Monthly Archives: January 2020

When the caring is too much

By Christine Sacco-Bene and Fay Roseman January 13, 2020

With the proliferation of research and information focusing on human-animal interactions, counselors are more aware of opportunities to incorporate animal-assisted interventions as part of their clients’ treatment. However, there is a population of clients who have been overlooked in this equation until recently — veterinarians. In fact, the mental health of these professionals is an emerging area of research and mental health treatment. We (the authors of this article) have also seen the pressures of this field firsthand with our family members and friends who are veterinarians and veterinary students. The sheer level of stress and strain they experience on a day-to-day basis has a significant impact on their work and personal lives.

For that reason, this article focuses not on animal-assisted interventions or the benefit of animals in their humans’ lives but rather on the increasing need of mental health attention to the helpers who take care of our pets and service animals. Note that although the information presented here may be applicable to others who work to care for animals, we are focusing specifically on veterinarians and veterinary students in this article.

We depend on veterinarians to be kind, compassionate and attentive to their patients and their patients’ owners. Because of the multifaceted nature of veterinary service, the occupational stress of these interactions and the inherent professional isolation of the field can result in a number of mental health challenges, including compassion fatigue, burnout, depression and anxiety. Veterinarians face some of the same challenges that other health care professionals face, including working with a large number of stressed clients (people and animals), long hours, and limited financial resources. However, they also have the added pressures of meeting the difficult requests and expectations of pet owners, making the best decisions given difficult situations, and dealing with unwanted or sick animals.

In the Centers for Disease Control and Prevention report “Prevalence of Risk Factors for Suicide Among Veterinarians — United States, 2014,” Randall Nett and colleagues chronicled that veterinarians were found to experience serious psychological distress at a rate higher than the general U.S. adult population. Their survey of over 10,000 veterinarians in the United States further detailed that more than 1 in 6 veterinarians have experienced suicidal ideation. Belinda Platt and colleagues, in their study “Suicidal Behaviour and Psychosocial Problems in Veterinary Surgeons: A Systematic Review,” noted that these challenges have also contributed to the increasing rate of death by suicide among veterinarians. This information draws attention to the need for further consideration and development of support and assistance strategies for this community of helpers.

While neither of us has worked directly with this population, we do have a personal interest in this area. Christine has a close friend who is currently in her final year of veterinary medical training. The financial stress related to the cost of being in this professional program and uncertainty about how she will be able to pay off her college loans after graduation have caused her and her family significant worry. Even more startling are the stories about the strains the veterinary program puts on its students related to schedule, physical and mental demands, money, travel, etc. Christine’s friend has shared accounts of her peers breaking down in tears on a regular basis (sometimes several times a day), not sleeping or eating properly, pushing themselves to do more practice, and maintaining late night and early morning study times, sometimes alone and sometimes in groups, to prove themselves worthy to their faculty. The demands leave little (if any) time to engage in self-care, which seems to be affecting their current mental well-being and may be setting a precedent that will affect their mental health as they progress through their careers.

Fay’s daughter is a veterinarian who became interested in the high rate of suicide among veterinarians while she was in school for veterinary medicine. She explored the potential connection between compassion fatigue and suicidality and shared her work with Fay. After Fay’s daughter graduated and entered into veterinary work, she experienced the loss of colleagues to death by suicide. Our mutual concern about the high rate of death by suicide among veterinarians and the stigma felt by numerous veterinarians about seeking mental health counseling has prompted us to raise awareness of this issue with other counseling professionals. 

What veterinarians are saying about mental health

Some of the mental health issues that veterinarians face are similar to those faced by the general population. However, international studies, particularly in Europe and Australia, report more significant mental health concerns within the veterinary profession when compared with the general population or with other health care professionals. The 2012 article “Suicidality in the Veterinary Profession: Interview Study of Veterinarians With a History of Suicidal Ideation or Behavior,” by Platt and colleagues, indicates that specific challenges of workplace relationships, career concerns, patient issues, unreasonable work hours/work volume, and responsibilities related to clinical practice management are all contributing factors to veterinarians’ mental health issues. Research also notes that student debt and ethical dilemmas, most notably around issues of animal care and euthanasia, generate the highest levels of stress for this population. In a 2018 article for JAVMAnews (Journal of the American Veterinary Medical Association), R. Scott Nolen noted that veterinarians show a higher rate of psychological distress and have slightly lower degrees of well-being than does the general population. The seriousness of this dilemma is more significant when considering that 25% of veterinarians have considered suicide at some point in their lives and 1.6% have attempted suicide.

In their review of the practice of veterinary social work, Elizabeth Strand and colleagues found evidence suggesting that veterinarians may experience stress, anxiety and depression as early as their first year of study. High-achieving students are often drawn to veterinary medicine, and among this group, failure is not an option. Veterinary school is demanding and requires a great deal of time and energy from students, beginning with the acceptance process and continuing through clinical practical experiences. Rates of depression, self-harm, and suicidal ideation increase during the clinical year when students are completing medical rotations in various specialties of veterinary medicine. The rigor of each rotation and the requirement of completing multiple rotations, which can be located either near or far from home, present other challenges for managing stress and the life skills of students. Although the social support offered by family, friends, and veterinary faculty was found to be beneficial to these students, we believe the specialized training of mental health practitioners might improve outcomes for veterinary students during their course of study.

The debt acquired through the course of study can become a significant contributing factor to the stress levels experienced by veterinarians at the beginning of their careers. A review of the 2019 cost of veterinary medicine programs throughout the United States indicates that a four-year residential program can range from $168,000 to $329,000, whereas a nonresidential program can cost between $223,000 and $460,000. The median debt carried by veterinary school graduates ranges from $96,000 to $329,000. Given the significant cost of a four-year veterinary degree, it is easy to identify another reason for increased stress, anxiety and depression among this population.

The function of a veterinarian is not only to provide top-quality medical care to animals and to maintain a relationship with pet owners but also to do so in a compassionate manner, even when it creates significant stress for the veterinarian. Many veterinary professionals become overwhelmed when they need to offer emotional support and comfort to patients’ owners because they are not adequately equipped to handle the owners’ emotional responses. This is especially true when having to convey messages about a patient’s illness or death.

In her article “Moral Stress the Top Trigger in Veterinarians’ Compassion Fatigue,” Susan Kahler noted that giving bad news, managing adverse events, interacting with difficult clients, working in teams, and balancing work and home life create diminished levels of wellness for veterinarians. This work cannot be done in isolation, and the support staff in a veterinary hospital is a key component to the relationship between veterinarian, pet and pet owner. People trust that veterinarians will interact sympathetically with them, but managing these multiple relationships, in addition to providing ethical and professional care and respecting the dignity of the patient and patient’s owner, can be a challenge. This is especially relevant when considering that veterinarians encounter difficult issues — including cases of trauma, illness, abuse, terminal illness and death — on a regular, sometimes daily, basis.

Another identified contributing factor to the mental health issues of veterinarians is the ongoing pressure inherent in the daily operation of a clinical practice. In addition to the stress of managing the business side of the clinical practice (billing, inventory, equipment, payroll, legal, etc.), veterinarians are now dealing more frequently with “emotional blackmail,” which involves attempts to guilt these professionals for charging for their services. Just as we have seen in other industries, consumers of veterinary services are increasingly turning to social media to complain about products and service. In “Media’s Emotional Blackmail Is Killing Veterinarians,” Dr. Sarah Boston, a veterinary surgical oncologist, explained, “There are several results of this irresponsible reporting. The obvious one is the direct damage to the veterinary hospital and staff. There is also the widespread damage it does to all veterinary professionals when they receive the message that what we do is not valuable and should not cost money, and that we are terrible people who are only in it for the money.”

Suggestions for all helpers

Until recently, wellness and mental health self-care were not included in the curricula of veterinary training programs. Because veterinarians tend to be empathetic and nurturing, they focus their efforts on caring for and promoting the health and well-being of animals and routinely put the needs of patients and patients’ owners above their own. In her article on moral stress, Kahler explained that moral stress is unique in that the typical stress management techniques are useless and may even contribute further to mental health challenges. She encourages these professionals to redefine their work ethic to include self-care.

Self-care is really a moral imperative for all professionals in the helping fields, including veterinarians. Helping professionals have a moral obligation not just to facilitate patient care but also to take care of themselves. In collaboration with university training programs, mental health care professionals and counselor educators can help start this process by integrating self-care, stress management skills, and education about mental health issues and substance abuse into veterinary school courses. The College of Veterinary Medicine and the College of Social Work at the University of Tennessee created a collaborative partnership in which focus is given to animal-human interactions, including the issues of compassion fatigue and conflict management.

University counseling centers can also be invited to have greater presence during professional development seminars with veterinary students. This can help erode the stigma of students and professionals seeking mental health care when it is needed. The colleges of veterinary medicine at both Ohio State University and Colorado State University have taken proactive positions in providing resources and education to their students about mental health and self-care.

In addition to reaching out to veterinary programs to capture the attention of students, professional counselors might consider reaching out directly to veterinary professionals. The integration of tools to manage school-work-life balance should be incorporated at both the student and professional levels.

Moral stress and its associated challenges — compassion fatigue, burnout, depression and anxiety — can feel insurmountable to manage. Veterinarians are generally problem-solvers, analytical thinkers and high achievers. They tend to be task oriented and strive toward order. These characteristics certainly help veterinarians to be good at their jobs, but they do little to help these professionals remain good “in” their jobs. Although veterinarians are empathetic toward their patients, some may lean toward low self-awareness and struggle with understanding or dealing with their own emotions. Incorporating opportunities to promote emotional intelligence during veterinary programs and professional development trainings can help these professionals to become more aware of their emotions and the emotions of others, which in turn facilitates better management of themselves and their relationships with colleagues, staff members and patients’ owners.

Mental health professionals can assist veterinarians with increasing awareness of their emotional reactivity and help them take a more proactive approach to self-understanding and emotion regulation. Daniel Goleman popularized the psychological theory of emotional intelligence and its five components: self-awareness, self-regulation, internal motivation, empathy, and social skills. These components can easily be assimilated into training and wellness interventions. Emotional intelligence enhances the individual’s ability to reroute their thinking, allowing them to move away from their initial emotional response to situations (including avoidance) and toward more action-based reasoning.

Many times, veterinarians with a history of suicidal thoughts or behaviors do not talk about or share their experiences with anyone because they feel guilty or ashamed. Their silence may also be attributed to a fear that reaching out will affect their job, or simply to a feeling that they do not have time to seek help. Providing a space for group work, whether in person or virtually,  allows veterinarians to develop support networks. Kahler explains that group time presents veterinarians with a setting to talk about and debrief their experiences and memories together in an open, safe forum. When this group interaction occurs, the group members start making sense of their situations and learn that they are not isolated in their experiences.

One of the major stress factors for this group of professionals is their reported lack of time. Especially for those with busy schedules or those who work in rural areas, telemental health services may be a particularly attractive option.

In addition, bibliotherapy is a brief adjunct intervention that is helpful with a variety of psychological problems. It can be a resource for veterinary professionals with busy schedules or for those who work in locations far from traditional mental health offices. Bibliotherapy is used to increase clients’ understanding about what they are experiencing, and it promotes agency in their treatment. In their systematic review of the use of bibliotherapy in the treatment of depression, Maria Rosaria Gualano and colleagues explain that there is a self-help element to bibliotherapy. It teaches, through the reading of specific material, a number of strategies designed to regulate negative emotions and explains how to practice them in daily life. Bibliotherapy interventions are best used in conjunction with counseling. They can be used between counseling sessions to enhance clients’ commitment to working toward health and well-being.

Finally, mental health professionals can help by providing education, maintaining open opportunities for collaboration, and advocating with the veterinary field to promote well-being and reduce stigma around mental health issues and counseling.

Conclusions

The suicide rate among veterinary professionals is higher than that of other professional fields due to the unique responsibilities of veterinarians. Veterinarians, like other helping professionals, are at risk of giving too much of themselves to their patients and their patients’ families, their staffs, and their businesses and leaving little time for themselves because of their natural qualities of compassion, empathy and caring. A variety of stressors, starting during veterinarians’ programs of study, can lead to mental health issues over time.

On the basis of what we have learned, we believe that providing access to counselors and other mental health professionals could help veterinary students become more proactive in managing some of the emotional challenges they may face as they move through their programs of study. In addition, counselors working with veterinarians in the community can help these clients identify any unhealthy coping methods and provide opportunities for promoting resiliency and wellness. This may require offering strategies that extend beyond the counseling office because of the veterinary profession’s time demands.

Resources

Various resources are available to counselors working with these gifted healers and for veterinarians themselves.

The American Veterinary Medical Association (AVMA) lists several articles and resources for its members and for those who work as veterinarians. Among the areas highlighted under AVMA’s professional development dropdown menu at avma.org are well-being and peer assistance.

The University of Tennessee veterinary social work program provides referrals and resources to people in veterinary practice. The university’s S.A.V.E (Suicide Awareness in Veterinary Education) mental health education program, which was created to honor a colleague’s last wishes, has served as a model for mental health education in veterinary schools across the country (see vetsocialwork.utk.edu and vetmed.tennessee.edu/SAVE).

The National Suicide Hotline (suicidepreventionlifeline.org) provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, seven days a week.

 

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Christine Sacco-Bene is a licensed professional counselor and licensed mental health professional. She is an associate clinical professor in the Rehabilitation Counseling Department at the University of South Carolina. Over her 15 years as an educator, she has been an advocate for students and professionals in the field of counseling (and in all helping professions) to engage in self-care activities to support their mental well-being and professional growth. Contact her at christine.sacco-bene@uscmed.sc.edu.

Fay Roseman is an associate professor in the counseling program in the Adrian Dominican School of Education at Barry University in Florida, where she also served as the coordinator for practicum and internship. As a practitioner certified in the Myers-Briggs Type Indicator, she teaches career development and other courses in the master’s and doctoral programs. Contact her at froseman@barry.edu

 

Letters to the editor:  ct@counseling.org

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

 

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

Our most-read articles of 2019

Compiled by Bethany Bray January 9, 2020

Which counseling topics grabbed the most reader attention in 2019?

Close to 150 articles were posted at ct.counseling.org in 2019. Professional issues – including self-disclosure with clients, starting a private practice, impostor syndrome and the pros and cons of providing online therapy – topped the list of most-read articles at CT Online in 2019. Also popular were pieces on client issues such as perfectionism, parenting, couples counseling, impulse control, domestic violence, teen issues and social anxiety, among others.

Some of the top search terms that brought people to the site in 2019 included play therapy, polyvagal theory, self-care for counselors, empathy fatigue, countertransference, parenting in the 21st century, multicultural competence and cultural humility.

The most-read articles posted in 2019 at CT Online (ct.counseling.org)

  1. Counselor self-disclosure: Encouragement or impediment to client growth?” (Feature, February magazine)
  2. Establishing a private practice” (Cover story, April magazine)
  3. The messy reality of perfectionism” (Feature, March magazine)
  4. Is there an epidemic of emotional support animals?” (Member Insights, February magazine)
  5. The pros and cons of contracting with online counseling companies” (Member Insights, January magazine)
  6. When yelling doesn’t work” (Feature on parent/child discipline, May magazine)
  7. Finding strength in sensitivity” (Feature on sensory processing sensitivity, October magazine)
  8. Client suggestibility: A beginner’s guide for mental health professionals” (Member Insights, August magazine)
  9. Addressing intimate partner violence with clients” (Cover story, July magazine)
  10. Advice for the highly sensitive therapist” (Online exclusive posted in September)
  11. Five social, emotional and mental health supports that teens need to succeed” (Member Insights, September magazine)
  12. More than simply shy” (Cover story on social anxiety, August magazine)
  13. Taming impulses” (Feature, August magazine)
  14. Counselors as human beings, not superheroes” (Cover story, October magazine)
  15. The pretend professional” (Member Insights on impostor syndrome, July magazine)
  16. Grieving everyday losses” (Cover story, May magazine)
  17. Making it safe to talk about suicidal ideation” (Cover story, September magazine)
  18. Parent-child interaction therapy for ADHD and anxiety disorders” (Member Insights, March magazine)
  19. Procrastination: An emotional struggle” (Feature, November magazine)
  20. The miscommunication model and the WDEP system” (Knowledge Share on couples/relationship counseling, June magazine)
  21. Going beyond sadness” (Cover story on depression, November magazine)

 

 

 

What was your favorite article of 2019? What would you like to see Counseling Today and CT Online cover in 2020?

Leave a reply in the comment section below, or email us at CT@counseling.org

 

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Uncovering the root cause of mother-daughter conflict

By Rosjke Hasseldine January 8, 2020

An experienced counselor recently admitted to me that she felt out of her depth when a mother and adult daughter both came to see her for help with their incessant arguing. She said that she struggled to identify the core reasons for their arguments, and she knew that the communication skills and boundaries she tried to instill in them did not address the core reasons for their relationship difficulties.

Sadly, this counselor is not alone. Colleagues frequently tell me that they feel unprepared when it comes to working with mothers and daughters. They blame the absence of specialized training. This lack of focus on the mother-daughter relationship creates unnecessary anxiety among counselors and psychotherapists, and frustration for female clients. For example, only in 2016 was the Adult Daughter-Mother Relationship Questionnaire developed (for more, see Julie Cwikel’s article in The Family Journal). And in my office, all too often I hear mothers and daughters voice their frustrations about the lack of specialized help.

In this article, I share two insights that will help counselors understand the dynamics between a mother and daughter of any age. These insights come from the mother-daughter attachment model I have developed through my 20-plus years of listening to thousands of mothers and daughters of all ages from different countries and cultures. The model makes the complicated dynamics between mothers and daughters easy to understand, explains why mothers and daughters fight, and teaches how mothers and daughters can build strong, emotionally connected relationships.

I chose to specialize in the mother-daughter relationship back in the 1990s because that relationship is central to women understanding themselves. My relationship with my mother had shaped who I was, and when my daughter was born 30 years ago, I knew I had to change the harmful themes that were being passed down the generations. What began as a personal quest became my professional mission.

Mothers and daughters frequently tell me that they feel ashamed about their relationship difficulties. They feel that they “should” be able to get along because popular wisdom tells them that mothers and daughters are supposed to be close. This societal expectation makes mothers and daughters blame themselves for causing their relationship difficulties. The truth is, if my years of experience providing therapy are any indication, many women currently experience mother-daughter relationship conflict.

Based on the inquiries I receive from mothers and adult daughters from different countries, I believe that a larger, societywide dynamic is contributing to their relationship conflict. Often, I hear “hormones” being blamed as the cause for relationship problems, whether it is the teenage daughter’s or pregnant daughter’s hormones, or the menopausal mother’s hormones. Another common reason mothers and daughters give to explain why they are not getting along is their differing or similar personality traits. I have never found hormones or personality traits to be the core reasons for mother-daughter relationship conflict, however. Rather, I have concluded that society sets mothers and daughters up for conflict.

In the first insight, I show that the mother-daughter relationship is not difficult to understand once we realize that mothers and daughters do not relate in a cultural vacuum. In recognizing that mothers and daughters relate within a sociocultural and multigenerational environment, the dynamics between them become easier to grasp. We see how life events, restrictive gender roles, unrealized career goals, and the expectation that women should sacrifice their needs in their caregiving role all shape how mothers and daughters view themselves and each other and how they communicate. To illustrate this dynamic, I share the story of my work with Sandeep, a young college student from England (name and identifying details have been changed).

In the second insight, I explain how patriarchy’s way of silencing and denying what women need is the root cause of most mother-daughter relationship conflict in different cultures around the world. To illustrate, I share my work with Miriam, a doctor from Sweden who comes from a feminist family (name and identifying details have been changed).

Miriam and Sandeep come from different countries and cultural backgrounds, and their families are on opposite ends of the women’s rights continuum, yet their core relationship problem is the same. Both Miriam and Sandeep come from families in which women have not learned how to ask for what they need.

Insight No. 1: Mothers and daughters relate in a sociocultural environment

As is the case with any couple, mothers and daughters rarely fight over what they say they are arguing over. Sandeep and her mother were no exception to this rule. Sandeep was a young college student who lived at home. Her parents immigrated to England from India before Sandeep was born. Sandeep had three brothers, but she was the family’s only daughter.

Sandeep came to see me because she was feeling depressed about how critical her mother was. She was struggling to juggle her college work with the housework her mother and family expected her to do. She said her mother would accuse her of not being a good enough “housekeeper” and not caring enough for her mother when she was ill, which was often.

Sandeep had consulted a counselor before me who had suggested that her mother might be suffering from a personality disorder. I never got to meet Sandeep’s mother and work with her clinically, so I was unable to validate whether this might be the case. Regardless, even if Sandeep’s mother did have this diagnosis, it did not provide Sandeep with the answers
she needed.

Instead, Sandeep needed to understand the multigenerational sociocultural environment in which she and her mother lived. She also needed to understand what was going on in this environment that apparently caused her mother to be so angry and critical, and what caused Sandeep and her mother to believe that it was Sandeep’s responsibility to do all the housekeeping.

When I start working with new clients, I map their mother-daughter history. This is the primary exercise in the mother-daughter attachment model. It is an adaptation of the genogram exercise that family therapists use. The maps focus on the three main women in the multigenerational family, which in Sandeep’s case was Sandeep as the daughter, her mother and her grandmother. I map the experiences the three women have had in their lives, including the gender roles that have defined their lives and limited their choices and power. I also map how the men in the family treat their wives and daughters. Mother-daughter history maps provide an in-depth analysis of the multigenerational sociocultural environment in which the women in the family live and what is happening within that environment to cause mothers and daughters to argue, misunderstand each other, and disconnect emotionally. (Detailed instructions on using this exercise with clients are available in my book The Mother-Daughter Puzzle.)

Sandeep talked about her grandmother’s and mother’s lives and arranged marriages and shared how verbally abusive and controlling her father and grandfather were. She said the males in the family were encouraged to go to college and build their careers, while the females were expected to stay at home to help their mothers. As Sandeep provided these details, her family’s patriarchal structure came into sharp focus. Sandeep represented the first woman in her generational family to finish school and go to college.

Sandeep’s family believed in what I term the “culture of female service,” a global patriarchal belief system that views women as caregivers, not care receivers. Families that subscribe to the culture of female service expect mothers and daughters to be selfless, sacrificial, self-neglecting caregivers. This belief system does not recognize women as people with needs of their own.

Although I never met Sandeep’s mother, it was apparent to me (based on Sandeep’s descriptions) that she had internalized this family belief and did not know any other way of being. This meant that she did not understand Sandeep’s desire to go to college or her fight for her independence. I suspected that Sandeep’s independence felt threatening to her mother. Several reasons explain why Sandeep’s mother was so critical of her daughter and why she behaved in an emotionally manipulative manner — for example, by becoming ill just when Sandeep was busy with an assignment or exam.

First, Sandeep wanted to live a different life than her mother and grandmother had lived, and this likely made Sandeep’s mother feel alone and abandoned. Her only understanding of being female was that of women as caregivers and of “good daughters” stepping into their mothers’ shoes and walking repeats of their mothers’ lives. Sandeep’s mother had done that, her mother had done that, and she expected Sandeep to follow in that role. I suspect Sandeep’s wish for a different life and different relationships felt like a rejection to her mother. It made her feel that her daughter was criticizing the life and values she believed in as a mother.

Second, Sandeep’s mother could have been jealous of her daughter’s freedom and opportunities, even though she probably was unaware that her criticism and anger were rooted in jealousy. Sandeep’s freedom and opportunities might have been an uncomfortable mirror for Sandeep’s mother, reminding her of the freedom she never had and the dreams she had to relinquish.

Third, the mother’s attempts to keep Sandeep from graduating and leaving home could have been linked to her own fight for emotional survival. Sandeep reported to me that she was the only person who gave her mother love and care, so the thought of Sandeep leaving home must have been terrifying to her mother.

For mothers and daughters to build a strong, emotionally connected relationship, it is optimal for both parties to engage in couples therapy. However, if one person is not able, or willing, to participate, healing is still possible. In Sandeep’s case, her mother did not want to participate in therapy. This did not prevent Sandeep from working on understanding and improving her relationship with her mother, however. When one person changes their behavior, the relationship changes to incorporate the new behavior. Of course, Sandeep and I had little control over how her mother would respond to the changes Sandeep needed in their relationship.

My work with Sandeep involved teaching her how to listen to her own voice. Sandeep had become an expert on responding to what her mother needed and being a “dutiful daughter,” but she had little idea about what she wanted for herself, beyond finishing her degree. Sandeep did not know how to ask herself what she thought, felt, or needed emotionally because that conversation was not spoken in her family. My role as a mother-daughter therapist was to help Sandeep uncover the sexism she had inherited from her mother and grandmother that had silenced her voice. I helped her understand the gender inequality her family and culture normalized, and I taught her how to claim her own ideas of who she wanted to be and what she needed in her relationship with her mother — and in all her relationships.

I also helped Sandeep navigate the pushback she got from her mother and father when she stopped complying with their demands to be the family’s unpaid housekeeper. I helped her to understand her mother’s and father’s perspectives so that she had empathy for them and encouraged her to recognize that their anger and criticism weren’t as personal as they felt, originating instead from their cultural beliefs. Alongside Sandeep’s increased understanding of her family’s sociocultural environment, I helped her increase her entitlement to speak her mind, reject unreasonable demands, and carve out her own life path.

Sadly, Sandeep’s parents did not react well to her behaving differently from what they expected of a “dutiful daughter.” After Sandeep left home, her family’s anger and accusations that she had dishonored the family became alarming, leading her to obtain a restraining order against her parents and siblings. Through her therapy, Sandeep learned the degree to which her family members did not tolerate women challenging their long-held beliefs about what women could and could not do and could and could not wear. I had to help Sandeep stay safe and grieve the loss of her family even as she gained her own voice and life.

Insight No. 2: Mothers and daughters fight over their denied needs

My clients have taught me that the denial of what women need, especially when it comes to women’s emotional needs, ripples below most mother-daughter relationship conflict. As I write in The Mother-Daughter Puzzle, when a family does not speak the language that inquires after what women feel and need, mothers and daughters are set up for conflict. It creates an either-or dynamic in which the mother and daughter fight over who gets to be heard and emotionally supported in their relationship because they do not know how to create a normal in which both are heard and supported.

In every mother-daughter history map I draw, I see how the silencing of women’s needs harms women’s emotional well-being, limits their ability to advocate for themselves in their relationships and workplaces, and perpetuates gender inequality. I see how this dynamic makes women invisible, and how being invisible makes women hungry for attention. The inability to openly and honestly ask about what they need creates emotionally manipulative behavior between mothers and daughters and sets daughters up to have to mind read their mothers’ unspoken and unacknowledged needs.

Miriam, a client from Sweden, contacted me for help with her adolescent daughter. Miriam and her mother had benefited from the women’s movement fight for women’s rights. Miriam and her mother were doctors, and Miriam’s husband and father were extremely supportive of their careers. But just like Sandeep and her mother, Miriam and her mother had internalized and normalized the culture of female service, and Miriam’s daughter was angry about her mother’s selflessness.

Miriam’s daughter felt that she had to mind read what her mother really felt and wanted, and she was tired of it. She desired an emotionally honest relationship with her mom. She wanted to feel free to say what she felt and needed and for her mother to speak her mind and stop the guessing games. Miriam’s daughter did not want to feel responsible for meeting her mother’s unvoiced and unacknowledged needs.

The silencing of women’s needs is an intergenerational dynamic that gets passed on from mother to daughter because the mother is not able to teach her daughter how to voice her needs openly and honestly. When the daughter is expected, often unconsciously, to listen for and meet her mother’s unvoiced and unacknowledged needs, the daughter is learning to become an expert on understanding what her mother needs, not on what she needs herself. This means that the daughter will grow up to be as emotionally mute as her mother, thus setting up her future daughter to try to learn to interpret and meet her unvoiced needs.

Women’s generational experience of being emotionally silenced and emotionally neglected is a common theme between mothers and daughters. Happily, I am seeing a huge shift from adult daughters in their 20s, 30s and 40s who are waking up to this patriarchal theme and wanting change. These daughters recognize that they have learned — from their mothers and from society in general — to be far too tolerant of being silent and practicing self-neglect. More daughters are asking their mothers to join them in therapy so that together they can change these inherited behavioral patterns. Mothers and daughters are teaming up and pioneering a new normal in their families — a normal where women are speaking up and demanding to be heard. And they are passing on this new normal to the next generation of sons and daughters.

Mothers and daughters have always led the call for women’s rights. When we understand that mother-daughter attachment disruption or conflict tells the story of how sexist beliefs and gender role stereotypes harm women’s voices and rights, the mother-daughter relationship becomes an unstoppable force for change at the worldwide and family levels.

Sadly, Sandeep’s mother was not able to join Sandeep in her fight to challenge her family’s sexist cultural beliefs. I inferred that too much neglect made Sandeep’s mother emotionally unable to think her way out of her powerlessness. Miriam, having had a far more supportive and empowering upbringing, was able to join her daughter to find a new normal for women within their family. This mother and daughter team coached each other as they decontaminated themselves from their internalized sexism and self-silencing habits.

The mother-daughter relationship has tremendous power to change women’s lives around the world. When mothers and daughters band together, they create an impenetrable wall of resistance against family members who are threatened by women claiming their rights. I have had the honor of working with many pioneering mothers and daughters who dared to dream of a reality in which mothers and daughters are no longer starving for attention and fighting for crumbs of affection. These brave mothers and daughters recognize the harm that patriarchy, sexism, and gender inequality inflict on women, and they have decided that enough is enough. In essence, they are saying, “With us, it must end.”

 

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Rosjke Hasseldine is a mother-daughter relationship therapist, author of The Silent Female Scream and The Mother-Daughter Puzzle, and founder of Mother-Daughter Coaching International LLC (motherdaughtercoach.com), a training organization. She blogs for the American Counseling Association and has presented her mother-daughter attachment model at professional conferences, on Canadian television, and at the United Nations Commission on the Status of Women. Contact her at rosjkehasseldine@gmail.com or through her website at rosjke.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.

Grieved: A firsthand account of enduring a client grievance as a counselor

By Jessica Smith January 7, 2020

I learned in graduate school that most counselors will experience three things in their careers: a client who dies by suicide, a client who overdoses, and a client who files a grievance. I remember hoping that I would be the exception to the rule. Throughout my career, I tried to do everything in my power to avoid that grad school prophecy. But fate had other plans: Last year, one of my clients filed a grievance against me.

Shame breeds in secrecy. In my experience, being the subject of a client grievance is one of the most shaming — and isolating — events a counselor can encounter. Those who choose to speak openly and honestly about the grievance process are often met with judgment and criticism. In an effort to help combat the silence and stigma, I’m sharing my story with the hope that it will provide guidance and support to other counselors who are going through this difficult and trying process. I want to remind others that they are not alone on this journey while also offering a road map for a way through. It will be OK.

One of the things that helped me get through the grievance process was conceptualizing it in terms of Elisabeth Kubler-Ross’ grief cycle. I tell my clients that the stages are the road map for grief. If I had a road map, then I had a direction to go, and I was not stuck or lost. I did not know when I would reach acceptance, but I knew that it was on the horizon if I just kept moving forward.

 

Denial and shock

Early last year, while checking my email in a Target parking lot, I saw a message from the Department of Regulatory Agencies (DORA) sitting in my inbox. In Colorado, DORA is the governing body that issues licenses to providers while also handling consumer grievances. My heart began beating quickly. I felt dizzy and nauseous. I walked into the store to return an item at the customer service counter, and I had to will my legs to move forward and my mouth to speak. I felt like everyone around me could see a massive letter “G” tattooed across my forehead. My hands began to shake as I drove home so that I could read the email at my desktop computer. As I read through the entire message from DORA, I started to cry.

A few weeks prior, I had taken on a new client at my practice. Interestingly, my intuition immediately suggested that this client would be challenging. The second session reinforced my sense that building a therapeutic relationship with this client was going to be a rough road. The third session didn’t happen — the client was a no-show, no-call. When I reached out to the client through a text message, she said that she did not want to schedule a future session with me, so I discharged her from therapy that afternoon. I had a feeling this would not be the last time that I heard from this client. My intuition was correct.

I received an email from the client that night, criticizing me for the way I had handled the interaction. She thanked me for helping her but asked me to explain my “side of the story.” Because I had already discharged her from therapy and felt that any potential future counselor-client relationship would be negatively impacted by the exchange, I told her that I no longer felt comfortable working with her. Again, I had a feeling this would not be the last time I heard from this particular client. My intuition was right again.

 

Bargaining

DORA was citing me for poor communication and abandonment. I immediately reached out to a friend and former colleague who had worked with an organization that completed assessments for DORA. I knew she had also been through the client grievance process a few years prior. As I prepared for our discussion, I looked up everything I could find on the internet about the grievance process, client abandonment, HIPAA, and mental health statutes. Nothing was clear, and most of the information seemed contradictory.

On the phone, I laid out the facts of the case before my friend. Like many others I would talk to along the way, she thought it likely the case would be dropped. Thankfully, the grievance was not based on a verbal exchange; resolving the case would not depend on pitting my word against the client’s. My friend advised me that I might need to seek legal counsel, and we discussed my official response to the complaint, which I typed up immediately and sat on over the weekend.

The following Monday, I gathered the client’s file and submitted it to DORA, along with my response to the grievance. I also reached out to my insurance carrier to let it know about the grievance. All the while, I was hoping the case would be dismissed so that this nightmare would end. Due to the benign nature of my case and the cost, I chose to hold off on hiring legal counsel at the beginning, but my insurance provider encouraged me to reach out to a lawyer if the case continued any further.

 

Depression

The grievance was all I could think about. It consumed me. I would fall asleep ruminating about it and wake up the next morning to a continuation of my thoughts from the night before. Or, just as often, I would wake up in the middle of the night, my anxiety quickly rising as I remembered that this was not a dream — it was really happening to me. I prayed for it all to go away. I wanted to return to a sense of normalcy. I began second-guessing myself and the image I was presenting to my clients at work. I felt on edge and afraid that something else would happen. I feared that this grievance process would not be the end of it.

I had been in the field for seven years and had never experienced an issue like this previously. I had provided services in challenging and demanding settings, including detoxes, residential treatment facilities, and jails, and I had never before had a client complain to a supervisor or another colleague about my work.

Because the personal is professional and the professional is personal in our work, it can be hard to separate the two. This makes it difficult to prevent internalization during the grievance process. I felt like a bad counselor and, thus, a bad person. At the same time, I felt confused because I had other clients telling me that I was an incredible therapist who had helped them change their lives for the better and become the best versions of themselves. I tried to hold space for all of these experiences and live in the gray, but it was tiresome and tough to do.

Fearing judgment and criticism, I was mindful of who I shared my troubles with. I was in a vulnerable place and was already attacking and beating myself up enough without someone else adding to the punishment and suffering. Like most therapists, I am attuned to nonverbal cues and underlying speech tones and was always looking for them when I told my story to fellow counselors. For the most part, I chose to keep the experience to myself and a few confidants, but I knew that wasn’t enough. I also needed the perspective and guidance of other professionals during this demanding time, so I shared with people in my therapist support groups. The majority of the people I told were empathetic, nonjudgmental and supportive, but there were a few whose faces dropped once I told them. There were still others who tried to use my story as their own personal case study, which was disappointing and disheartening.

I felt like I was in a dream, observing this entire experience happening to me from a distance. I believe that, at the time, this was a necessary coping strategy. I had to compartmentalize the experience so that I could go to work each day and meet with clients at my private practice. I likened it to being sued by your company and continuing to show up for work every day, knowing what is happening around you and within you.

I questioned myself constantly and considered what I could have done differently. I read through the mental health statutes and searched HIPAA forums, but nothing was transparent and straightforward. I tried to look up articles, podcasts and research on the grievance process but could find only one research article from the 1990s on the impact of the grievance experience on psychologists. It helped to know that my experience of the process was normal and valid, but it did not ease my fears.

 

Anger

I have two licenses in Colorado, which is advantageous in my work — except for when I going through the grievance process. My double licenses made it doubly difficult because my case had to go before both boards. The two licensing bodies can have differing opinions and sanctions, but I learned early on that once one board reaches a verdict, the other board often follows suit. I received an email informing me that the Colorado State Board of Licensed Professional Counselor Examiners would be the first to review my case, in May. I had submitted my paperwork in February, so it would be months before I would know the resolution of my case. I was learning that the grievance process is a prolonged waiting game.

Meanwhile, I was expanding my practice and interviewing contract therapists. Then, in April, I received an email from the Colorado State Board of Addiction Counselor Examiners informing me that my case had gone before its board first, without my knowledge. I was blindsided. I was in the middle of doing interviews but, thankfully, had a break, so I drove home. I made it about halfway before pulling over to the side of the road to read the rest of the email. My mind was blown. I felt like my sense of reality was crumbling.

The Board of Addiction Counselor Examiners had found me “guilty” of the allegations and was moving the case forward to Colorado’s Office of Expedited Settlement. I found a lawyer online and emailed him from the side of the road. I felt powerless and out of control and needed to find a way to regain my sense of self-agency. I knew that taking action was the way for me to do that. I didn’t want to have any regrets about what I could have or should have done, so I was finally ready to get legal assistance for this fight.

I met with the lawyers the following week and learned that they were receiving three to five grievance cases per day. In the past, they said, they had received only three to five grievance cases per month. After our meeting, I looked up the list of therapists involved in disciplinary actions through DORA’s website, and the numbers were staggering. There are approximately 26,000 counselors in Colorado, and more than 11,000 have received disciplinary action.

I was angry — with myself, with the system, with the profession, and with the client. I felt so much anger pulsating through me that I wanted to scream and to run away, both at the same time. I thought about walking away from it all — leaving the counseling profession, giving up my licenses, and moving on to a different, safer, easier path.

Mainly I thought, “Why me?” I felt myself moving into a victim mentality as I had done in the past when going through trying experiences. Because I have been victimized in my past, this is an easy role for me to assume when I am experiencing pain and suffering. I blame others and shut down.

Anger is an uncomfortable emotion, but I knew I was meant to have it in this moment because it would lead to motivation, change and movement. I could harness it or let it eat me alive. It was my choice alone.

 

Acceptance

Like many grieving people, I remained stuck for some time in the anger phase. Anger feels powerful and motivating, unlike sadness, which is exhausting and debilitating. However, I always go back to the saying that “anger is like taking a cyanide pill and hoping it will kill your enemy.” It only ends up hurting you in the end. My anger toward myself, the client, the system and the profession would not serve me. It would end up eating me alive if I allowed it to.

I was walking home from work one day when suddenly it began to rain. Completely unprepared, I had nothing to keep me dry. It was only a mild shower, however, so I said out loud, “If it keeps raining like this, then I’ll be OK.” It started raining harder. Undaunted, I said again, “If it keeps raining like this, then I’ll be OK.”

And then it began to pour. I was halfway home, caught in a storm without a raincoat. All I could do was surrender. I was broken open. The armor of anger I had been parading around in fell away as I began to cry. “I surrender,” I said aloud. “I get it. I’ll always be OK.” I started to smile as tears mingled with the raindrops running down my face. Nature has a way of asking us to let go of our resistance and surrender.

I released my anger in that moment, realizing that I’d been aiming most of it at myself. I began the slow process of forgiving myself and coming back home to the idea that we are all doing the best we can. I never meant to hurt the client, and I had no malicious intent in my actions. I had done the best I could in that moment and with the situation.

I moved into acceptance by making meaning of the experience and discovering that it was meant to realign me with my soul’s calling and purpose. I realized that I cannot veer far off my course in life before the universe pushes me back into my lane.

 

Lessons learned: Seek support, ask for help, find allies

It is difficult to share with others what it’s like to go through the grievance process, but it is also incredibly necessary. As is the case with any grief process, we need sources of support to call on to ground us and anchor us when we feel like we are floating away or losing sight of our true selves. As professional counselors, we may make mistakes, but that does not make us bad people. We need to be reminded of our goodness and wholeness.

It is essential to surround ourselves with genuine and unconditional love and to have a safe place to cry and yell without fear of judgment or criticism. When all we want is to lie on the ground and give up, our support systems can lift us up and keep us moving forward. And, finally, we need to be reminded that counseling is extremely difficult work.

My only regret about the whole process is that I did not seek legal counsel sooner. I wonder what might have happened if I had not been deterred by the nature of my case and the cost. Although I now realize that I needed to go through this process to realign my priorities and path both personally and professionally, I sometimes question whether things would have turned out differently if I had sought the assistance of a lawyer in formulating my response to the grievance originally.

Retaining attorneys earlier in the grievance process might not have helped me avoid the verdict of “guilty,” but it likely would have provided me more peace of mind. In fact, once I sought legal counsel and spoke with my lawyers, I felt a sense of ease and relief. As I mentioned, I was restless and waking up frequently during the nights, but after that initial afternoon meeting with my lawyers, I got my first full night’s sleep in two months. I am aware of how vital regaining the ability to rest was to enduring the trauma of the grievance process. Sleep heals.

Later on in the process, I connected with the Colorado Counseling Association (CCA). I remember saying to myself, “DORA protects the consumers, but who protects the counselors?” This was my answer. I went to an event sponsored by CCA and learned more about the advocacy work it does to support and help counselors. Specifically, it is fighting to change the vague and subjective language of the clause in the mental health statute of “best practices” that was cited in my case and many other cases as a catch-all category for disciplinary actions. Here were even more people on my side who were passionate about advocating for counselors and changing the system.

During the grievance process, someone had said to me that the tower I had built with all I had believed to be true was crumbling and falling, leaving behind a pile of rubble and debris. My beliefs about my career had been built on shaky and rocky ground to begin with, so it was inevitable that they would all come tumbling down eventually. Now that the collapse had ended, I had to decide what to do with the debris. I could choose to walk away from the bricks and stones in the rubble, or I could use them to build a new tower on stronger ground.

I am still in the process of rebuilding, and I know that it will be a slow and methodical project. I am fulfilling the stipulations from DORA and considering the future. I am not sure if I will ultimately want to maintain both of my licenses. For now, however, I have chosen to keep them. But I know that the choice is mine — no one else’s. I now have a solid foundation on which to build my tower.

With each placement of brick and stone, I feel stronger and more powerful than I was before this experience. My battles scars and wounds will influence how I build my tower, but they will not halt or control the construction. As Carl Jung said, “I am not what happened to me; I am what I choose to become.”

 

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Jessica Smith is a licensed professional counselor and licensed addiction counselor with a private practice, Radiance Counseling (radiancecounseling.com), in Colorado. Contact her at jsmith@radiancecounseling.com.

 

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ACA members: Facing a dilemma about ethics, business practices or risk management? Contact the ACA Ethics and Professional Standards Department at (800) 347 6647, ext. 321 or email: ethics@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.

Deconstructing anxiety

By Todd Pressman January 6, 2020

I have always found it tremendously frustrating that our rational minds can’t convince us that most of our fears and anxieties are nothing to be afraid of. Many of my clients express the same frustration. As philosopher Michel de Montaigne said, “My life has been full of terrible misfortunes, most of which never happened.” Sadly, this is true for many of us, and no amount of positive thinking, affirmation or even cognitive transformation will touch any but the most superficial layers of anxiety.

In my early teens, I began a search for answers to this problem. It started with the questions that all good adolescents ask: Why are we here? Who am I really? What can be done about suffering? As a young man, this inquiry took me literally around the world as I met and had exchanges with a Zoroastrian high priest in Mumbai, a Zen master in Kyoto, fire walkers in Sri Lanka, and fakirs in Bali, as well as many of the leaders in the “consciousness” movement. One of my primary takeaways was that anxiety is fundamental in the human experience … and universally so.

This really caught my interest because I recognized the constant fear, sense of threat, and hypervigilance that seemed to be required to “survive” as not only overwhelming but as a fruitless way to live. Later, I channeled this interest into a career as a psychologist and devoted myself particularly to the study of anxiety. At some point in my search, I concluded that anxiety was not just fundamental, but the single greatest source of suffering in life — more central, even, than depression.

Over the years, my personal exploration and work with clients began to reveal certain repeating patterns about the fundamentals of anxiety. From this evolved a new model for treatment that has been gathering significant attention, not only for its effectiveness in treating anxiety but as a new therapeutic approach in general. It synthesizes several modalities, Eastern and Western, to deconstruct anxiety to its most elemental components. Positing a “basic anxiety” (cf. Karen Horney) as the underlying cause of our difficulties, the model pinpoints the precise moment and mechanism by which anxiety took root and altered our perception, creating a world of distorted and painful experience.

The model lays out what is in many ways a radically new understanding of the origin of anxiety, both in the individual and in the evolution of humanity. It describes the arrival of a “core fear” — one’s overriding interpretation of life as dangerous, and a “chief defense” — one’s primary strategy for protecting oneself from that danger. The core fear and chief defense create a singular dynamic that, according to the model, is the true wellspring of basic anxiety. Together, they open up a Pandora’s box of all our fear-based experiences, creating an anxious worldview.

The deconstructing anxiety model presumes that our original state of being is one of wholeness and fulfillment. But at a young age (and perhaps even in utero, as per Otto Rank’s concept of the birth trauma), we have our first contact with danger that establishes our core fear. Our mother leaves the room, and we think it is forever. Our father is distant and cold, and we are left wanting.

With the arrival of the core fear, we must choose a strategy for self-protection — our chief defense. This strategy, because it assumes “something out there is against us,” has us see ourselves as separate from the whole — from others, from what we need, from fulfillment. Armed with our chief defense, we embark on a quest to reclaim our original well-being.

Because this quest is motivated by fear (the fear of being separate from what we need), it can never succeed: With our focus on avoiding fear, our attention becomes consumed with all of the dangers that might sabotage our search. In this way, the core fear and chief defense become the original cause and perpetuator of our unhappiness. As a strategy to protect us from danger, they project our fears onto reality so that we may be “prepared” for them. This projection creates what I like to call a three-dimensional, multisensory hologram — a living, breathing perceptual distortion based on anxious premises. The great problem of human suffering is that we forget this is only a projection and take the hologram to be “real.”

Combining insight and action

What to do about this very human predicament? According to our model, we must thoroughly deconstruct our anxiety down to the core fear and chief defense that created the trouble in the first place. Only then can we see that they are made up of learned constructs, built from childhood assumptions that no longer serve us.

This sounds ordinary enough, but the model completely redefines what it means to perform such a deconstruction. It is only when we arrive at the “root of the root,” the original “mistake” in thinking (again, both in the individual and in humanity as a collective), that we can truly achieve the insight to show us that our fears are not founded. This depth of insight is rare. So often, we are mystified about why we suffer; despite our best efforts and insights, we become lost in the catacombs of unconscious fears, with no sure compass to direct our course.

Even if we do achieve true insight into the original thought of fear at the root of suffering, we may still need, as neuroscience shows, to take corrective action if we are to truly resolve anxiety. This is because fear can get written into our physiology in ways that insight alone cannot heal. Finding the correct action to take that will truly expose the illusion of our fear can also be challenging.

So, the right combination of insight and action is our goal. For this purpose, the deconstructing anxiety model has developed two powerful techniques that quickly reveal one’s core fear and chief defense. These diagnostic tools cut through our confusion and explain the original source of our suffering with comprehensive insight. Such insight suggests the necessary tools for action (also given in our model) to resolve the problem. Taken together, these practices help one get “behind the camera,” so to speak, that is projecting our individual and collective worlds of anxious perception.

Finding the core fear

The process of deconstruction starts with an exercise for finding one’s core fear called “Digging for gold.” With this technique, we may quickly and reliably reveal — or we may do so for our clients — the fundamental thought that has been distorting our perception for a lifetime. This exercise is the cornerstone of our model, using a process of deconstruction that goes directly to the root fear underneath all the rest. Here’s how it works:

Begin (or have your clients do so) by writing down a problem on the top left of a page. Any problem will do, because all problems are born, as we shall see, of the same core fear. Make sure your answer is stated as an actual problem and written in a short single phrase, such as “My friend slighted me” or “I can’t pay my bills.” Then write one of the following three questions on the right side of the same line of the page. Choose whichever of these questions seems most fruitful:

1) Why is that upsetting to me?

2) What am I afraid will happen next?

3) What am I afraid that I will miss or lose?

Answer the question with another short single phrase, written on the left side of the line below the first problem. This answer should state a new problem that brings you one level closer to the core fear underlying the original problem. Ask one of the same three questions on the right side of that second line and respond with a short single answer on the third line on the left. Continue with this process until you arrive at what you will clearly recognize as the core fear — a fundamental truth about the real source of the problem with which you started. (See box below for structure of exercise.)

You will know you have arrived at the core fear when you a) keep getting the same answer to the questions and can no longer find a deeper source of fear and b) have an “aha!” experience, a profound recognition that the answer explains something essential at the bedrock of your thinking. Spontaneous connections between the core fear and important events from the past will become apparent, sometimes accompanied by an evocation of powerful emotion and even catharsis.

The real significance of this tool, however, is that as you repeat it with various problems, you will discover that it reveals not only the root of a particular issue or issues but the one true root of literally any problem you can have. This is necessarily so because the core fear is your fundamental interpretation — the overarching assumption — of how the world can be dangerous or threatening. (Note: There are five core fears, or “universal themes of loss,” that capture the basic interpretations of danger that we all make. They are 1) fear of abandonment, 2) loss of identity, 3) loss of meaning, 4) loss of purpose and 5) fear of death, including the fear of sickness and pain.)

Because it is so threatening, so ego-dystonic with our previous state of wholeness, once we land on the core fear interpretation, it makes a powerful imprint on the psyche. We hold on to it as our key to survival — that which will make sense of the danger we’ve encountered and prepare us to be ready for it in the future. It becomes our new understanding of the world, the filter through which we will interpret every experience that presents (or that we can imagine might present) the possibility of danger.

Finding the chief defense

Once we have found our core fear, we must decipher our chief defense, defined as the primary strategy we use to protect ourselves from the core fear. Just as we do with the core fear, we cling desperately to the chief defense, believing it is necessary for survival. But in using this strategy, we unwittingly lock ourselves in to further anxiety because we are reacting to the idea of the core fear as if it were real, as if we are indeed in danger and our protective maneuvers are necessary.

As per the premise mentioned earlier, this is always a distortion of the truth. If we were to examine the real situation, we would at worst find a problem we can deal with rather than the catastrophe our core fear would have us imagine. More often than not, we find the situation we feared holds no threat at all — that the entire idea of danger was made up, a residue of childhood beliefs long held but never challenged.

To find the chief defense then, we simply ask ourselves, “How do I habitually respond to the core fear (or any threat to well-being, since all arise from the core fear)?” We have become so accustomed to our chief defense as our automatic (and only) response to problems that we don’t usually consider alternatives. But as a way to get perspective on our own presumptive response, we can ask ourselves, “How might someone else respond differently in this situation?” or “What is my typical response (overall) when I am challenged or threatened?”

We can also look at many of the major decisions we have made in life and how those decisions were designed to protect us from the core fear of those moments (e.g., the fear of making the wrong decision). There are several other methods for getting insight into one’s chief defense (complete descriptions of these practices can be found in my other publications), but all of them are really different ways of asking, “What is my personality style?” Because it is the core fear and chief defense that set our unique manner (our “personality”) of interpreting and responding to the variety of circumstances life can throw at us.

It bears repeating: The great discovery in this approach is that the core fear-chief defense dynamic gives a sweeping and comprehensive explanation about why we suffer. It not only builds our personality but outlines the entire way we have learned to orient to and interact with life. The extent to which we struggle is the extent to which we have not resolved these fundamental driving forces. Remember, even though they may take care of a problem in the moment, all defenses backfire in the end, reifying and exacerbating the problem they were supposed to protect us from. As we repeat these exercises over and over, we can demonstrate for ourselves that there is, in fact, one core fear and one chief defense operating behind the scenes whenever we are not experiencing the deep fulfillment and sense of wholeness that was our original state.

Once armed with insight into the core fear and chief defense, we are ready to take corrective action. The deconstructing anxiety model has developed several new techniques, including “The Alchemist,” “The Witness” and “The Warrior’s Stance,” for dismantling the chief defense and resolving the core fear. Each of these techniques has been demonstrated clinically to be highly effective in shaking off the hypnotizing effect of fear and waking us up to the truer reality it was hiding. Like pulling back the curtain in The Wizard of Oz, we “do the opposite” of what our chief defense would have us do, thereby exposing the core fear it was hiding. It is this unveiling of the core fear — the secret, primal source of our difficulties — that shows it to be ineffectual. It is but a mouse that roared, casting huge and grotesque shadows on the wall but carrying no real threat.

There isn’t space in this article to go into detail with these techniques, but each is designed to pinpoint the exact moment that our chief defense is applied. By targeting this moment, we may “do the opposite” and expose (rather than defend against) the core fear, revealing its true and distorted nature. But to do so, we must thoroughly move through the fear (at least in imagination) to “disobey” the command of the chief defense. This enables us to pull back from the automatic responses of our personality style, seeing them as arbitrary and encouraging a more effective reply. Combine this with the understanding that there is one core fear and one chief defense responsible for our way of being in the world, and these exercises give us the ability to unravel the entire world of projection that comes from them. It allows us to see through the appearance of danger and shows anxiety to be a lie — an optical illusion if you will — distorted by so much smoke and mirrors.

Case study

Peter (not his real name) was a 48-year-old man who suffered from generalized anxiety disorder. He was especially anxious about the idea of physical sickness and pain and of emotional rejection, and he struggled with the limitations of being human. It was evident from our first meeting that he had been raised by an overprotective mother who had shielded him too well from the exigencies of life.

When Peter was 9 months old, he became very sick and was hospitalized. In addition to the physical pain he experienced, he must have been terrified about being separated from his mother in a strange, cold environment with strange people poking and prodding him. When he returned to the security of his home, he regressed, clinging tightly to his mother and showing behaviors he had previously grown out of. He stayed young and dependent throughout his childhood.

At age 14, Peter began a tumultuous adolescence, experiencing his hormonal changes as an overwhelming challenge to his identity. His first response was to try to cling to his parents for comfort, but for the first time since his hospital experience, they were not able to calm him. This increased his anxiety all the more and solidified his core fear, which he described to me as being “exposed to the elements and to death, without any real security.” His response at age 14 was to make a powerful resolve that if his parents could not protect him, then he would find a way to gain a sense of control on his own.

As Peter grew older, this translated into various behaviors (what the deconstructing anxiety model calls “secondary defenses”) in which he would be “the best” at whatever he pursued: the best student, the best athlete, the most popular kid at school and so on. These behaviors represented his strategy for trying to reclaim the sense of safety and security he once knew. Putting these secondary defenses together, he described his chief defense (the umbrella description overarching them all) as “I have to be special.”

This response style would become Peter’s personality, following him throughout his life. Although it created a good deal of ambition in Peter — a drive to evoke his fullest potential — it was clear this drive was compelled by fear, a somewhat frantic need to be special. Therefore, it belied his anxiety of accepting the necessary limits of the human condition in a way that could have led to real growth and transformation. Instead, Peter felt stuck in a self-repeating loop that was the cause of his generalized anxiety — every time he became anxious, he would try in earnest to “beat” the problem, looking for the next way to prove his worth and “specialness.” Like any defense, this would provide momentary relief but then backfire, inevitably creating more anxiety when Peter was confronted with some new vulnerability, thus beginning the process all over again.

In our work together, Peter quickly uncovered his core fear and chief defense and developed a healthy appreciation for the futility of the strategy they proposed for well-being. With these insights in hand, we began the exercises for correction in the deconstructing anxiety program. In each, we gently but firmly confronted Peter’s chief defense of being special and practiced “doing the opposite.”

These exercises targeted the exact instant when Peter would defend against his core fear and provided a structure for safely and completely moving through the defense. In doing so, Peter could see the impulse to exercise his chief defense as an arbitrary choice. This allowed him to live through (in imagination) the full force of his core fear, coming to a deep acceptance of that from which he had been running his entire life. Sticking with this process, Peter’s chief defense “dissolved” (his word), no longer able to convince him that there was something threatening to defend against. He had faced his fear of not being special and relaxed into the fact that he was “ordinary, just like everyone else.” However, he no longer interpreted this as a source of pain or disappointment.

Quite the contrary, with a great look of surprise on his face, he stated, “It’s so freeing to be ordinary. I see how my whole life I’ve been working so hard to prove I’m special. All that did was keep me anxious, always worrying about failing at my goal. How ironic. I wanted to be special so I could get love and security. But I was the one keeping myself apart from that, thinking I had to be more than I was in order to earn that love.”

This is not an isolated example. Every time we face the core fear without the interference of the chief defense, we will find that the core fear is not “real” in the sense we had thought. This is the promise of deconstructing anxiety: When we clearly see the hidden forces that have been driving our lives, we can take those therapeutic actions that will set us free. This means moving through the chief defense that was hiding our core fear, exposing ourselves gently but firmly to the fear, and discovering that our core fear does not have the power to carry out its threat as promised. Even if a problem remains to be managed, it does not represent a true call for fear once the assumptions that made it frightening are stripped away.

What’s more, we find that the vast majority of our fears and anxieties are completely made up, projections built on ideas learned long ago that have no bearing on our circumstances today. This is the great key to freedom, a prescription for how to live our lives from a new premise — one based not on fear and anxiety but on the ability to consciously choose our way according to our highest ideals and deepest fulfillments.

 

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Todd Pressman is a licensed psychologist, author and speaker specializing in the treatment of anxiety and the pursuit of fulfillment. His most recent book, Deconstructing Anxiety: The Journey From Fear to Fulfillment, was published this past summer (see toddpressman.com for more information). Contact him at pressmanseminars@gmail.com.

 

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

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.