Monthly Archives: January 2020

From Combat to Counseling: Getting started in counseling military clients

By Duane France January 29, 2020

We want to help people. It’s a common reason many choose to become professional counselors. Maybe we’ve been told we’re good listeners. Maybe we have lived experience with overcoming mental health concerns. Whatever led us to counseling, we want to use our skills to help people. At some point, we may decide we want to help people in the military population: service members, veterans and their families. Perhaps we want to help military kids because we have a couple of our own, or we were one. Or, we want to support military spouses in post-military life because they’re an underserved and under-resourced population.

Having a clinical focus on serving the military population is admirable. More importantly, it’s necessary. With critical mental health access shortages in the Department of Veterans Affairs (VA) and Department of Defense (DOD), and studies that show that community providers are not as culturally competent with the military population as VA and DOD clinicians, it’s essential to increase the military population’s access to timely and competent mental health services.

Counselors often ask me: How do I do it? I may want to serve veterans and their families, but how do I get there from here?

Here are some critical points to consider if you’re interested in working with the military-affiliated population.

 

Know why you’re doing it

Understanding your motivation for serving veterans is critical. More importantly, it’s an ethical responsibility for counselors. In order to give the highest quality of service to those we work with, as well as to be true to ourselves, we need to understand what it is that got us into this work and why we want to do it.

What are your personal and professional motivations to serve this population? Like me, are you a veteran yourself, or (also like me) a child of a veteran? Are you a military spouse who has the lived experience of your partner’s service? Or do you have no prior direct affiliation with the military, but happened to work with the population during your clinical training? Regardless of your background, it’s essential to understand why you chose this particular population to serve.

Photo by U.S. Army Master Sgt. Alejandro Licea/defense.gov

Understand your limitations

Along with why you’re doing it, it’s important to understand your limitations. This could mean that you may have some familiarity with one aspect of military culture but recognizing that you’re not an expert in all military culture. Or that you may come up against some things in your clinical work that you’re not prepared for, and you didn’t know would bother you. I remember several years ago when working with a veteran, a session in which they were recounting significant racial discrimination while they were in the military. This discrimination was the source of their depression rather than PTSD as most people (including the client) assumed. As I was listening to the veteran recount their story, I found myself getting angrier and angrier, to the point where I started to lose concentration and therapeutic objectivity. The former senior noncommissioned officer in me was offended at the experience.

What I didn’t realize was that this was a psychological reaction on my part to two different things: the blatant disregard for the military values that I hold dear shown by the veteran’s leadership, as well as my own unresolved emotional response to racial discrimination in my childhood. A classic example of countertransference. Counselors like me, who identify as military-affiliated, must assess for and address potential countertransference. Just because a counselor is a veteran doesn’t make them the best counselor for veterans, and we need to be aware of the limitations of our own personal experience.

Where do you start?

So understanding why we want to serve veterans is essential, and it’s also important to understand the limitations that we may face, but what about the practical aspects of serving this population? As in, specifically, how do you help? I often hear how difficult it is for professional counselors to serve in the VA (although the department is currently putting a lot of effort into creating more licensed professional mental health counselor positions). And if you’re not in the VA or DOD, but want to help veterans, where do you go? How do you find internships, post-graduate placement or positions for a fully licensed counselor?

There are several suggestions that I often give to those counselors who reach out to me, asking about how they find positions in the community that serve veterans. First, do some research in your area. Are there mental health clinics that primarily serve the military population? Organizations like the Cohen Veterans Network may be a useful resource for internships or to get your pre-licensure hours, or clinics like the one I work for, the Family Care Center, in Colorado Springs. Even if they are not currently taking interns, they may have some advice for you.

Another potential source for positions is to see if there are other veteran services in your community that would be willing to add a clinical component to them. For example, the Veterans Village of San Diego, a nationally recognized leader in serving homeless veterans since 1981, has 27 mental health interns as part of their staff. Organizations that provide employment, housing, legal and financial resources to veterans may be willing to include a mental health component to their services.

And finally, there is a national program that may be of some benefit. Give An Hour is a national network of volunteer clinicians who serve the military population. I often recommend it as a resource for those veterans and family members looking for support outside of my local area. It is also a way to connect with other like-minded professionals serving the military population. If you’re looking to serve veterans in your area, it’s a good idea to reach out to those who are already doing so and network with them. You can find a list of clinicians in your area who are working with the military by searching for providers in your zip code, and reaching out and connecting with them on LinkedIn or through email. It’s likely that you will find one or two who would be willing to sit down and talk and give some professional advice on what serving the military looks like in your location.

Serving those who served

Dedicating your professional career to serving those who served and those who care for them is admirable and not to be taken lightly. Like many other underserved populations, it is necessary to understand the unique culture of the military and how it impacts our clients. Through diligence in our preparation, we can make sure to provide the best care possible for those who sacrificed much on our behalf.

 

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Duane France, LPC

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

 

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

Fostering immigrant communities of healing

By Lindsey Phillips January 28, 2020

During the months surrounding the 2016 presidential election, the rhetoric around immigration was so charged that Daniel Gutierrez, a licensed professional counselor (LPC) and American Counseling Association member, noticed a substantial uptick in panic disorders at a free clinic in Charlotte, North Carolina. One therapist even told Gutierrez about a client who was having panic attacks every time that a political ad played on television.

Four years later, Gutierrez, an assistant professor in the counselor education program at William & Mary and coordinator of the addictions emphasis for the university’s clinical mental health counseling program, says he still encounters immigrants who are terrified and no longer understand the immigration process in the United States. Many worry about family members back in the countries they left. Some worry that if they visit these family members, they may not be able to easily return to the United States themselves. Some are confronted by people screaming “Go back home!” as they shop for groceries or walk down the street. Fear, guilt and worry are constant emotions for many immigrants, notes Gutierrez, who is also faculty director of the New Leaf Clinic at William & Mary in Williamsburg, Virginia.

In fact, Gutierrez says that providing counseling services to immigrant populations can sometimes feel like working in a hospital emergency room. “We’re just trying to stop the bleeding for a minute, and sometimes we don’t have time to look at some of the other concerns,” he says. “You don’t even know where to start. There’s so much trauma and anxiety.”

“They have such a history of past trauma that it overshadows everything,” Gutierrez continues. “They’ll have this experience on the border crossing or in their home country, and when they get here, that [experience] influences every relationship.” Gutierrez has seen cases in which a mother has difficulty connecting with her partner and children because of the guilt she feels about a trauma that happened while the family was crossing into the United States. For this reason, counselors often have to deal with larger presenting issues — trauma, anxiety, depression — before they can work on other concerns such as relationship issues, he explains.

Immigrants also face myriad stressors after migrating to a new country, and these stressors take a toll on their mental health. In fact, researchers have identified an immigrant paradox in which recent immigrants often outperform more established immigrants in areas of health, education, conduct and criminal justice.

This paradox illustrates how damaging acculturative stressors such as financial concerns, insufficient living conditions or food, cultural misunderstandings, an inability to communicate or speak a new language, lack of employment, and isolation can be to immigrants. Lotes Nelson, a clinical faculty member at Southern New Hampshire University who often presents on this topic, points out that these stressors can result in symptoms of anxiety, depression, posttraumatic stress disorder (PTSD), conduct disorders (especially for children) or substance abuse issues.

Isolation and the lack of a support system can cause immigrants to turn inward and internalize their symptoms, says Nelson, who lives in St. Augustine, Florida, and, as an LPC and approved clinical supervisor in North Carolina, offers distance counseling services. Her clients who are immigrants often report feeling that something isn’t right — their heart is racing all the time or they constantly feel sad, for example — but they can’t pinpoint what it is or why they feel this way. In addition, they frequently lack people they trust to talk to about their concerns.

One problem is that accessibility to counseling services is limited for immigrant populations. Gutierrez, author of the chapter “Counseling Latinx Immigrant Couples and Families in the USA” in the forthcoming book Intercultural Perspectives on Family Counseling, says that immigrants are less likely to receive mental health services, and when they do, the services are often lower quality than what the majority culture receives. “The counselors who are offering the care [to immigrant populations] are overwhelmed with large caseloads. They are about to hit burnout. … The immigrant stories of journeying over are [also] really difficult,” he explains.

In addition, Gutierrez finds that the counseling profession doesn’t have enough practitioners who understand the cultural implications and nuances of working with immigrants.

Nelson, a national certified counselor and a minority doctoral fellow of the National Board for Certified Counselors, also points out that immigrants may not voluntarily seek counseling because many have not been exposed to mental health care until reaching the United States. So, at least initially, she says, they may not consider counseling to be an acceptable service or treatment. When someone is not familiar with the mental health care process or if they question the validity of therapy, then they are not going to easily share their thoughts, concerns and fears in counseling, explains Nelson, a member of ACA.

Gutierrez and Nelson agree that to overcome some of the barriers that immigrants face in receiving mental health care, work must be done on the part of counselors to cultivate personal relationships and build trust with them. Counselors need to understand where each individual client is from and what that person’s transition to living in the United States has been like. Gutierrez also stresses that if they truly want to make a difference, counselors must enter into partnerships with immigrant populations and the communities that serve them.

Overcoming language barriers

Language is often a barrier when working with immigrant populations, and finding bilingual counselors can be a problem, according to Gutierrez. In 2009, when Gutierrez lived in Orlando, Florida, he sought his own mental health counselor but found only five who were Latinx and spoke both Spanish and English.

Gutierrez, co-founder of the annual Latinx Mental Health Summit, also points out that native Spanish speakers will sometimes use physiological terms to talk about psychological illness, which results in diagnoses being missed or lost in translation. For example, in some Latinx cultures, people may say, “My heart hurts” or “I have pain in my heart” to describe sadness.

Nelson has observed that immigrants who are experiencing anxiety also commonly describe their symptoms physiologically, such as having abdominal pains. Some clients may believe that a stomachache is purely physical and not related to mental health, she points out.

Counselors can overcome some language barriers by working with interpreters. Because of the complexity of translating mental health terms and concepts, Nelson cautions counselors to make sure they are working with qualified interpreters, not just individuals who happen to speak the language. With some clients, certain mental health terms or symptoms may not exist in their cultures, so their language may not even have a word to describe it, she adds.

Nelson invites interpreters to ask her questions to clarify and help them make sense of what they are translating. She also requests that they translate her words verbatim to the client to avoid potential misinterpretations.

Finding qualified interpreters can also be a challenge, Gutierrez points out. Nelson and Gutierrez have used interpreting agencies, hospitals and university language departments to find interpreters. Once counselors do find someone qualified, they then need to ensure that the translator will keep clients’ information confidential, Gutierrez adds. He recommends that counselors have interpreters sign confidentiality agreements. For him, the best-case scenario is working with interpreters in the helping fields (e.g., case management, nursing, health education) because they already understand the importance of client confidentiality.

There is also a danger of misinterpreting body language when working with clients from different cultures, Nelson notes. For example, whereas nodding in U.S. culture typically denotes comprehension, some clients raised in Asian cultures may nod because they are embarrassed about not fully understanding what is being communicated or don’t want to make the therapist feel bad that they don’t understand, Nelson explains.

Nelson has also had clients bring in their children to translate for them in session. When this happens, she explains to the client that even though the children may be capable of translating, the conversation may be beyond the child’s developmental age, so she would prefer working with a translator. However, some clients resist working with a translator and feel safe only when having someone inside their family unit translate their personal information. When this happens, Nelson respects the client’s preference but carefully explains the potential consequences of choosing that option.

Prioritizing family

Many immigrant populations place a high value on family, and this means that counselors should make it a priority too. “If a client has to choose between their child and being seen by [a therapist] … they always prioritize family. They always prioritize children,” Gutierrez says. “So, family cohesion is a stronger predictor of whether [immigrants] engage in services or benefit from services than [it is with] the majority culture.”

Gutierrez says counselors will be more successful engaging with immigrant populations if they offer family services, provide some form of child care, or help clients connect how their own well-being and mental health influence their children’s well-being.

Nelson agrees that counselors must find ways to incorporate the family if they are to be successful in reaching out to immigrant populations. Because child care can be a challenge for many of these clients, she suggests that counselors consider providing clients’ children with a separate room where they can color, watch movies or engage in other developmentally appropriate activities while their parents are in session. However, she acknowledges that this setup is not always possible, so counselors may have to find other ways to accommodate families.

Clients often come to see Sara Stanizai, a licensed marriage and family therapist and owner of Prospect Therapy in Long Beach, California, because they are navigating two conflicting messages: the individualist mindset widely embraced in the United States and the collectivist mindset often emphasized in their homes. Family was so central to one of Stanizai’s adult clients that the client’s mother had to speak with Stanizai before the client could work with her.

If clients come in discussing problems with their family and the therapist’s advice is to set better boundaries, this could work against the clients’ mental health and well-being because being with their family is a priority for them, Stanizai says.

Instead, she works with clients to reframe the issue with their families to find common ground. Rather than focusing on why a client is at odds with his or her parents, she helps the client think about the underlying motivations and values that they all agree on. For example, the client may agree with the parents’ desire for them to have more opportunities and to be successful, even if the client doesn’t fully agree with the parents’ high expectations or demands to get straight A’s.

Because of the stigma that often surrounds mental health within immigrant communities, some clients may not feel able to talk openly with their families about counseling. This is strange for them because they have such strong family units, Gutierrez points out. An inability to turn to their families can prevent these clients from going to counseling because they fear getting “caught,” he adds.

Thus, confidentiality becomes particularly important when working with immigrants whose communities may stigmatize counseling or whose experiences or undocumented status could prevent them from freely sharing their stories. For example, if an individual’s pastor refers the client to Nelson, she will make a point to say, “I know you came here because your pastor recommended counseling, but this does not mean that what you share here goes back to your pastor. This meeting is for you, and anything you say here will stay within this room.”

When working with clients who are immigrants, counselors should consider the individual’s overall support system, which can include family, friends, faith leaders, community elders, local organizations, medical doctors and other professional service providers, Nelson says. She reminds her clients that she is just one part of their support system. For example, if spirituality is important to a client, then she will say, “It sounds like you have great respect for your worship leader. I want you to continue to go to them while you are also coming to counseling. You have a whole host of support around you.”

“If you as a counselor [have] … tunnel vision — ‘this is me and my client’ — when working with immigrants, then it’s more than likely not going to be successful,” Nelson says. “Because if you only look at one of those resources, such as friends, [clients] are going to get a fraction of the treatment that they need.”

Partnering with the community

Gutierrez learned the value of community and partnerships when he worked as a counseling professor at the University of North Carolina at Charlotte (UNCC). Mark DeHaven, a distinguished professor in public health sciences at UNCC, taught Gutierrez about community work and connected him with Wendy Pascual, the former director of Camino Community Center, a local free clinic.

Through his partnership with Pascual, Gutierrez learned that the clinic had 85 people on a waiting list to receive mental health services. He also discovered that primary care was often a starting point for immigrants to receive services. The majority of people at the clinic had mental health issues related to depression, anxiety, stress or trauma, and these issues were often a significant driver of their physiological complaints (e.g., diabetes, high blood pressure). The physical illness was often just a symptom of a mental health concern — one that was going untreated because of a lack of qualified counselors and services.

Gutierrez worked with Pascual and a team of academics, including DeHaven, to fulfill this need and reduce mental health disparity within the immigrant Latinx community in Charlotte. Graduate counseling students at UNCC agreed to provide counseling services for the clinic, so the services remained free for the immigrant population and operated as part of the students’ counseling training.

Gutierrez notes that counselors need to enter into partnerships if they want to make a difference in immigrant communities. He stresses the word partnership. “There’s a difference between partnership and collaboration,” Gutierrez notes. “Collaborating with people in a community is OK; you do your stuff and then you go back home. But partnership [involves] … joining with people in the community and … adopting their mission and vision.”

Partnerships allow counselors to reach immigrant communities and better understand clients’ cultural values. For clients who are immigrants, it is often about the personal relationship and building confianza, or trust, Gutierrez says. But he notes that in Spanish, the word confianza goes further than just trust. “It’s confidence. It’s connection. It’s partnership. It’s someone who invites you in to break bread,” he explains.

Gutierrez cautions counselors not to assume that immigrant clients are going to come to them. Instead, he advises counselors to work within the communities they want to serve. He also recommends attending community events such as church celebrations or local festivals as a first step toward building these partnerships. By attending the annual Puerto Rican festival in Charlotte, he was able to foster relationships with individuals and learn more about what work was already being done to help immigrant communities.

Counselors should “just follow the crowd backward,” he advises. For example, they can look for people organizing food and backpack drives or voter registration efforts and connect with them because these people are the ones who are already doing great work in the community.

Partnerships have also assisted immigrants in finding Nelson, who notes that most of her clients come to see her because of referrals from religious leaders, resettlement agencies or other clients. She also agrees that immigrant families value seeing counselors out and about in their communities, including at events, festivals, fairs, their places of worship and so on.

Even so, counselors must remember to uphold their ethical obligations, such as protecting client confidentiality, during such community interactions, she notes. When a client brings Nelson a flyer for an upcoming event, she carefully weighs her ethical obligations with the needs of the client: Will attending the event harm or benefit her relationship with the client? Could it in any way interfere with the client’s treatment or the progress the client is making?

She also has conversations with the client about boundaries. They discuss how the client wants to handle this dual relationship and talk through scenarios concerning what could happen as a result of Nelson attending the event. Will the client acknowledge her (and vice versa) when they see each other? How does the client want to explain their relationship to family members and friends who may be at the event?

For Gutierrez, the faith-based community has been the biggest asset in working with immigrant populations. In churches and other spiritual communities, immigrants can typically use their own language, connect with others like them, and feel safe and heard, he explains. For this reason, Gutierrez advises counselors to work with pastors and other spiritual leaders to educate them about the benefits of professional counseling. Often, that is all practitioners need to do to increase the number of immigrants who seek counseling, he says.

Gutierrez tested the power of spirituality for immigrant communities by holding identical educational counseling courses (with the same curriculum and instructor) in a clinic and in a church. Whereas only 20-30% of immigrants completed the course at the clinic, 90% of those attending the class at the church stayed because they said they felt the class was closer to God and more aligned with their beliefs, Gutierrez says.

If clients value spirituality, counselors can integrate that into their sessions and adapt interventions to include spirituality (adhering to the competencies developed by the Association for Spiritual, Ethical and Religious Values in Counseling), Gutierrez says. For example, counselors might ask clients how they understand a situation from their own religious or spiritual perspective, or they could discuss the use and function of meditation and prayer, as appropriate, he explains.

Nelson has had immigrant clients with symptoms of depression or anxiety report that “I’m possessed by the devil because I feel this way.” Other clients have told her that in their home country, they would have been taken to church and prayed over for days or weeks for having such feelings. When this happens, she relates mental health needs to medical ones because the concept of medical health is often familiar to these clients, even if mental health is not. She asks them where they went when they had physical pain. When they respond that they went to see a doctor or a healer in their village, she compares that process to seeking a mental health professional to figure out why they feel sad or feel like something is not right with them emotionally, psychologically or socially.

Diagnosing the person, not the culture

“We’ve treated culture in counseling sometimes likes it’s a diagnosis,” Gutierrez asserts. He explains that practitioners sometimes try to adapt counseling approaches to fit specific cultures — for example, using cognitive behavior therapy (CBT) with all Latinx clients. But this method ignores the differences within cultures, he says. CBT may work well for one Latinx client, but another Latinx client may prefer psychoanalysis.

“Good cultural accommodation or adapting culturally responsive care starts with a good conversation about what the client needs and the services you provide,” Gutierrez says.

“There’s still a human being in that chair. … It’s less about the strategies you use and more about the person you’re working with … because they’re dealing with multiple layers of stress, challenges and stigmas. So, find out what their story is before making some assumptions,” he advises.

Being culturally responsive may mean adjusting the length of counseling sessions, Gutierrez notes. Even though a 50-minute clinical session is standard practice in the United States, shorter sessions may work better for some immigrants, he says. 

Likewise, Nelson says it is dangerous for counselors to quickly settle on a diagnosis without knowing the client’s overall picture. On the surface, it may look like an immigrant client is dealing with anxiety over moving to a new country, but counselors should consider everything the person has experienced in their life before, during and after migration, she explains. Past and ongoing traumas and adverse childhood experiences can shape a person’s development and can potentially lead to disruptive behaviors, PTSD, depression and anxiety, she adds.

To learn about clients’ immigration experiences, Nelson often says, “Tell me what you went through physically and mentally. What was the living situation when you were migrating, and what is it now? What kind of threats did you experience?”

Often, clients will resist answering these questions because they are not yet willing to focus on the traumatic experiences they went through, Nelson says. Many clients respond along the lines of “I don’t think about that. That’s over now. I want to focus on the here and now” or “That’s just what I had to do to get here and to get a better life.”

When clients dismiss their past experiences, Nelson respects where they’re at emotionally and cognitively and doesn’t push them to share more of their story in that moment. She admits that it is easy as a counselor to develop an unspoken agenda with clients, so she continually reminds herself that counseling is about allowing clients to tell their stories when and how they need to.

Both Gutierrez and Stanizai stress the importance of counselors educating themselves about different cultures and not placing the burden of this education on clients who are immigrants. Although multicultural training courses can be helpful, it is often equally (if not more) beneficial to learn from the community itself, Stanizai says. Gutierrez agrees that immersion is the best teacher, so he advises counselors to put themselves in settings where they are surrounded by people different from themselves.

Stanizai, who specializes in working with first-generation/bicultural Americans and runs an Adult Children of Tiger Moms support group, advises counselors to spend time reading books and watching media written for and by people in the culture they are working with. “Find a local news source, a radio station, novels or nonfiction that can educate you on not only specific topics but also cultural values and beliefs,” Stanizai says.

Cultural awareness helps counselors learn about privilege, avoid making assumptions or buying into stereotypes about groups of people, and better understand how being an immigrant within mainstream American culture can affect clients’ beliefs and mental health, Stanizai says. Most immigrants will not care whether counselors are familiar with every cultural custom, such as marriage contracts, but they will care, she says, if counselors have a surprised reaction — e.g., “What is that? That’s so different!” — to something they share about their culture.

No matter how much counselors educate themselves, they can never learn about all of their clients’ different experiences and cultures. Gutierrez finds that sometimes counselors are scared to talk about race and ethnicity out of concern about potentially making a mistake. This fear can turn into overcorrection and cause counselors not to ask important questions, he notes.

It is OK, Gutierrez says, for counselors to directly address the issue of a client’s race or ethnicity differing from that of the counselor. For example, a counselor could broach the topic by saying, “My family is Latinx. My parents came here from Cuba. You are Asian. I wonder how you feel about getting help from someone whose background is different from yours?” 

Gutierrez and Stanizai also advise counselors to take a tutorial stance when working with immigrant clients by asking questions about their unique experiences. Counselors could ask, “What was it like to grow up in your family? How much did culture play a part in your childhood? How is your family different from your best friend’s family? How is it the same?”

Counselors’ hubris can also be a barrier to working effectively with clients who are immigrants, Gutierrez warns. If counselors feel like they are going to be savior figures and fix all of the immigrant’s problems, then that mindset undercuts the progress of the client, he explains.

Stanizai agrees. “It’s easy for very well-meaning therapists to get caught up in trying to prove to their clients that they are good people,” she says. “You want to make sure that you’re not processing [clients’ stories] for your own benefit. … That’s really off-putting, and people can sense it a mile away.”

Clearing the way for immigrants

Counselors only have to sit and hear one immigrant’s story or journey to realize how resilient they are, Gutierrez notes. “I don’t give them solutions. They find them,” he says. “They’ve pulled themselves through all these difficulties and challenges, so there’s this amazing resilience in them.”

Often, the pressures and demands of life, of having to concoct strategies to get to work and home, weigh on them, so Gutierrez says he simply provides them with a safe, secure space where they don’t have to feel all of that extra pressure. “Usually I’m just clearing the way for them,” he says.

Providing this space can take many forms. One therapist Gutierrez knows often has clients sing old hymns or folk songs as a symbolic way of allowing them to recapture a piece of their soul that they may have lost during their journey. In this safe space, clients can grieve what they have lost or what worries them in their own way, Gutierrez explains.

Counselors might also consider simply sharing a cup of coffee with their clients. Gutierrez recalls one immigrant client from early in his counseling career who demonstrated his resourcefulness and taught him how to “break the rules.” The client brought Gutierrez a bag of coffee as a thank you, but Gutierrez explained that he couldn’t accept the client’s gift for ethical reasons. The client said, “Oh, so you can’t take it from me?” So, the client opened the bag, walked to the coffee machine and made two cups of coffee. The client then said, “Well, I’m going to drink a cup. We can share it together.”

This moment was a turning point for Gutierrez. Now, he often enjoys a cup of coffee with clients while they talk in session. This small gesture counters some of the hostility and challenges that immigrants face, especially in today’s environment. As Gutierrez points out, it also creates a comfortable counseling atmosphere that will help immigrant clients find peace and lets them know that “there’s room for [them] here.”

 

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RELATED READING: See the online exclusive article “Straddling two worlds,” which explores the complex and critical issue of identity development among immigrant populations.

Also, check out Counseling Today‘s 2016 Q+A with Gutierrez, “Counseling interns get firsthand exposure to immigrant experience.”

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. 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.

Living with — and beyond — OCD

By Bethany Bray January 24, 2020

In popular culture, obsessive-compulsive disorder (OCD) is often portrayed through characters who can’t bring themselves to step on cracks in the sidewalk, who are germaphobes, or who are obsessed with cleanliness and organization. These “hang-ups” are often played for comic effect.

“There’s a huge misconception that OCD is cute and quirky,” says Shala Nicely, a licensed professional counselor (LPC) with a practice in Marietta, Georgia, who specializes in treating OCD and related disorders. “There’s nothing further from the truth. That [stereotype] keeps people from seeking help. They think they just need to ‘get it together’ and deal with it.”

In reality, OCD can be debilitating, says Nicely, who has lived with the disorder since she was a child. Individuals with OCD are haunted by unwanted and invasive thoughts that are often self-critical, fear-inducing or disturbing. One of the classic portraits of OCD is the person who won’t touch a doorknob without a sleeve pulled over their hand out of fear of contracting germs. But that is only the tip of the iceberg when it comes to the different types of compulsions — whether external, such as repeated hand-washing, or internal, such as rumination — that individuals with OCD feel subjected to in order to keep themselves safe.

OCD can be “hell on Earth,” Nicely asserts.

“It puts people in absolute misery. It makes people’s lives smaller and smaller and smaller,” she says. “Having OCD is like living with an abuser 24/7. It’s incredibly mean, it’s very critical, and [it] can be violent. It is being yelled at by your own brain and you can’t get away from it.”

The tipping point

Justin Hughes, an LPC who owns a private practice in Dallas, specializes in treating clients with OCD, anxiety and other mental health issues. He says many of his clients seek treatment because they are overwhelmed by intrusive thoughts or because their compulsions and routines are interfering with their daily life — taking up enormous amounts of time and causing them stress or even physical pain. Other clients come to treatment because a parent, spouse or loved one noticed the toll that OCD was taking on the person and expressed concern.

Karina Dach, who specializes in treating OCD and anxiety at her private practice in Denver, says clients sometimes come to counseling knowing that “something doesn’t feel right” but without realizing that they have OCD. “They may say things like, ‘I feel stuck,’ ‘My brain won’t let me move on,’ or ‘I can’t stop thinking about this or imagining this.’ They might feel like something is wrong with them or worry that these thoughts and fears mean something bad about their character or them,” explains Dach, an LPC and licensed mental health counselor.

Clients who come to counseling with OCD may be struggling with self-criticism and intense feelings of shame, guilt, anger, worry and fear, Nicely adds. Intrusive thoughts are common with OCD, and for some people, these thoughts can involve the idea that they might somehow end up killing, injuring or sexually molesting someone, including their loved ones. As these thoughts repeat themselves over and over, the individual may begin to believe the content of these thoughts and feel a deep sense of shame or embarrassment.

In fact, clients struggling with OCD may be hesitant to share the worst of their intrusive thoughts because they can involve things that are criminal or dangerous. “Some [individuals with OCD] really do think they might be a closet murderer. They’re afraid to share that, [thinking that] they might get in trouble,” Nicely says.

Given that insight, Nicely says, counselors should not hesitate to follow up conversations about intrusive thoughts and worries in session by asking clients if there is anything else they have been too scared to share. These clients should be reassured that counseling is a safe and confidential place to share whatever they are going through, Nicely adds.

Obsessions + compulsions

The National Institute of Mental Health reports that an estimated 1.2% of U.S. adults experience OCD each year. This prevalence is higher for females (1.8%) than for males (0.5%). The lifetime prevalence of OCD in the U.S. is 2.3%.

Jeff Szymanski, a clinical psychologist and executive director of the International OCD Foundation, notes that even though the prevalence of OCD is not increasing, mental health practitioners may see more people who struggle with the disorder in their caseloads in the future because of a gradual, general increase in awareness and a reduction of stigma regarding
the disorder.

OCD is characterized by two components: 1) recurring and intrusive thoughts (obsessions) and 2) excessive urges to perform certain actions over and over again (compulsions) to prevent or counteract the recurring thoughts. The types of obsessions and compulsions that individuals with OCD can experience are wide-ranging.

Not all recurring thoughts can be categorized as OCD obsessions, Szymanski stresses. “Obsessions in OCD are also ego-dystonic, meaning that the individual doesn’t like or want them. … Some recurring thoughts people like to have,” he says. “In lay language, people say things like ‘I’m obsessed with baseball.’ This means they like baseball. They may even spend a lot of time ‘compulsively’ following baseball. But this doesn’t interfere with their life, and it is something that is invited, not something they are trying to get away from.”

OCD-related obsessions can include unwanted sexual thoughts, religious obsessions, fear of contamination (by dirt, germs, chemicals or other substances), fear of losing control of yourself, fear of being responsible for harm to oneself or others, fear of illness, and myriad other concerns. Compulsions can involve:

  • Washing and cleaning tasks (including personal hygiene)
  • Checking behaviors (such as checking news headlines over and over to ensure that nothing terrible has happened, or checking multiple times that a door is locked)
  • Repeated actions such as blinking or tapping
  • Performing certain actions multiple times (e.g., opening and closing doors, going up and down stairs)
  • Asking questions (possibly to include the same or similar questions over and over) to seek reassurance
  • Internal actions such as repeated prayers, counting rituals, and repeated mental review or replaying of past scenarios and interactions

(Get an in-depth explanation of OCD from the International OCD Foundation at iocdf.org/about-ocd.)

“If a counselor begins hearing the exact same things [from a client in session], worded or behaved in similar ways, this is a good indicator [of OCD] to watch out for,” Hughes says. “Many of my clients are good at exactly quoting themselves on what they’ve said before. Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away.”

Compulsions can also involve avoidance behaviors. For example, Dach once had a client, a new mother, who was experiencing intense thoughts and fears about harming her baby. She would avoid interacting with her child — particularly being in the bathroom with the child while he was being bathed — because she felt it was safer to be away from him.

OCD-related avoidance can spill over into the life choices that clients make, such as where they work or live, what their hobbies are or even the words they use, Dach says. Individuals with OCD sometimes exercise another form of avoidance — breaking up with a partner because they fear the doubt, uncertainty and risks involved in having a relationship. However, they soon find that ending the relationship doesn’t quell their rumination, Dach notes.

Individuals with OCD “operate on a risk-adverse level,” explains Dach, a member of the American Counseling Association. “You find them checking a lot, asking for reassurance, accommodating their fears and compulsions. … It’s terrifying and it takes over people’s lives. We see OCD as this mental bully. You are a complete prisoner to your fears. People with OCD just want to protect themselves and their loved ones.”

Obsessions are often a reflection of a person’s deeply held values, such as being a good parent, keeping their family safe, or being a good person, Dach notes. Focusing on these values can be a source of leverage when counseling clients with OCD. When working with the new mother who had intrusive thoughts about harming her child, Dach talked with the client about how her fears were based in the values she possessed of wanting to connect with her child, be a good mother and keep him safe.

“If you can find what the client’s values are, that can be very powerful,” Dach says. “Maybe you fear rejection and failure but value excelling in a career. Finding those values can make a really clear [therapeutic] path to work on and find motivation.”

Several of the counselors interviewed for this article recommend that practitioners use the Yale-Brown Obsessive Compulsive Scale to assess clients for OCD and to get a full evaluation of clients’ obsessive thoughts and compulsive behaviors. If clients identify numerous behaviors and thoughts that they experience from the assessment’s detailed checklist, counselors should work with them to “triage,” creating a plan of care to address their most pressing or concerning issues first, Nicely says. Seeing the fearful thoughts and tortuous behaviors that they’ve been experiencing included on the checklist can serve to normalize clients’ experiences and demonstrate that they aren’t alone in their struggles, she adds.

Distinguishing OCD

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders categorizes OCD under a cluster of diagnoses that also includes body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder.

OCD can be complicated to identify because the disorder often co-occurs with other issues such as bipolar disorder, anxiety-related disorders, depression, eating disorders and substance abuse, notes Nicole Hill, an LPC who co-authored an ACA practice brief on OCD. Because clients with OCD often struggle with multiple presenting concerns, the disorder can be hard to pinpoint. In addition to delving into these clients’ distress, counselors should complete full biosocial assessments to get a clearer picture of their life and family history, social landscape, early childhood experiences and other contextual factors, says Hill, a professor and dean of the College of Education and Human Services at Shippensburg University in Pennsylvania.

Although there is no one particular cause of OCD, research indicates that there may be a number of contributing or correlating factors, including genetics and family-based factors, autoimmune issues, and the brain structure involved in transmission of serotonin. Being aware of the client’s full context — especially whether other family members have OCD — can provide counselors a better understanding of the person’s experience and risk factors, says Hill, an ACA member who co-authored a chapter on OCD and related disorders in the 2016 book Diagnosing and Treating Children and Adolescents: A Guide for Mental Health Professionals.

OCD is easier to pinpoint in clients who describe overt compulsive behaviors, such as checking the weather forecast repeatedly. Asking questions to probe the depth and root of clients’ fears can help uncover mental compulsions that aren’t as immediately noticeable, such as mentally reviewing the activities of their day over and over again, repeating a conversation or a word to themselves a certain number of times, or saying a certain prayer repeatedly, Dach says.

To probe clients’ experiences, Dach suggests counselors begin by asking how they deal with stress and anxiety. It is certainly normal for people to experience anxiety from time to time, and it is true that individuals with anxiety disorders may be confronted by intrusive thoughts, ruminate, and perform certain coping behaviors. With OCD, however, the worry, fear and compulsive behaviors become so all-encompassing that they impair the individual’s ability to function. For example, most people wash their hands to keep from getting sick, but individuals with OCD may wash their hands a certain number of times, for a certain length of time, or until it feels “right” to them, Dach says.

“We all have this inner voice that’s telling us what’s safe and not safe. But someone with OCD has a faulty alarm system. They’re more vigilant. A whole battle can be happening internally on what’s safe and what it takes to be safe,” Dach explains.

To uncover compulsions that are internal (and, thus, less apparent to others), Dach suggests asking clients questions along the following lines:

  • Are there words or statements that make you feel better or that you say to yourself? Do you do something a certain number of times in your mind until it feels right?
  • When you’re lying in bed, is that when your mind wanders the most? What are you thinking about? Is it about your day and what you could have done differently? What you
    did wrong?
  • When you enter a room, what’s the first thing you do? Do you beeline straight to where you need to go, or do you scan the area first to feel safe?

From there, Dach suggests asking clients what would happen if they weren’t able to complete whatever action they felt compelled to perform. “If there is clear distress in their answer, that may indicate OCD,” she says.

Another indicator that OCD may be present is if the client doesn’t respond to methods that counselors typically use to help individuals with their negative thoughts, says Hughes, the Dallas-Fort Worth advocate for OCD Texas, a regional affiliate of the International OCD Foundation. “If a client isn’t improving from certain methods — especially things like cognitive restructuring in cognitive behavioral therapy — this is ‘Getting Stuck 101’ and needs further assessment,” Hughes says. “Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence-based way and approached it the same as regular old automatic negative thoughts. This is not typically helpful.”

OCD is disruptive, not only to the individual’s ability to function but also to their family life, says Hill, whose past clinical work included treating juvenile clients with OCD via play therapy. Parents and families often restructure their routines or make accommodations to work around a loved one’s compulsive behaviors, especially if the individual with OCD is a young child. OCD behaviors can be very concerning to parents and, in some cases, embarrassing in public situations. In making accommodations, the family typically feels like they are doing what they can to help the person, but that approach is actually counterproductive, Hill says. In reality, accommodating or yielding to OCD behaviors can exacerbate the issue.

Counselors shouldn’t hesitate to involve a client’s family in OCD treatment (if applicable and with the client’s consent) or to reach out to collaborate with social workers, family counselors or other professionals who may be working with the family, Hill says. Counselors can play a vital role in educating parents and family members about what an OCD diagnosis entails and clarifying the therapy goals for their loved one. They can also offer helpful, nonaccommodating ways to intervene when the person’s OCD spikes. Hill says that in her past work with juvenile clients, she often saw the severity of OCD decrease when she used filial play therapy with children and parents. This approach served to bolster their relationship, problem-solving skills and communication patterns. It also instilled a focus on positive behavior and empowering the child, she says.

Working with other treatment providers

Research has shown that a combination of therapy and psychiatric drugs, especially exposure and response prevention (ERP) therapy and serotonin reuptake inhibitors, can be particularly helpful to people with OCD.

“Attending to clients’ socioemotional and cognitive issues [in counseling] will be helpful, in addition to medicine,” Hill says. “Research consistently shows that the both/and approach is best, with medication and therapy.”

Medicine can “turn down the volume” on clients’ OCD so that therapy can help them manage their rituals and compulsions, says Nicely, who estimates that three-quarters of her clients take medication. Eventually, if clients and their prescribers agree it is the best course of action, their medications can be tapered back as their coping skills are strengthened in counseling.

Although professional counselors cannot prescribe medications, they must always consider their clients’ use of medications — and be proactive in working with clients’ medication prescribers — when looking at the whole picture of treating OCD. With clients’ consent, counselors can check in with these other treatment providers about clients’ symptoms and progress in counseling.

“I always worked on a team with other professionals,” says Szymanski, who was previously the director of psychological services at McLean Hospital’s OCD Institute in Massachusetts. “It is important to ensure that some time is spent coordinating care and that everyone’s work is complementary and not getting in the way of each other. It is equally important to inquire from the client how the team format is working for them and to ask them for specific feedback and encourage them to give direct feedback to each of their team members.”

Coordinating care among multiple treatment providers can be challenging, but it is worth it to work toward the best outcome for the client, Hughes asserts. Even imperfect, one-way communication stands to benefit the client.

“Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life,” Hughes says. “In complex cases, it is almost unheard of for me to not [reach out to] another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers’ schedules and to communicate what we can, how we can. This often looks like me leaving a psychiatrist a voicemail after release is given and not hearing back, but at least they have the information.”

In addition to professionals who prescribe them medications, clients may be seeing other practitioners for treatment of issues such as depression and substance abuse that often co-present with OCD. This offers opportunities not only to coordinate care but also to make other health care professionals who do not specialize in OCD treatment aware of the disorder’s nuances. These professionals can also be alerted to the pitfalls of inadvertently undermining the client’s work in counseling by feeding their compulsions through accommodation or reassurance, Hughes says.

Many other comorbidities in clients will often improve by treating their OCD first, Hughes adds.

Exposure and response prevention

Research has identified ERP, a type of cognitive behavior therapy, as the most helpful and effective therapeutic method for treating OCD. All of the counselors interviewed for this article recommend its use with clients who have OCD. The International OCD Foundation refers to ERP as the “gold standard” for treating OCD and more helpful than traditional talk therapy methods.

In ERP, clinicians use gradual exposure to desensitize clients to the OCD-related thoughts, compulsions, situations or objects that are invoking fear and worry in them. With each exercise, the client works to overcome a triggering thought or scenario without responding with a compulsive action. This is the “response prevention” part of ERP. Exposure work is done both in session with a counselor and outside of session as homework for clients to complete on their own.

Counselors should be aware that clients’ OCD is likely to spike as they begin ERP treatment, Nicely says, because it removes the compulsions that have given them reassurance in
the past.

Over time, ERP empowers clients to confront thoughts and situations that they often would have tried to avoid previously, Dach says. “When someone has intrusive thoughts, they tend to [try and] push them away, and it effectively boomerangs. Pushing things away and trying to avoid them only empowers [the OCD] and gives it too much value,” she explains. “This [ERP]
puts them in the driver’s seat. They are the driver, instead of the fear deciding their choices.”

With the new mother mentioned earlier in this article, Dach used incremental exposure exercises to help her overcome her fear of harming her baby. At first, the baby was left outside of the counseling room with a caretaker while the client met with Dach. They started small, exposing the client to words that were triggering, such as “baby” or “bathing.” As the client progressed, Dach asked her to bring the baby into sessions. Even taking the baby out of his car seat and putting him on her knee was triggering to the client at first, Dach recalls. Dach would talk the client through each exercise, asking her throughout to monitor her level of distress on a scale of 1 to 10.

Eventually, the client graduated to exercises that included changing the baby’s diaper in session. In time, the client was able to work toward bathing her child at home, which had been one of her most fear-inducing obsessions.

Giving clients exposure assignments to work on between sessions is a critical part of ERP, Dach says. This can include creating a “worry script” in which clients write out imagined worst-case scenarios for themselves. For example, for one client, the scenario might involve going to the mall or another public place and losing control of themselves so that they vomit or yell and cause a scene, Dach says. The client imagines everyone staring at them, the client dying of embarrassment and then being banned from the mall. The client writes out all of the details of what they are feeling, seeing and experiencing in this imagined scenario. Next, the client reads or rewrites the story script repeatedly or records themselves reading it and listens to the recording over and over, Dach explains.

“It’s like watching a scary movie 1,000 times. It might be scary when you watch it the 1,000th time, but [it’s] not as terrorizing as the first time,” she says.

Dach uses the metaphor of working at a garbage facility to explain the effectiveness of ERP: On your first day, you notice the smell of the garbage and it’s so disgusting to you that you can’t even eat your lunch. But the smell bothers you less and less as you return to work each day and, eventually, you barely notice the smell at all.

ERP is granting permission “to open the doors to your dungeon and hang out with all these skeletons that you’ve got hiding in there,” Dach says. “If you grab your sleeping bag and pillow and hang out in there, eventually you’ll be more comfortable being around them.”

Hughes recalls one client with OCD who was struggling with severely distressing thoughts about harming her children. The client had no history of harm or abuse. Over time, the client found it difficult to differentiate between reality — that she would never intentionally hurt her children — and her intrusive thoughts about having impulses to stab her children, Hughes says.

“She knew [these fears] were irrational, yet it felt so real to her,” Hughes says. “As can be very typical, the stress also took a toll on most every area of her life, [including] making work difficult.”

ERP work began with small exercises the client learned to conquer while staying present with her distress and without turning to compulsions, Hughes says. The client was able to integrate ERP assignments into her daily life with the support of her loved ones, church community and her own desire to be able to engage with her family without fear of harming them.

She soon graduated to script writing and larger exposures that involved holding knives and stating her feared thoughts aloud (appropriately and not in front of her young children), Hughes says. For example, the client would work outside in the family garden and repeat to herself the worst-case scenario she had written in her scripts: “I’m wanting to use these yard tools to kill my daughters.” Later, she added more distressing content: “I want to stab them, and I’ll get arrested and divorced and be hated by my kids.”

Other exposures involved holding a butcher knife firmly for 15 seconds at a time (and eventually longer) while repeating her scripts. Over time, the client worked toward being home alone with her children, bathing her children, and ultimately cooking for her children (including using knives) while her husband was out of town.

Now the client’s OCD symptoms score so low on the Yale-Brown Obsessive Compulsive Scale that she would be considered subclinical, Hughes says. “In relapse prevention planning, [this client] understands the chronic nature of OCD and the necessity of staying on top of her good progress, with the plan to follow up at occasional intervals for ‘booster sessions,’” Hughes says. “I gain so much joy from stories like these.”

Tolerating uncertainty

ERP is effective because it empowers clients to tolerate the uncertainty that is at the core of their fear and worry, Nicely explains. The crux of the problem is not a client’s worry over contracting HIV or stabbing their husband, she says, but tolerating the uncertainty of whether or not those fears might happen.

“The hallmark question of OCD is ‘what if’ and having doubts,” says Nicely, the author of the 2018 book Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life. Treating only the content of a client’s worries without teaching the client to tolerate uncertainty will simply lead the OCD to surge (or resurge) in another area of the client’s life, Nicely notes.

For ERP to be effective, it requires commitment and trust between the client and practitioner. Nicely explains to each client that the work requires a cognitive shift — that trying to avoid anxiety and OCD triggers actually makes them worse.

In working with clients with OCD, Nicely uses the acronym JOY: Jump into anxiety, opt for greater good, and yield to the anxiety. Nicely goes into detail about this method in the 2017 book she co-authored with Jon Hershfield, Everyday Mindfulness for OCD.

She asks clients, “What if we didn’t push the anxiety away? What if we brought it toward us? Can you handle it?” Then she points out an example of how the clients are already handling uncertainty by taking the first step of coming to counseling. Bringing anxiety toward them is equal to taking away OCD’s power, she explains.

Nicely books a double session with clients for their first exposure treatment. After the exposure work, they process what happened together. Nicely asks questions such as: Was it as hard as you thought? What did you learn? Did you learn that this is something that you can do to get your life back?

“If you do [triggering things] over and over again, then the brain begins to learn that these things aren’t the problem,” Nicely says. “The reason that our brain is putting these thoughts up front is because we’re reacting to them. The brain is learning when you’re allowing it to stay at a high level of anxiety.”

“OCD is a biological issue,” she says. “Our brains [in those with OCD] are structurally and functionally different than those without OCD. You can’t think your way out of this. It’s a brain disorder, and ERP changes the way our brain functions.”

Nicely uses a concept she calls “shoulders back” with both herself and her clients. She says that squaring one’s shoulders can serve as a physical reminder that whatever a person’s OCD is telling them, it doesn’t matter, and they can act as if it’s irrelevant.

“Ultimately, we want people to hear all of this [OCD triggers] in their heads and go on and have it bother them less and less,” Nicely says. “We want them to live in a world of uncertainty and not have it bother them and act as if their intrusive thoughts don’t matter.”

It can also be helpful for clients to imagine what their OCD “monster” looks like or even to give it a name. Nicely does that herself, even speaking to her OCD when it begins to surge. Nicely thinks of her OCD as something that will always be a part of her. It’s something that, at its core, wants her to feel safe.

“It’s exceptionally important [for clients] to realize that OCD is part of them, but it is not them,” she says. “That will help them to conceptualize the process. Think of it as something that has been torturing you. Talk back to it and tell it where you want it to go.”

Reassurance

The compulsions associated with OCD often arise out of a person’s urge to find reassurance and feelings of safety, Dach says. As helping professionals, counselors’ natural reaction may be to try to comfort these clients by telling them that their worst fears will not come true. But in the case of clients with OCD, offering reassurance is actually doing harm and reinforcing behavior, Dach stresses.

“No one knows whether or not the fear will happen — not the therapist [and not] the client. But the client will search and search and search for reassurance, an illusion of security and control,” Dach says. “If a practitioner gives them reassurance, they’re making the condition worse.”

When Dach finds clients asking questions as a means of seeking reassurance in sessions, she explains that she will answer questions to provide education or information but not for the purposes of offering reassurance. “It may be a hard pill to swallow, but we [counselors] need to sit with their uncertainty together and model what it looks like to sit with distress,” Dach says.

When clients express anxiety over the possibility of vomiting in a public place or some other OCD-related fear coming true, counselors shouldn’t reassure them that it won’t happen, Dach says, because there is no way to ensure that it won’t. Instead, she says, counselors can respond with questions such as, “If you did vomit, what’s the worst thing that could happen? What would it feel like? How do you know it’s going to happen?”

“The possibility is there, but the probability is low,” Dach says. “I can’t tell [the client] whether or not something is going to happen. The best we can do is put ourselves in a situation [via exposure] to learn what’s going to happen. Then I offer to lean into that discomfort [with the client].”

On the same team

There is sometimes a misconception among mental health professionals that exposure work can traumatize clients, but that simply isn’t true, Dach stresses. Therapy with a practitioner specially trained in ERP is hard work — it’s asking a client “to walk into their worst nightmare and have a party” — but it’s also incredibly effective and rewarding, she says.

“This is an extremely collaborative intervention. We’re on the same team. It’s not forcing [clients] to do things. It is asking them to get close to the thing they’re afraid of the most. You [the counselor] are there to offer gentle pushing, but it’s all choice-based,” Dach says.

Nicely and Hughes say that clients with OCD tend to be incredibly brave and also deeply caring. It is inspiring, Nicely says, to watch clients tackle such hard things in therapy and become more resilient.

“For many reasons, I love work with clients who have OCD,” Hughes adds. “I have found that they are some of the kindest, hardest-working and most conscientious individuals on this planet. This is where I believe many of their personality strengths arise once [they move] through pathology. It is a joy every day to see recovery, growth and maturity bloom out of suffering.”

 

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The International OCD Foundation offers a wealth of resources and information on its website, iocdf.org, as well as training programs, an annual conference, and local affiliates around the country.

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Contact the counselors interviewed for this article:

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OCD is not an adjective

It’s not uncommon for people to describe themselves in casual conversation as “obsessed” with a television series or “OCD” about the way they organize their closet.

Professional counselors can be agents of change when it comes to casual use of the language related to obsessive-compulsive disorder (OCD), says Shala Nicely, a licensed professional counselor in Georgia who specializes in treating the disorder. She encourages counselors to be mindful of their own language and to gently correct those who misuse OCD-related terms.

One place to begin: Stop using OCD as an adjective, she says. Someone might be meticulous or detail-oriented or neat, but he or she is not “OCD.” To say “I’m so OCD” about something can discourage people who really do have OCD from seeking treatment, especially if that offhand pronouncement comes from a mental health professional, Nicely says.

 

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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.

Straddling two worlds

By Lindsey Phillips January 23, 2020

Because immigrants often feel like they are straddling two worlds — their origin country and their new one — identity development is complex and critical for this population. Immigrant clients often tell Sara Stanizai, a licensed marriage and family therapist and owner of Prospect Therapy in Long Beach, California, that they have one foot in each culture and don’t fully fit into either one.

When people feel like they don’t fully belong to any one community and are constantly hiding one or more aspects of themselves to try to fit in, they question their identity and choices, Stanizai explains. She finds this is especially true for emerging adults who are figuring out their careers. Immigrants may be successful at their jobs, but they often feel like they are failing because they are hiding or ignoring a part of their identity in the process, she says.

Daniel Gutierrez, an assistant professor in the counselor education program and coordinator of the addictions emphasis for the clinical mental health counseling program at William & Mary, points out that straddling two worlds involves code switching between language and cultures: People alter their behavior and speech to accommodate different cultural norms. They may act and speak one way at home and another way when they are at school or work or out with friends. “You can’t be who you are naturally. You have to switch depending on the social context or you have to abandon your home culture to succeed, and then you feel guilty all the time,” says Gutierrez, who is also faculty director of the New Leaf Clinic at William & Mary.

Gutierrez finds that many immigrants question their identity (for example, “Am I Korean enough? Am I white enough?”). Immigrants may feel that they need to reject their home culture to fit in with their new one, so Gutierrez recommends asking clients, “How do you identify? Whom do you connect with? What does your social network look like now? How do you make sense of what’s home?”

Immigration can also cause intergenerational conflict because family members acclimate to the new country and culture at different rates. The expectation that even after immigrating, children will continue to behave as they did in their origin country can lead to conflict, says Lotes Nelson, a clinical faculty member at Southern New Hampshire University. She often hears clients say that their children are “behaving like Americans” because they are being disrespectful to them or dressing and behaving in a way that is embarrassing to the family. These clients often ask her, “What do I need to do to make sure our children follow our culture and behaviors?”

Nelson, a licensed professional counselor and approved clinical supervisor in North Carolina, acknowledges that this isn’t an easy conversation to have, but she invites families to talk through their feelings. One framework that she finds helpful is the ABCDE model (which is part of rational emotive behavior therapy) because it helps clients reflect and reframe their thinking about a certain situation or emotion.

Nelson, a member of the American Counseling Association, briefly illustrates how this model works: Take a 13-year-old child who is no longer interested in going to church (the “A” or activating event). The parents may interpret this change as a sign that coming to the United States was a mistake (the “B” or belief), Nelson says. They may feel responsible for their child no longer practicing their spiritual values, and these emotions may manifest as anger at the child (yelling or physically punishing the child; the “C” or consequence).

To help parents challenge their interpretations of the event and their emotional response to it (the “D” or disputing), Nelson may say, “Let’s explore your impression about what has occurred for your child. Tell me more about this belief that coming to America might have been a mistake for you and your family. I wonder how else you might view this new experience.”

Closely examining the situation with a new perspective often helps clients navigate their emotions and thoughts more effectively and helps them find a way to move forward, she explains. In this example, the parents may realize how living in the United States has exposed their child to different beliefs and how their child now has friends who don’t go to church. So, the parents make a new plan: They will continue discussing the significance that religion plays in their culture in the hope that the child’s rejection of church is not permanent (the “E” or effects).

Younger generations of immigrants may also feel indebted to their parents for their sacrifices, such as moving to a new country to provide them with better opportunities or paying for their education. As a result, they may choose a career path — one they don’t want — just to honor their parent’s wishes, says Gutierrez, a licensed professional counselor in North Carolina and Virginia and an ACA member.

He recalls working with a family who possessed conflicting notions of academic success and happiness. The mother thought her children were not doing well in school, but the kids said they were doing fine. Success for the mother meant her children getting straight A’s and becoming successful medical doctors. Her children resented the added pressure because they didn’t value straight A’s in the same way.

Gutierrez says his role as a counselor is not to wave his finger at family members but to teach them how to communicate with one another. In a sense, he operates as a referee, making sure each person pauses and clearly states back what they heard the other person say.

With this particular family, Gutierrez asked the son, “What do you think your mom is going to say this week?”

The son said, “She’ll scream at me about not finishing my homework or about getting a B on my last math test.”

Gutierrez asked, “What do you think she wants from you? What do you think she means by always bringing up school and grades?”

The son replied, “She only cares about grades and about me becoming a doctor. She doesn’t care about what I want out of life.”

The mother was in the room and heard her son’s perspective. Later in the session, she had the chance to share her side of the story. She expressed how yelling over her son’s grades was the way she expressed her love for him because she didn’t want him to struggle the way she had. This exchange caused the mother and son to become emotional because they both gained a deeper understanding of the other’s feelings and the underlying motivations of the mother’s actions, Gutierrez shares.

Stanizai finds that immigrants are often used to having external validation or external measures of success, so in therapy, she helps clients move to internal ones. For example, a client might be getting pressure from their family to get straight A’s and become a lawyer or doctor, and this pressure is affecting the client’s mental health. Stanizai would help the client identify the internal qualities and strengths that they possess that are not dependent on the expectations or circumstances of others. For example, she might help the client realize that they will succeed in whatever career they choose — even if it’s a different career from what the family wants — because they possess a good work ethic.

“A lot of anxiety comes from feeling overwhelmed and feeling responsible for so many people other than [themselves],” Stanizai says. “If people feel they have no other choice than to cut people or cultures out of their life, then that can make people feel disconnected and depressed.” Feeling “othered” or isolated can exacerbate symptoms of mental health issues such as depression and anxiety, she adds.

Because it is so isolating to not fully fit into any one group, Stanizai started an Adult Children of Tiger Moms support group to give immigrant children a safe space to talk about these issues and find others who have similar experiences. She has noticed that the group, which has people from various types of cultures, has become its own culture — one that is validating and healing to its members.

Groups are often more accessible for people who may not be able to commit to weekly individual counseling sessions. In addition, they tend to help people overcome any stigmas they have about therapy because when participating in a group, individuals often feel like they are taking a class, not going to counseling, she adds.

Stanizai has noticed that a common thread often emerges in her group sessions: No matter how successful the participants are, they all feel like they are letting their families down. Many group members report feeling unhappy at their jobs, yet they feel that they have to stay because of family expectations. They also note feeling guilty because their parents often assume they will move back home — either to their hometown or into their parents’ house — after they graduate.

Stanizai had one client who graduated and found a job in a city that was far away from her parents. The client felt so guilty that she went back to visit them every weekend. Stanizai asked the client, “Why do you think your parents want you to move back home? Why is that so important to them?” The client said, “My parents worry about me, and they want to stay connected.”

Stanizai worked with the client to brainstorm ways that she could connect with her parents without having to go home every weekend, such as using a video chatting app or inviting them to her apartment for dinner. The client decided to email her parents more often, and she found that doing this actually helped her and her father grow closer, Stanizai says. They would exchange long emails, and in writing each other, they were sharing more details about their lives than they did when the client went home and sat quietly watching TV with her father.

“Parents really want [their children] to be successful and happy, Stanizai says. “The framework for what that looks like might be different from [the client’s], but they can respect and honor that and also open their [parents’] eyes to what is important to them without completely turning their backs on [their family] so they can both coexist.”

This intergenerational conflict serves as a microcosm of the constant struggle between identities that immigrants often face. With counseling, these clients can come to terms with these identities and finally find their footing.

 

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For more on working with clients who are immigrants, read the in-depth feature article “Fostering immigrant communities of healing” in the February issue of Counseling Today.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. 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.

Reconciling disability studies with mental health counseling

By Emily Cutler January 21, 2020

Growing up Jewish and queer in a conservative part of Birmingham, Alabama, I faced some pretty severe bullying as a child and teenager. It was a common occurrence for me to be called anti-Semitic slurs and mocked for looking and acting different. I was excluded by almost all of my classmates and had very little social support.

As a result, I struggled a great deal with my mental health. I felt depressed and anxious almost every day, and there were times when I felt sheer panic and terror about the prospect of attending school. Because I never seemed to fit in, I was convinced that I was fundamentally unlikeable and that the only positive quality I possessed was my near-perfect academic track record. So, on top of the anxiety and depression I felt as a result of being bullied, I also put enormous pressure on myself to score perfect grades. Any score less than 100 would send me into a spiral of shame and self-hate.

I cried a lot, and this worried many of the adults around me. I was sent to a number of therapists throughout my childhood. Most of them focused on figuring out ways to get me to stop crying so much. I was prescribed medication, exercise and an array of breathing techniques. Some of the therapists worked on encouraging me to act more “normal” — perhaps if I didn’t talk about my academic interests so much, or if I stopped trying to be the teacher’s pet, or if I were just less sensitive, then more of my classmates would like me.

Although some of the advice was useful, there were many times I walked out of therapy continuing to feel like something was wrong with me — that it was my fault that I was being bullied because I was just too weird and different to understand how to act like everyone else. More than anything else, I was frustrated with myself for not being able to stop crying or feeling depressed.

 

An empowering approach

My experiences with and perspective on therapy changed drastically when I went away to college. After struggling considerably with the transition to a new city and new environment, I reluctantly sought counseling from my university’s mental health center. I can still remember my first session. After answering some questions about my childhood during the intake, I said, “I know I must seem really messed up. Everyone hated me in high school, and now I just started college and I still don’t fit in. There’s something wrong with me. I know it. I just can’t fit in anywhere.” I could feel myself starting to tear up, so I immediately apologized for crying. “And on top of that, I am so overly emotional! I must be your worst client.”

My new counselor raised his eyebrows and looked up from his notes. “I was actually about to say that the way you’re reacting seems normal to me. It sounds like you had a pretty difficult time in school, and that was hard for you — it would be for anyone. And the transition from high school to college is hard too, which is also normal. I don’t know if I’ve met anyone who didn’t struggle to make friends in the first few months of college. I think it shows that you have a lot of resilience to get through all of that and to reach out for help.”

I was shocked. Here was a counselor who was not saying that anything was wrong with me or that I needed to change myself to fit in better. In his opinion, I was having a natural reaction to the circumstances I had been through. I’d never heard anything like it before.

Over the next several months, I went from viewing myself as an unlikeable weirdo to a person who is different (and perhaps weird in a good way!) but still deserving of acceptance and belonging. I started to see my uniqueness as a strength. Instead of encouraging me to change myself to fit in, my counselor empowered me to seek out on-campus groups and spaces where I would be accepted. As a result, I joined my campus Hillel as well as Active Minds, a student mental health organization. My counselor also encouraged me to stand up for myself in instances of bullying. Above all, he never pathologized my emotions or told me it was wrong to feel sad or depressed. I finally felt that I was being given the space to process and react to some of my experiences as a child.

 

Finding my path

Later on, I began to get involved with initiatives and organizations that focus on combatting prejudice and social injustice. I interned at the Anti-Defamation League of Philadelphia during my senior year of college, and I completed an honors thesis on weight-based bullying (bullying due to a child’s weight or size). Eventually, through my coursework and through my involvement in different advocacy communities, I found my way to disability studies, a discipline that centers the voices of people with disabilities and explores philosophical, cultural and sociological perspectives on the experience of disability.

Generally, the field of disability studies challenges the idea that disability is solely or primarily an individual defect in need of medical treatment. Instead, it posits that disability is the result of a multitude of factors, including societal exclusion and inaccessibility. The perspectives encompassed by disability studies greatly resonated with me as someone who cares deeply about challenging social injustices and exclusion rather than primarily changing individuals. Over the past several years, I have become intricately involved with disability studies research and advocacy.

One of my most pivotal moments has been coming to view myself and accept my identity as a person with a psychiatric disability. Embracing that identity has allowed me not only to accept myself and reduce my shame around having experienced mental health struggles, but also to become connected to a community of people with similar experiences and perspectives. I started working with the National Empowerment Center, an organization led by and for mental health consumers. With the center, I develop advocacy initiatives, educational programming and workshops that center the voices of people with lived experiences of mental health challenges and advocate for increased self-determination and acceptance of people with psychiatric disabilities.

The most meaningful and fulfilling part of my work has been spending time with people who have psychiatric disabilities, sitting with them through difficult times and empowering them to advocate for their rights and self-determination. My work has often included responding to people in crisis and providing space for them to experience strong emotions and extreme states.

 

A ‘fit’ for counseling?

My passion for that kind of intensely interpersonal, relational work sparked my interest in becoming a mental health counselor. As I began to explore the possibility of pursuing a graduate degree in counseling, I became increasingly certain that it was the right choice for me. There is little I care about more than supporting people with psychiatric disabilities to gain agency over their lives and experience community, connection and meaning. However, I also wondered how my disability studies background and perspective would fit with my role as a counselor. Whereas the disability studies field seeks increased acceptance and accommodation of disability in society, the counseling field often seeks to treat or prevent psychiatric disability. Would it be possible for me to reconcile both of these goals and perspectives?

I am only in my third semester of graduate school, so I do not yet fully know how I will integrate my disability studies background with my role as a mental health counselor. However, I believe it will be quite possible to do so.

In my own experience with counseling at my university’s mental health center, I felt that my counselor focused much more on encouraging me to accept myself and to find spaces where I would be accepted than on changing me or “fixing” me. I hope to take this same general approach with my clients. I believe that person-centered therapy and other humanistic approaches to counseling provide an excellent framework to accomplish this. These approaches require therapists to work with clients from a position of unconditional positive regard and to support clients in discovering their strengths rather than operating from a deficit-based model.

I also believe it is important to learn from counseling approaches developed by and for other marginalized communities. For example, while homosexuality used to be pathologized as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders, many counselors now practice LGBTQ-affirming therapy. This approach supports LGBTQ clients in accepting themselves and decreasing any feelings of shame they may have related to their identities. Similarly, feminist therapy focuses on empowering women and people from other marginalized groups to advocate for themselves and to challenge injustice in their daily lives. Similar approaches could be applied to counseling clients with disabilities, including those with psychiatric disabilities.

I do not mean to suggest that psychiatric disabilities should never be treated or prevented. Many people with psychiatric disabilities want treatment such as cognitive behavior therapy, dialectal behavior therapy, and medication. Neither should exercise and breathing techniques be discounted because they are very useful for many people. However, there is no reason why the social and systemic factors affecting a person should not also be explored. In fact, professional counselors have an ethical and moral obligation to encourage people with disabilities to advocate for themselves. If clients are facing prejudice or discrimination on account of their psychiatric or other disability (or other difference), it may be helpful to explore ways of addressing that with them. Counselors can also encourage clients to request disability accommodations and link them to organizations such as peer-run wellness centers and peer support groups through which they might find acceptance and social support.

The 20/20: A Vision for the Future of Counseling initiative, sponsored by the American Counseling Association and the American Association of State Counseling Boards, reached a consensus definition of counseling as “a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals.” I believe that the disability studies field complements and enhances this goal rather than taking away from it. As a future counselor with a disability, I look forward to empowering my clients to accomplish their goals and to stand up to any injustice that stands in their way.

 

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Emily Cutler is a graduate student in clinical mental health counseling at Troy University in Tampa, Florida. In addition to pursuing her studies, she provides training and consultancy on the topics of disability rights, trauma-informed care, suicide prevention, peer-run mental health services, and the Health at Every Size paradigm. Contact her through her website at emilyscutler.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.