on the cutoff score of this self-test. Instead, she recommends having a conversation about how the client marked each item on the scale. This approach focuses less on the total score and more on the person’s experience overall and with each item.

Smith also advises counselors to be careful about interpreting the results from these test items or problem-solving a client’s distress too early on the basis of these initial conversations. In addition to risking misdiagnosis, counselors run the risk of not being seen as credible by clients who have been deeply thinking about issues related to this trait for a while, she says.

Wired differently

Misunderstandings about the sensory processing sensitivity trait also occur when it is assumed that this population is just sensitive to lights and sounds. It is more than that. The brains of highly sensitive people are wired differently than the brains of other people. A 2018 post on the website Highly Sensitive Refuge notes four differences in the brains of highly sensitive people:

  • Their brains respond to dopamine differently.
  • Their mirror neurons (which allow people to “mirror” the behaviors of others and be more empathetic) are more active.
  • They experience emotions more vividly than others (as enhanced by their ventromedial prefrontal cortex).
  • Their brains are more finely tuned to noticing and interpreting other people.

A recent fMRI study published in Brain and Behavior found that highly sensitive people have increased brain activation in regions related to awareness, action planning, empathy, and self-other processing. Lombard, who specializes in working with teenagers and adults who are highly sensitive, shows clients brain scan images from studies such as this one to illustrate how the highly sensitive brain differs in emotional situations such as watching a scary movie or seeing a picture of a loved one. She finds that these images help normalize the trait for clients.

On a podcast for Unapologetically Sensitive, Esther Bergsma, a counselor in the Netherlands and an expert on high sensitivity, reported that highly sensitive people have more brain activation, especially in the areas surrounding social context (e.g., wondering what others think about them, how others view them, or if others accept them). Bergsma pointed out that always being tuned into social contexts is a strength; it is only when people can’t regulate their emotions well that it leads to increased anxiety and stress.

Because people who are highly sensitive have to process more information and can experience nervous system overload as a result, they can be prone to chronic health conditions if they do not have adequate self-care and downtime, says Bjelland, author of The Empowered Highly Sensitive Person: How to Harness Your Sensitivity Into Strength in a Chaotic World.

She likens the way that highly sensitive people deeply process information to cups of water being dumped into the nervous system (“the container”). Highly sensitive people might have 100 cups that they dump into the container, whereas other people have only a few cups to dump. In other words, these individuals notice and process more detail. For example, a highly sensitive child in a classroom might simultaneously notice that a teacher is upset and the happy expression on a classmate’s face across the room and a tree branch tapping against the classroom window.

One way to simplify these brain differences is to think of the brain as two parts: the emotional brain and the cognitive brain. The emotional part of the brain in highly sensitive people is more activated, and if it becomes too activated, the cognitive part of the brain goes to sleep in a sense, Bjelland says. “That’s why [highly sensitive people] might have a hard time with emotional regulation and can get stuck in worry, rumination, anxiety and overwhelm,” she explains. “During times of high stress, the brain cannot tell the difference between a real threat and a perceived threat, so it sends out alarm bells in the system to prepare for fighting or fleeing. In those moments, [highly sensitive people] can’t even access facts, memory and rational thought because that all comes from [the] cognitive brain.”

However, counselors can teach clients ways to reactivate the cognitive brain to support their system and to let the brain know that it isn’t time to send out those alarms, Bjelland continues. For example, she uses a simple breathing technique to calm the body and let the brain know that the person isn’t in danger. Clients breathe in for four counts, hold for two counts, and exhale for seven; they repeat this for about five to seven breath cycles. “The exhale is very long and slow because that sends a signal to your brain that you are not in danger and that it can stop sending out adrenaline and stress hormones. When you exhale slowly, your brain realizes you are OK because that is not how you breathe when you’re in danger,” she explains.

The counting part (whether done out loud or silently) is important because it helps “wake up” the cognitive part of the brain, she adds.

Reframing the perception of sensitivity

As a highly sensitive person herself, Bjelland grew up hearing the negative messages often directed toward people with the sensory processing sensitivity trait: “Why are you so sensitive? What’s wrong with you? Why are you reacting that way?” When people hear those messages as children, she says, they do begin wondering what is wrong with them.

That internalized message is why psychoeducation about the trait is so important, along with validating clients’ experiences. Most highly sensitive people spend their entire lives feeling misunderstood and that something is different about or wrong with them, Bjelland says. Therapy is the place where these clients can begin changing this narrative and turning it into something empowering, she notes.

In her experience working with this population, Bjelland finds that clients often have a transformative experience once they realize that their temperament is normal, that they are not alone, and that they can take steps to improve their experience.

On the other hand, Smith has noticed that some highly sensitive clients experience a grief response after first learning about the trait. They may need time to grieve that they are unlike the other 80% of the population and yet live in a world designed by those without the sensitivity trait, she observes.

Sawyer, a licensed mental health counselor and art therapist, also helps clients reframe their negative experiences, such as being labeled crybabies as children. Counselors can help clients understand that they feel both negative and positive emotions more intensely than other people do. So, when they cried, they were just naturally expressing what they were sensing, which is normal for someone with this trait, she explains.

“They don’t have the problem,” Sawyer says. “It’s the perception that they have a problem that can turn it into one.” So, rather than thinking that they can’t control their emotions, clients can come to understand that with the right support, they can regulate their emotions. They can also take pride in the fact that they feel not only sadness on a deeper level than most people do but also experience incredible happiness, Sawyer says.

Lombard carefully selected the name of her private practice, Strong and Sensitive, to counter the tendency to equate sensitivity with weakness. Many of her clients come in with low self-esteem because of negative stereotypes about being sensitive. She reassures them that it is a normal temperament variation and not a problem. By normalizing the trait, counselors can help clients to embrace it and see it as a strength rather than a weakness, Lombard adds.

Smith teaches clients to more effectively communicate with those who seem to point out sensitivity as a problem. For instance, rather than taking on the onus to defend their sensitivity, clients could ask the other person, “What part of my sensitivity are you having a problem with?” This question reverses the normal assumption that something is wrong with the client’s sensitivity and shifts the conversation to how the other person may need to adjust his or her language or thinking to help problem-solve the relationship dynamic.

Susceptibility to the environment

Research has shown that in a positive developmental environment, highly sensitive children are more likely to thrive than are their peers who are not highly sensitive. However, in a stressful environment, highly sensitive people tend to do worse than do their peers who are not highly sensitive. In other words, this population is highly susceptible to both the good and bad aspects of their environment — a concept known as differential susceptibility.

A highly sensitive person once told Bjelland that when she was younger, her parents made her wear a wool sweater. After repeatedly asking her parents if she could stop wearing it because the material bothered her, they simply replied, “Wear it anyway.” Bjelland notes that this is an example of a highly sensitive person not being supported, and that circumstance can lead to problems.

Bjelland has also noticed that if a highly sensitive child has anxiety, then almost always one or both parents do too. Therapists can’t easily help anxious children if they have an anxious parent, she says, because the child mirrors the parent and will feel unstable if the parent also feels that way.

Parents who are highly sensitive should also be on counselors’ radar because they can suffer from overstimulation and neglect of self-care, Lombard says. The highly sensitive population is also more negatively affected by sleep deprivation, which is common for parents of young children, Lombard notes. She has noticed that highly sensitive parents are sometimes so focused on being the best parents they can be that they don’t take good care of themselves, pumping breast milk constantly or not making time for meaningful adult conversation, for example.

Lombard and Sawyer both recommend that highly sensitive parents get extra support in the form of family members, friends, daycare or a nanny. If finances are an issue, these parents could consider setting up a rotation with another trusted parent to watch each other’s children on occasion, Lombard says. She also encourages highly sensitive parents to wear earplugs or noise-reducing headphones when appropriate because they turn the noise down a bit and can lessen overstimulation.

Other life changes such as a death in the family, menopause, illness or other stressful events can make highly sensitive people feel unbalanced and overwhelmed, especially if they aren’t taking care of themselves, Bjelland says. If they experience too much emotional activation, they may temporarily lose access to the tools and strategies they normally use to cope with overstimulation, she adds.

To counter this, Bjelland tells clients to keep a “positive journal” to record positive events, such as someone saying something nice to them, or techniques that make them feel good, such as going on a hike in nature. Then, when they are having a bad week, they will have a visual record of self-care tips and positive reminders.

The acceptance of sensitivity within a culture also affects one’s environment. Some clients, but especially men, deny having this temperament because society reinforces the idea that sensitivity is not a positive characteristic, Smith says. (Research suggests that the sensory processing sensitivity trait is equal among men and women.) Thus, counselors should be careful about labeling clients as highly sensitive.

Lombard agrees. In fact, if a client grew up in a machismo culture that considers sensitivity to be negative for men, then she might not directly use the term “highly sensitive person” because it may distract from their treatment or therapeutic progress. “Depending on the culture and family of origin, men can carry more shame around [their heightened] sensitivity,” Lombard says. Instead, she mentions that all people have different temperaments and explains that some situations, such as witnessing a car accident, for example, might affect them differently. She also teaches these clients many of the same coping skills without labeling them as being for highly sensitive people.

Bjelland, who is a global educator on this trait and teaches courses for highly sensitive people, doesn’t see as many self-esteem issues in cultures where sensitivity is more accepted. “In the United States where it’s not so accepted, we see a lot of self-esteem issues. And that’s connected to shame too. Most of us walk around with the narrative that something is wrong with us because that’s what we’ve been told,” she says. “Helping to change the client’s narrative to a positive one, where they recognize why this trait is important to the world, is incredibly important.”

Recently, a male client who identified as highly sensitive came to see Sawyer because he needed a safe space to talk. He was struggling to find and maintain a romantic relationship because he found that women often wanted a stereotypical man — someone bold, assertive and athletic. As they talked, Sawyer discovered that he had internalized the belief that being sensitive was negative, which caused his own social anxieties and made relationships even harder for him. After Sawyer reassured the client that he possessed a normal temperament trait and explained its four main characteristics, he felt less self-judgment.

Although simply providing psychoeducation around the trait can be liberating for some clients, counseling often requires a longer process to help clients begin shifting their negative self-perception of being “weak” or “weird,” she adds.

Mindful changes in an overstimulating world

The good news is that highly sensitive people can makes changes so that their lives are more compatible with this trait and they can more readily cope with the challenges posed by living in an often insensitive and overstimulating world.

Bjelland recommends that highly sensitive people carve out two hours of alone time per day and dedicate one complete day each week to downtime. Not surprisingly, many clients balk at this suggestion, saying they don’t have the available time to do that. Bjelland will ask them to try it for one week and, according to her, they will universally report that they had more energy and were more productive because they were more focused, calm and balanced.

Bjelland also advises clients to follow a slower routine in the morning to help set the tone for the day. Why? Think of the nervous system like a motor, she says. If a highly sensitive person jumps out of bed to get the kids ready for school and then races into work, their nervous system revs up, she explains.

The process of slowing down applies to the bedtime routine as well because, as Bjelland points out, this population often struggles with sleep issues. “If a highly sensitive person wakes up from having a good night’s sleep, they get to have their full 100 points of energy for the day, but if they’re having sleep issues, maybe they’re only going to get 50 points for the day, and they’re already starting out depleted,” she says.

She often tells clients to adopt a ritual of doing the same five things before bed, such as taking a warm bath, reading a nonstimulating book, listening to soft music, meditating, and shutting off all electronics. By the time they reach the third action, the brain realizes sleep is coming, she explains.

“You’re teaching them a new type of self-care because [they’ve] been trying to do what the 80% [of the population that is not highly sensitive] are doing, and it’s not working,” Bjelland adds.

Smith agrees that counselors may need to have conversations centered on how self-care for these clients may differ from what rejuvenates other people. For example, if a highly sensitive person tries to relax by going to a concert with lots of lighting and sound effects after work with friends, he or she may instead feel drained and overstimulated by the end of the night.

Overstimulation is a difficult challenge for people with the sensory processing sensitivity trait because they need so much downtime, Lombard points out. She finds mindfulness techniques helpful for teaching these clients how to stay in the moment and self-regulate. For example, a highly sensitive person may find a coffee shop with loud music and people talking overstimulating. However, counseling can provide the client with strategies to successfully navigate such a space. For instance, perhaps the client limits his or her amount of time in the coffee shop or brings noise-canceling headphones, Lombard suggests.

Because these clients feel so deeply, they often need help learning to calm their nervous systems, Lombard continues. Highly sensitive people “are taking in so much more sensory information, and it’s really overwhelming,” she says. “And sometimes [they’re] not even aware, if [they’re] not mindful, of what it was that made [them] feel down or anxious.” She asks her clients to meditate daily using an app such as Calm or Ten Percent Happier and practice breathing techniques to help them become more mindful, present and calm.

Sawyer also suggests that clients use meditation apps such as Headspace or Insight Timer and practice yoga. Sometimes, even the simple act of closing one’s eyes, listening to nature sounds, or going to a quiet spot such as a bathroom or car can be helpful, she adds. The key is finding activities that “help retrain the brain to slow down [and] pay more attention to what’s happening in [the] body,” she says.

Retraining the brain in this way also helps highly sensitive people realize that they have some control and do not have to feel overwhelmed all the time, Bjelland says. For example, every time clients catch their mind wandering during meditation and bring it back to what they’re focusing on, such as their breath, it is like strengthening a muscle. Then, if clients become overwhelmed at work or a large event, they have trained their brains to notice, and they recognize that they need to take a break, she explains.

To help clients exercise this “muscle,” Bjelland instructs them to ask themselves two questions every time they go to the bathroom: 1) How am I doing? and 2) What do I need? This process makes them aware of preventing depletion or overwhelm, she explains. “Highly sensitive people tend to be very externally focused because they’re always scanning the environment for other people’s needs,” Bjelland says. “Most highly sensitive people need to be taught how to explore internally to learn what they need without always filtering it through other people’s needs.”

Of course, the heightened sensitivity to one’s environment also has benefits. Smith has often heard highly sensitive people talk about spending time in nature because there isn’t as much stimulation there. It is a place where they can escape and delight in the beauty of the natural world.

For some highly sensitive people, listening to a bird chirp or watching a sunset can elicit intense feelings of joy or elation, Sawyer says. Spending time in nature — simply walking barefoot in the grass, for example — can also help calm the nervous system, she adds.

Lombard recommends that counselors take these clients outside if they can or, alternatively, bring the natural world into their offices with nature sounds or a water fountain to help create a sense of calm. Lombard has noticed that clients often feel calmer when they see, touch or hear water, so she frequently has clients listen to the sounds of a rainstorm or flowing brook.

Learning to communicate one’s needs

Although highly sensitive people’s empathetic nature often makes them great partners in life and work, relationship issues are one of the primary reasons that they seek counseling. “Highly sensitive people in relationship are going to be so attuned to what the other person is feeling that sometimes they allow that to dominate over their own needs,” Smith says. For example, they may take on more work to please their boss even when they are already overwhelmed.

Smith finds role-play beneficial for helping these clients learn how to assert themselves in relationships. In counseling, they can safely practice communicating their own needs even if it initially seems strange or dramatic to them, she says.

Because highly sensitive people often hold themselves up to the standards of the 80% of the population that is not highly sensitive, they may not be aware that they need more downtime or need to do less so they can maintain their health and wellness, Sawyer says. To help these clients identify their needs and build new habits and coping strategies, she sometimes has them create a values collage of images that speak to them or make them feel good. Through this visual exercise, clients often will discover a common theme, such as nature. The values collage also serves as a reminder of ways that clients can calm an overstimulated nervous system the next time they find themselves in a stressful or overwhelming situation, Sawyer says.

For example, if a client’s collage contains mainly pictures of the ocean, Sawyer will ask how much time the client is spending near the beach or water. If the client says only once or twice a month, Sawyer will recommend increasing the time that the client engages in activities that will replenish them. For example, the client could go for regular walks on the beach or, if that isn’t feasible, pull up YouTube videos of ocean waves and sounds or simply take a bath to connect with water.

Working with these clients also involves helping them learn to set boundaries and communicate their needs, Sawyer says. She finds that nonviolent communication, an approach developed by psychologist Marshall Rosenberg, is a useful tool for highly sensitive people because it provides them with structure for setting boundaries. This type of communication involves:

  • Observing what does or does not contribute to their well-being
  • Identifying how they feel in relation to what they observed
  • Identifying the needs or values that cause their feelings
  • Making a request to fill that need or have that need met (the concrete actions they would like to see)

Sawyer provides a hypothetical case example. A highly sensitive person is worried about going on vacation with her friends because they are extraverted. The client also fears she will be expected to participate in every activity they have planned and that she won’t get enough downtime. First, Sawyer would help this client identify her needs and preferences for this trip. The client says she would like to have the room farthest away from the common areas because it will provide less stimulation if others stay up late talking. She would also like to tell her friends that she will opt out of an activity to stay in and read.

Next, Sawyer and the client discuss her fear of appearing antisocial if she communicates these needs to her friends. Sawyer uses emotional freedom techniques to help the client ease that fear and calm her nervous system. She asks the client to identify her fear. The client responds, “I feel nervous about talking to my friends.” Sawyer then asks where she feels that fear. The client says, “My stomach feels like it has butterflies.”

After ranking the intensity of the feeling (on a scale from 1 to 10), the client taps different pressure points while repeating the phrase, “Even though I feel nervous about speaking to my friends, I deeply and completely accept myself.” The goal is to have the intensity of her fear drop to a 2 or below.

Next, Sawyer and the client role-play scenarios of the client having this conversation with her friends. For example, she could say, “I’m someone who needs downtime. Would it be OK if I stay in from an outing so I don’t feel so anxious?” or “I’m excited about this trip and love hanging out with you, but I wanted to let you know that I will probably need a couple hours of alone time each day.”

Being a more sensitive counselor

Highly sensitive people “have higher responsivity to counseling interventions,” according to Smith. “Where they have positive fit with the counselor, they do better or they have more of a treatment response, and they seem to get more out of the counseling relationship.”

But how can counselors ensure that they are a good fit for a highly sensitive client? Smith recommends that counselors first think about their own temperament because it will inform any strategy they use. Are they highly sensitive, or are they among the other 80% of the population? At the same time, highly sensitive therapists shouldn’t assume that clients’ experiences are the same as their own, she adds.

“The 80% are very capable of working with highly sensitive people, but they need to be very careful of their own biases because they represent the majority,” Smith continues. “They may jump to a conclusion, or they may have some internalized negative biases of people who are highly sensitive.” If counselors aren’t aware of their internal biases, they risk unintentionally perpetuating some of those negative messages in the therapeutic process, she says. “And the highly sensitive person is coming to counseling because they’re looking for something different than what they’re getting in society.”

The good news is that “many counseling approaches would work well if the counselor is able to adapt it in light of what they know of the client’s high sensitivity,” Smith says. For example, if the counselor stares intently while the client is doing a sand tray intervention, then the client could become overstimulated and have a negative experience, making the intervention less effective, she explains. Instead, the counselor could step back and say, “I’m going to let you do this activity for 10 minutes. I’ll be over here doing my notes.”

Counselors should also think about the way they use language and how the highly sensitive person might perceive it. “The highly sensitive person is probably going to pick up more on nuanced language because, in general,” Smith says, “they’re wired to pick up more subtleties in their environment.” This also includes tone of voice, surroundings in an office, and nonverbal language, she adds.

Bjelland advises counselors to consider the environment in their offices. Is the lighting too bright? Is the client looking into a window? What is the texture of the couch? Does the office have a lot of strong smells such as cleaning products, perfumes or incense?

Smith also cautions counselors to be careful with cognitive behavior therapy. Because highly sensitive people process their environment and emotions deeply, asking them to think about cognitive distortions — the simple ways that the mind convinces a person that something isn’t true — can seem simplistic to them. It can even come across as patronizing to ask a highly sensitive client to reframe a cognition when he or she is having thousands of cognitions on a very deep level, Smith adds. Instead, she suggests saying, “Are these cognitions or depths of processing working well for you, or are these cognitions moving more into rumination?”

Counselors should also be careful when using interventions that might not value the depths of processing because they may unintentionally indicate that there is something wrong with the way the client is processing information, she notes.

Counselors also have the opportunity to reinforce clients’ gift of high sensitivity by validating the strengths and positives of the trait, Smith says. For example, a teacher might feel frustrated because he or she can’t soothe a crying boy. But a highly sensitive child in that same class probably would have noticed that the boy is upset because his crayon rolled under his desk, or the highly sensitive child might even notice the crayon rolling under the desk before the other child does and could grab it and prevent the boy from getting upset in the first place.

Thus, working with highly sensitive people can have far-reaching effects. As Bjelland points out, “You’re really creating a domino impact across the globe when you help a highly sensitive person lift off that layer of overwhelm and help them access those gifts and teach them how to care for their sensitive system because when they are thriving, they go out and help people and make a difference in the world. It’s just who they are.”

 

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The highly sensitive therapist

Many professional counselors don’t just treat highly sensitive clients — they have the sensory processing sensitivity trait themselves. Find out how they manage the benefits and challenges of this trait in the article “Advice for the highly sensitive therapist,” available exclusively at CT Online.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.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.

Counselors as human beings, not superheroes

By Bethany Bray September 23, 2019

I’m only human after all

I’m only human after all

Don’t put the blame on me

Don’t put the blame on me

These lyrics played over and over on radio airwaves in 2017 as the rock-and-blues-infused single “Human,” by British singer-songwriter Rag’n’Bone Man, topped the charts.

Given the role they play in helping others to overcome challenges and live their best lives, professional counselors are sometimes assumed to themselves be impervious to life’s challenges. But in truth, they’re “only human after all,” not superheroes. The personal and intense nature of professional counselors’ work can spill over into their lives outside of the office — and vice versa. And the very skills and instincts that make them good counselors, including a passion for helping others, can leave them vulnerable to “what if” thinking and even burnout if left unchecked.

“One of our strengths is also one of our weaknesses. We have a lot of emotion and empathy, and we have to channel it. It can be like a river that overflows its banks,” says Samuel Gladding, a professor of counseling at Wake Forest University and a past president of the American Counseling Association. “It’s kind of like water and a spigot. If you don’t turn off the water in your house, you either run out of water or pay a very high price to the water company. If you don’t cut off your thoughts about clients, you also pay a very high price.”

Clinical counselors may routinely second-guess whether they are doing enough to help clients or wonder how a client who is no longer under their care is now doing. If left unchecked, such thoughts can become all-consuming and impede on a counselor’s personal relationships and overall wellness.

Neither are counselors automatically immune to the problems with which clients struggle, from anxiety and depression to grief, trauma and unhealthy coping behaviors. Holding a counseling degree or license also doesn’t guarantee that practitioners will make all the right decisions when it comes to their own personal relationships. A misunderstanding with a spouse or partner or a discipline issue with a child can seem all the more frustrating for a professional counselor who works on relationship building and communication with clients on a daily basis.

Learning to manage such issues often comes with time, as counseling professionals gain experience. But it also takes a measure of intentionality, from consulting with colleagues and engaging in professional development activities to practicing good self-care and setting boundaries, Gladding says.

It’s also helpful to accept that it is not a matter of if: Personal and professional issues will intertwine, and challenges will crop up throughout a counselor’s career. The key, Gladding says, is recognizing them and being open to growth — the same mindset that counselors use with their clients.

“We, as counselors, have our struggles,” he says. “If we’re wise, we acknowledge them, are aware of them, and work with others to resolve them and open up. Like Albert Ellis said, we’re fallible human beings. We’re not going to be perfect, and we’re going to make mistakes.”

Blurred lines

It’s likely that counselors will face a personal crisis, loss or upheaval at some point (or at various points) throughout their careers. Counselors are no strangers to mental health disorders, divorce, trauma, addiction problems, and other issues that bring clients to therapy. In most situations, however, it is not feasible for counselors to stop working until their personal issues resolve.

The 2014 ACA Code of Ethics does not address this scenario directly. However, it does caution against practitioner impairment (see standards C.2.g. and F.5.b. at counseling.org/knowledge-center/ethics). Professional counselors are called to “monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired.” At the same time, the ethics code urges counselors to help colleagues and supervisors recognize when they are impaired and to “intervene as appropriate to prevent imminent harm to clients.”

This begs the question: How does a counselor know when he or she is becoming impaired? Self-awareness and honesty — with self and with colleagues — are imperative, Gladding says. Warning signs will be different for each individual but might include feeling hesitant or reluctant to go into client sessions or experiencing intense emotions, including anger, during and after sessions.

“Just like we would report a client who is a danger to themselves or others … when we see our colleagues or fellow counselors being impaired or not doing well, we have a responsibility to confront them, talk about it, and offer them help,” says Gladding, a licensed professional counselor (LPC).

Practitioners need to know their own boundaries and to be able to recognize when they are “tiptoeing on boundaries” that can signal impairment, says Jessica Lloyd-Hazlett, an LPC and an assistant professor of counseling at the University of Texas at San Antonio. Being able to admit that you’re impaired as a counselor is difficult but vitally important.

Lloyd-Hazlett experienced the depths of grief after her mother passed away in June 2018. She continued teaching through the summer, but that fall, she found herself feeling irritable, becoming easily overwhelmed, and “struggling to simply show up to class and be in front of students.”

She could still push herself to do what needed to be done, but on most days, she struggled, Lloyd-Hazlett recalls. It was then, through a combination of self-awareness and some gentle intervention and support from friends and co-workers, that she realized she needed to take a step back and seek counseling herself.

“The things that you want to sweep under the rug, those are the hardest and are the things that are going to come back and bite you,” says Lloyd-Hazlett, a member of ACA. “Realize that. Recognize when you’re trying to sweep things away.”

Although it is vital to have a support system in place, Lloyd-Hazlett says no amount of preparation will fully shield counselors from situations that can cause professional impairment. That’s why it is important for counselors to be able to recognize when they’re in over their heads and to be willing to seek help.

“In our profession, one of our responsibilities is being well so that you can bring yourself [to clients and students] authentically,” she says. “My mom’s death was a huge experience, but we have little ones all the time that give us a chance to practice self-care and self-reflection. Have an ongoing willingness to practice what we preach. [Self-care and self-reflection] can be buffers prior to coming into something severe. At the same time, there’s a measure that you can’t prepare for. It’s going to be hard and nasty. It’s important to have those skills and practices to be able to come back to, and [to] seek outside help.”

When helpers need help

Lloyd-Hazlett had assumed she was ready for her mother’s death because she and the rest of her family had so much time to prepare; her mother had been ill for more than 20 years with multiple sclerosis. When she visited her mother in hospice for the final time, they were able to share a special connection and say goodbye, even though her mother had lost the ability to speak.

Cognitively, Lloyd-Hazlett understood grief, both from her counselor training and from having personally counseled clients who were grieving. But when her mother actually passed away, Lloyd-Hazlett found that she wasn’t as prepared for it as she had thought. She describes the experience as a “ripping open,” as something that shook her to her core.

Lloyd-Hazlett was in a work meeting when she got the phone call telling her that her mother had passed away. Despite her mother’s many years of declining health, the news still came as a shock to Lloyd-Hazlett. She recalls returning to the work meeting and trying to function until a co-worker pulled her aside and urged her to take some time for herself to process the news.

Lloyd-Hazlett recommends that counselors dealing with personal issues make a point of identifying the “safe people” in their lives who won’t shy away from talking with them about tough topics and personal struggles. Determine who can “help you recognize what is going on and be there with you — not try and fix [you], but provide hope,” she says, adding that she learned that recommendation in a grief support group.

Many factors have played a role in bolstering Lloyd-Hazlett through her grief, but she says the most important was making the decision to seek individual and group counseling for herself. It was freeing, she says, to participate in group work simply as “Jessica, who is grieving her mom,” instead of “Jessica, the counselor.”

In addition, the experience of being guided and cared for by another practitioner helped her let go of nagging thoughts and feelings of “I should be able to do this,” she says. It was liberating to accept that she did not have answers at that time in her life, she adds.

Another aspect of Lloyd-Hazlett’s healing process has been learning to label her struggles as grief instead of shortcomings. After the death of her mother, Lloyd-Hazlett initially felt a sense of shame that she was somehow slacking or falling behind in her work as a counselor educator. Supportive co-workers suggested to her that she might want to rethink and adjust the schedule of classes she had set for herself. After seeking help and attending counseling, Lloyd-Hazlett came to realize that her need to lighten her workload now and then was a symptom of grief, not a personal failure on her part. In the months that followed, she canceled classes on a couple of occasions or had someone else fill in for her when she needed a break.

Lloyd-Hazlett says the experience of processing her mother’s death while working has taught her that personal struggles “are going to happen in our lives and our careers as we develop and grow.” It has also allowed her to experience the full length and depth of the grief that often brings clients to counselors’ doors, while giving her greater appreciation for the supports in her life, including her co-workers, friends and loving husband.

In addition, it has sparked an interest in providing grief work or hospice counseling to clients at some point in the future. For now, however, Lloyd-Hazlett knows she has more grieving of her own to do before she is ready to help those going through their own seasons of loss.

“The human experience is hard. It’s OK, and it’s good and beautiful,” she says. “There’s going to be loss and change [during a counselor’s career]. It’s going to be part of the process. There’s a reason why our code of ethics talks about these things. It’s not that you’re a bad counselor; it’s that life intersects.”

Challenges at home

Counselors need to remember that, as Irvin Yalom has written, counselors and clients are “fellow travelers,” says Doug Shirley, a licensed mental health counselor (LMHC) with a private practice in the Seattle area. “It’s important to tear down the model that helping professionals are healed and well. We are all on a healing path and have needs and vulnerabilities,” says Shirley, an assistant professor of counseling at the Seattle School of Theology & Psychology.

One of the vulnerabilities that can easily throw counselors for a loop, says Shirley, is when challenges arise in their personal lives that also fall directly in their professional wheelhouse. That might include a discipline issue with a child, struggling to connect with a spouse during a disagreement, or missing the cues that a loved one is sliding into substance use or mental illness.

Counselors might find themselves frustrated, thinking, “Why can’t I figure this out?” notes Shirley, who wrote an article for Counseling Today in 2012 titled “Why counselors make poor lovers.” The skills that practitioners hone to become good counselors — such as keeping a professional distance from clients’ emotions — can actually hinder their ability to make personal connections if they’re not careful, he says.

Adding to the issue is that counseling professionals typically spend their workdays seeing clients (or teaching students) who are paying — even clamoring — to hear their thoughts and feedback. It can be jarring to come home and find that they aren’t capturing their spouse’s full attention or that their teenage son or daughter views them mainly as a conduit to obtain permission to play video games or go out with friends, Shirley notes.

“We’re all people before we’re professionals. But sometimes the cart gets before the horse — sometimes the professional comes before the personal — and it keeps us from the more advanced and sophisticated work of being human,” says Shirley, a member of ACA. “We can amass a lot of head knowledge about people, psychology, health and wellness, but it doesn’t necessarily help us to attend to our own wounds.”

Shirley met and married his wife, who is also an LMHC, when he was in his late 20s. They had both spent years building their professional careers and developing their counseling skills before they met each other. However, the couple soon discovered that their counseling skills did little to help them find intimacy and connection. In fact, they were often a hindrance, Shirley remembers. As a result, they had to unlearn some of the boundary setting that their counseling training had instilled in them.

What has helped, Shirley says, is counseling, both individually and as a couple. Shirley and his wife have continued to see counselors throughout their 15-year marriage and are “doing better than ever,” he says.

Shirley recommends that counselors find a practitioner who has experience with or specializes in working with helping professionals. “We [counselors] all have this defensive structure that makes us a lousy client,” Shirley observes. “So often I’m sitting there [in counseling] and thinking, ‘Oh, I know what he’s doing here,’ wink, wink. Will I answer his question honestly [or play into his technique]? We need a therapist who understands that and won’t defer to that.”

Similarly, if counselors don’t learn to step out of the “head knowledge” gained in a graduate counseling program, it can detract from their personal interactions, Shirley asserts. “We become very top-heavy. We have all of these facts and theory, but it’s not wisdom and patience and vulnerability. Those aren’t typically the things of graduate training programs,” he notes. “For me, as an intellectual, it doesn’t always help me when I’m talking with my wife or my sons. If I have information that should help me navigate the situation and I don’t allow myself to not know [that information], I overreact and walk away with some sense of guilt or shame.”

Shirley says his best interactions with his family happen when he shuts off his counseling skills and intentionally works to “know better.” This was the case in a recent conflict with his 12-year-old son, during which Shirley’s initial reaction was to turn to discipline. But a family trip to see the new Lion King movie, where Shirley watched the father-son dynamics of the story’s main characters play out on screen, sparked a realization that allowed him to take a step back from his professional knowledge.

“As a dad, I was inclined to be too firm, too reactive, before connecting relationally and personally with my son,” Shirley says. “There needs to be a resonance between parent and child that is palpable to the kid, and that’s what was [missing] with my son. I was reacting instead of knowing better and practicing what I preach.”

Shirley appreciates the reminder he often hears from his own counselor to take “three steps back” — a call to be an observer in personal interactions. “Because counselors have set ourselves up to be knowers, we’re not very good at allowing ourselves to receive. Often, the hardest work is to be willing and able to receive,” he says. “In our personal relationships, we need to remember that all of our work is to receive from others. I’m a much better husband when I can hear and listen and receive from my wife, as opposed to feeling that I know all the answers and know what’s going on. It’s being open and taking a step back when needed.”

Leaving it at the office

“It’s so easy to go home and think about a session you just had and what you can suggest next time, the tools you can use, and how to best help [a client],” says Ashley Waddington, a provisionally licensed LPC who works in a private group practice in the Columbia, South Carolina, area.

The challenges that counselors’ humanity can bring — concern for clients who have left their caseload, second-guessing themselves, “what if” thinking, empathy fatigue — often have no black-and-white answers. Professional community, personal therapy, boundary setting and self-care become all the more important when work begins spilling over into the personal realm.

The counselors interviewed for this article cite the following ideas and techniques as being particularly helpful when it comes to counseling professionals wrestling with their humanity.

>> Connect with peers: Waddington, an adjunct instructor in the counseling education program at the University of South Carolina, is a big proponent of supervision, not only for the hours required by graduate programs and state licensure boards, but across one’s entire career. She currently has three supervisors and finds it vitally important to talk things through with professionals of various perspectives. “Counselors are lucky to have the practicum experience. Not every profession gets that,” says Waddington, who recently served as co-chair of the ACA Graduate Student Committee and co-presented a session on “survival tips” for graduate students and new professionals at the ACA 2019 Conference & Expo. She also finds support via a Facebook group for counselors in private practice, where members bounce ideas off of one another, ask questions, and share tools and techniques.

Shirley also recommends that counselors debrief with other counselors via regular consultation. He is part of a long-standing professional consultation group that meets regularly in his area, but he also seeks additional input if challenges arise between meetings. He believes it is important for counselors to consistently pursue consultation, even when things are going well, he says, to gain perspective and to benefit from the rhythm of meeting regularly with fellow counselors.

In a similar vein, Gladding recommends that counselors attend professional development events such as ACA’s annual conference to stay up to date and to seek feedback from peers on challenges that are unique to the profession. For counselors who aren’t connecting naturally with their co-workers, or for those who work alone or in a setting dominated by colleagues from other professions, Gladding shares a little advice (via lyrics from Gloria Estefan): “Get on your feet, get up and make it happen.” Counselors need to be more intentional about finding community, he says, whether online, through travel to state or regional conferences, or by other means.

“Don’t let yourself be in isolation,” Gladding says. “That almost [never leads] to good mental health. We learn from others and thrive when we’re social. We’re not lone wolves; we’re gregarious. That’s how human beings are.”

>> Write it down: Transferring one’s inner thoughts to the page can help counselors process what they’re feeling, quell rumination, and spark self-reflection. “I keep a journal, and I would be the first to say there’s research out there that [maintaining] a journal helps keep us healthier in the short and long run,” Gladding says. “It helps us be more attuned to how we’re doing and how we’re living.”

Journaling can also spur deeper thought about what is and isn’t under a counselor’s control, Gladding says. “We can check up on [clients], but if we can’t, we let it go. In the end, we don’t have complete control over people. They’re not robots,” he says.

The same process applies to people and events in counselors’ personal lives. “My oldest son and his wife are teaching French in Casablanca, Morocco. I can’t obsess about that too much, even though it’s such a long way away and a land with different customs and culture,” Gladding says. “I have to trust that they can do that and do it well.”

>> Shake it off: Maintaining a schedule of back-to-back client sessions, each with the potential to bring intense and heart-wrenching issues to the table, can be draining, both mentally and physically, for counseling professionals. Clinicians who are intentional about resetting themselves between each client are more likely to keep sessions from blending together and may be better positioned to head off burnout.

Waddington had a supervisor who kept a feather duster in her office so that she could figuratively dust herself off after each client. The ritual helped her visualize closing the prior session and preparing herself for her next client, Waddington explains.

In between clients, Waddington often steps outside, stretches, or even lays on the floor of her office to reset and clear her mind. She also finds that leaving her office and finding another secured area to record client notes after an appointment helps her find closure and “finish” the session.

It can also be helpful, Waddington suggests, for counselors to take a shower once they get home, not necessarily because they’re dirty, but to “wash off the day.” They can visualize rinsing away the heavy topics and client issues they have been wrestling with all day.

“By simply using the basic cognitive approach of reviewing our day, picking out the emotions we felt, and using them to uncover our dysfunctional thinking and belief systems, we can address them so the day’s detritus can be left at the office and not remain in our head,” says Robert J. Wicks, an ACA member, professor emeritus at Loyola University Maryland, and author of numerous books, including The Inner Life of the Counselor. “When you go to the bathroom in a restaurant, there is a reminder [to wash your hands]. The same can be said metaphorically of counseling. We need to psychologically and spiritually decontaminate ourselves before returning to the rest of our lives.”

>> Get by with a little help from your friends: While professional connections can be a vital part of a counselor’s support network, connections with friends who aren’t helping professionals can be equally as valuable and refreshing, Shirley notes.

Spend time with “those who will stick with you through the bad and good and tell the truth,” he says. “Friends who aren’t counselors are key. These are the people who will keep us sane and give it to us straight. They often have their feet on the ground more than we do.”

Wicks agrees, asserting that counselors need “a robust and balanced circle of friends” to be able to thrive. He goes into more detail on this topic in his book The Resilient Clinician. Practitioners can benefit from encircling themselves with a variety of personalities, Wicks says, including friends who will challenge their thinking; be sympathetic and supportive; keep a counselor from taking themselves too seriously through good-natured teasing; encourage a sense of wonder; provide guidance without giving answers; and spur them to be their best.

>> Take care: The introduction to Section C of the 2014 ACA Code of Ethics urges counselors to “engage in self-care activities to maintain and promote their own emotional, physical, mental, and spiritual well-being to best meet their professional responsibilities.”

When it comes to self-care, it’s important to have a plan in place before challenges arise. Not only will the methods that counselors find effective vary from practitioner to practitioner, but a self-care routine will also need to evolve to meet changing needs throughout a counselor’s career.

Gladding suggests that counselors be intentional about spending time engaging in hobbies that help them decompress and find connection. Perhaps that’s singing in a choir, playing golf, watching birds — whatever piques their interest, he says.

Wicks advocates for alone time and spending time in reflective silence and solitude. As she has navigated her grief journey, Lloyd-Hazlett has found yoga helpful, as well as trying new things such as entering some of her paintings into a local art show. Waddington recharges through reading books on mental health topics in her personal time (she recommends Yalom’s The Gift of Therapy and The Grief Recovery Handbook by John W. James and Russell Friedman).

Shirley emphasizes the importance of wellness, including nutrition, exercise, getting enough sleep, and drinking enough water. These elements are often the first things to go when counselors get stressed, he notes.

Finding spiritual community is also essential, Shirley adds. The community doesn’t necessarily have to be a religious one; it can include spiritual connections found through group yoga classes, volunteering in the community, or other means, he says.

>> Keep it real: Professional boundaries must be maintained, but occasionally, “being human” in interactions with clients or students can be a powerful way to connect, Lloyd-Hazlett says. When it comes to self-disclosing to clients or students, such as mentioning that she is struggling with a loss, Lloyd-Hazlett says she lives by the philosophy “less is more.” However, self-disclosure, when done appropriately, can also serve as an example for others to be honest and open about their own struggles.

“The question needs to be, is this going to benefit my client? What is my motivation for wanting to disclose?” Lloyd-Hazlett says. “Being a human and having a human experience is so important to the counseling relationship. We can do that through different ways, including self-disclosure. When you’re struggling, just showing that and acknowledging that can be very powerful. What that disclosure looks like depends on the client or topic and where you are in your process.”

Counselor training teaches practitioners to remain professional and keep an emotional distance from clients while in session. However, Waddington urges counselors not to hold back if they are connecting with a client during an intense moment in session.

She recalls one client who was grieving the loss of her sister, who had died tragically in an automobile accident. The client’s pain was so raw that she couldn’t bring herself to say her sister’s name out loud. Waddington found herself with tears streaming down her face in session and apologized to the client for losing her composure.

But in their next session together, the client thanked her. “She said, ‘I’ve never had someone cry with me like you did. That was the first time I felt really heard, and [I knew] you understood what I was saying,’” Waddington recalls.

>> Know that you are enough: Waddington leaves notes for herself in her office with positive messages such as “You are enough” and “You just need to show up today.” These simple reminders help her curb overthinking and the urge to come into sessions with a mindset of fixing clients. “You don’t have to have this crazy technique to do with a client. Showing up is enough. … It’s not [our] job to fix them but to show up and work with them where they are,” Waddington says.

It’s a lesson Waddington has learned over time. She recalls one client who was severely depressed and unable to work. He left his house only to come to therapy once per week. Initially, she worked with him on big goals to improve his situation, including applying for jobs.

Waddington finds it helpful to check in periodically with clients in session to see how they are feeling about their work and progress in therapy. During a check-in with this client, he gave Waddington feedback that served as a reality check for her: You can do less for me. The client was feeling guilty about his lack of progress, and his self-esteem was taking a dive as a result.

After some self-reflection, Waddington changed her approach, working with the client on smaller goals and steps that could help him feel better day to day. In turn, his quality of life improved, she says.

“One thing I’ve had to learn and practice myself is that you don’t have to have all the answers and be the solution [for clients],” Waddington says. “[That’s] not our job. It’s our job to show up and listen.”

When self-doubt kicks in, Shirley urges counselors to remember that they’re part of a bigger picture. “When we get hung up on ‘Did I do that right?’ remember that we’re all in this together and doing the best we can do. Rumination and anxiety are really common when we’re in the messy business of helping people. Whatever we’re doing, we’re doing the best we can do. And, quite frankly, sometimes that is enough. And when what we have to offer isn’t enough, we need to go out and get extra support through referral or consultation, etc. That’s not a reflection on us as people, it’s just information.”

Boundary setting off the clock

Years ago, when Gladding was a new practitioner with a young family at home, a couple he was counseling called him on a Sunday afternoon with an urgent request to see him for an emergency session.

“I agreed to see them — and soon realized that they weren’t in crisis. They just wanted to blame each other for some things,” Gladding recalls. “I learned from it and [eventually] said, ‘I’ll see you during office hours, but I can’t see you now.’ That was a mistake on my part.”

It wasn’t the last time a client would contact him outside of working hours. In one instance, a client even showed up at his home on the weekend. While it’s certainly possible for clients to spiral into crisis situations at any time of day or any point of the week, Gladding says he has learned the importance of prioritizing boundaries. If clients contact him outside of working hours, he makes sure they’re stable, ensures they have crisis hotline numbers, and agrees to see them at the next possible opening during business hours. “I don’t want to downplay [clients’ pain], but boundaries have to be there, or we don’t do anyone any good at times,” Gladding notes.

The same goes for family members or friends who approach him for advice because he is a professional counselor. Gladding says he typically uses humor to diffuse the situation and redirect their questions. There is a reason that ethics guidelines urge against counseling family members and friends — because counselors simply cannot be objective in those situations, he says.

If Gladding notices an issue going on in the lives of those he knows personally, he says that he might make a gentle observation to them about what he’s seeing — without engaging in a counseling intervention — and offer to connect them to another counselor.

“I have a colleague who is always saying, ‘Check yourself before you wreck yourself.’ I like that because we can get into trouble if we get too much into something that’s happening” in the lives of family or friends, Gladding says.

Waddington sees such situations as opportunities to coach family members and friends on the benefits of professional counseling, and then supporting them through the process of finding a counselor clinician.

“When anyone knows that you’re a therapist, the floodgates open,” Waddington says with a chuckle. “People will start sentences with, ‘In your professional opinion …’”

In those situations, Waddington has a phrase that she responds with: Do you want my ears, do you want my advice, or do you want me to step in?

“Then, I am clear about what they really want from me. Often, they just want me to listen. I can listen all day, but it’s not my job to be your therapist, and I don’t want to be,” she says. “Often, I will say, ‘Let me help you find someone to talk to.’ … It’s not my job to help my cousin get through this [problem], but it is my job to help them find help.”

 

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Contact the counselors interviewed for this article:

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Additional resources

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

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

 

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

Letters to the editor: ct@counseling.org

 

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

Advice for the highly sensitive therapist

By Lindsey Phillips September 20, 2019

Erica Sawyer, a licensed mental health counselor and art therapist in private practice in Vancouver, Washington, knows firsthand the benefits and challenges of being a highly sensitive therapist. (Approximately 20% of the population has an innate temperament trait referred to as sensory processing sensitivity; individuals with this trait are categorized as “highly sensitive people.” Right after graduate school, she started working 40 hours a week at an enhanced care facility for adults with severe and persistent mental illness. She quickly realized that the constant needs in the 16-bed locked unit were overwhelming for her.

“It was very intense,” Sawyer says. “There were times I couldn’t even get out the door to take a break because there was a crisis with a resident trying to leave the facility, so we couldn’t open any of the doors. So, on my break time, I had to sit in an office where there were constant interruptions.”

Sawyer tried to escape the overstimulation by visiting the restroom, but she couldn’t stay long in there because there was only one bathroom in the entire facility and other people needed it.

On the positive side, she found she was able to connect with many of the residents in a way that surprised and baffled the other therapists. She realized, however, that being good at this type of work didn’t mean that it was a good fit for her.

In fact, Sawyer says she was on a path to quick burnout, so she determined to figure out what she could control — such as her work environment, her hours worked, and the type of clients she saw — and start making changes.

She went from a full-time inpatient position to a part-time outpatient position, but even that was too much because of the hours needed to get all the work done for her caseload of 70 people. “The quantity of clients, along with being assigned the higher needs cases, was far from optimal,” Sawyer says. “I was experiencing my own anxiety and had to go out to my car and do some tapping [therapy] to just manage the day.”

Now, Sawyer is working part time in her own private practice so that she can control the amount and type of clients she sees and the days and times she works. She also lets clients know that she can’t guarantee a response to an email after 5 p.m. Highly sensitive therapists have to recognize their stress points and the environments that aren’t conducive to their temperament because it’s not good for them or their clients, she adds.

Because highly sensitive people process more deeply, counselors with this trait may have difficulty leaving work at work, notes Heather Smith, a licensed professional counselor and an assistant professor of human development counseling at Vanderbilt University. It’s important for highly sensitive counselors not to compare themselves to counselors who do not have this trait, she says. Instead, they have to figure out their own needs and best practices. For example, they may need to see fewer clients per week or work fewer hours.

Elaine Aron lists some possible self-care practices for highly sensitive therapists on her website:

  • Practice “The Five Necessities” — believe your trait is real, reframe your childhood in light of this trait, heal from past wounds, don’t try to live like the other 80% of the population without the trait, and find a group of other highly sensitive people
  • Reduce therapy work time (ideally, no more than 20 hours a week)
  • Screen clients
  • Have downtime
  • Don’t take your work home
  • Charge clients appropriately
  • Find a good consultant
  • Seek out your own therapist
  • Take frequent vacations

Julie Bjelland, a licensed psychotherapist in private practice in California who specializes in working with people who identify as highly sensitive, recommends that highly sensitive therapists see no more than 10-12 clients per week. “You can’t see seven clients in a day as a highly sensitive person and be well because you’re taking in too much information,” she notes. Bjelland also suggests other ways that these therapists might reduce potential overstimulation and burnout. For example, they could increase their fees and see fewer clients per week, or they could see clients three or four times a week and then have three or four days off.

Smith, an American Counseling Association member who researches the sensory processing sensitivity temperament trait, advises highly sensitive therapists to create healthy habits to reduce overstimulation and to give their brains extra time to process. For example, counselors could schedule breaks between sessions, or they could make a point to finish their work notes before leaving for the day to avoid continuing to process this information when they get home. “Some of these practices can help over time to decrease the susceptibility to burnout,” Smith says.

Louisa Lombard, a licensed professional clinical counselor in private practice in California, makes a point to practice self-care habits. For instance, she takes a 30-minute break between clients so she can finish writing her notes, eat a snack, or engage in activities that she finds soothing, such as meditation or using essential oils.

Sawyer, also an ACA member, has colleagues who perform a ritual of literally washing their hands between clients as a way of letting that session and all of its associated information go down the drain before the next client.

Even though highly sensitive therapists have particular needs that must be addressed to avoid burnout, they also bring unique gifts to therapeutic sessions. Highly sensitive counselors “are well wired for this type of work,” Smith notes. “They’re going to process information more deeply. There are new research findings that suggest they have more mirror neuron brain activity and, thus, possibly stronger empathy.”

These counselors often have deep intuition and more attunement with others, and they tend to make clients feel safe and easily build rapport with them, Sawyer adds. As she points out, these qualities are “huge assets in being a good counselor.”

Bjelland, an author and global educator on the highly sensitive person, agrees that highly sensitive therapists have a lot to offer to clients because of these qualities. She finds that these therapists often have a strong connection with clients, are able to pick up on patterns and connections, and sometimes know things even before their clients do. She has had clients who weren’t able to reduce their anxiety even after working for years with other therapists. But within two to three weeks of working with her, their anxiety started to decrease.

Bjelland says highly sensitive therapists can benefit from thinking about the way that healers used to operate within a tribe: They had their own hut, and after they did their healing, they would spend a lot of time alone. “If you see one client, you’re going to need to process that session and then … rest and restore after that session,” Bjelland says. “Because if you take care of yourself well in this field, you can be a powerful healer.”

 

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Look for a related article, “Finding strength in sensitivity” in the October issue of Counseling Today magazine.

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.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.