Monthly Archives: April 2020

Jane Myers and Tom Sweeney: Servant leaders and advocates for the counseling profession

By Allen Ivey and Mary Bradford Ivey April 30, 2020

We have known Jane Myers and Tom Sweeney for over 20 years, during which time we collaborated on writing projects related to a mutual passion: helping to promote the well-being of all people.

When Jane died of cancer in 2014, it was a great loss to us personally and to the profession of counseling as a whole. Recently, we felt moved to interview Tom about Jane, as well as their substantial contributions to the evolution of the counseling profession.

Tom and Jane are the only [husband and wife] couple who have both been presidents of the American Counseling Association. They made a significant difference in their time as presidents, but they were equally influential as active members of ACA’s governmental structure.

Before turning to the interview we conducted with Tom, we’d like to touch on some of the areas in which Tom and Jane helped to shape the profession. During our interview, Tom shared some stories associated with several of these accomplishments.

The origins of ACA’s name: What we know today as the American Counseling Association began as the American Personnel and Guidance Association in 1952. The name was occasionally derided by some (“guidance is for missiles”), but it stuck until 1983, when I (Allen Ivey) introduced an alternative: the American Association of Counseling and Development (AACD). I thought the name spoke to the goals of counseling and implied a wellness/health orientation. The association thus changed its name and operated as AACD until 1992. Despite this, the concept of “development” was largely unclear to the public at that time. So, eventually, Jane and Tom helped propose our identity as simply the American Counseling Association. This three-word title succinctly defines who we are to the public.

Social justice: Jane and Tom remained social justice advocates throughout their careers. Tom, the son of Scottish immigrants, grew up in a racially and multiculturally rich community. As early as 1968 in what had been a segregated state university, he planned and directed the first in a series of fully integrated six-week-long summer institutes for 50 counselors from 13 Southern states living together in a dormitory. These and other programs were funded by the General Electric Foundation Educators in Industry program.

Jane’s brother had developmental disabilities. Her mother, a special education teacher, imbued in Jane a genuine love and respect for people with disabilities. Jane’s counseling career began as a state vocational rehabilitation counselor. By her own report, Jane’s administrator thought her too strong of a social justice advocate on behalf of her clients. So, Jane went on to earn a counseling doctorate, during which time she learned of the needs of older adults. Thus began her efforts in gerontological advocacy, research and teaching.

One of Jane’s gerontology students once told her that as this student was entering Jane’s classroom, a colleague professor of Jane’s said, “Don’t go in there. That area is irrelevant.” Finally, we are seeing these clients as central to our work as counselors.

Licensure: Tom took a first step toward counselor licensure in 1974, when he proposed licensure for counselors in an article titled “Licensure in the helping professions: Anatomy of an issue.” (More about this topic in the interview.)

Accreditation: Preparation standards are the foundation for counselors’ scope of practice and ethics. Accredited educational programs are crucial for professional creditability. The clear definition of standards directly impacts counseling curricula and staffing. Tom (1981-1987) and Jane (1994-1996) both chaired the Council for the Accreditation of Counseling and Related Educational Programs (CACREP). In addition, Jane almost single-handedly helped to establish a gerontological curriculum, competencies and CACREP specialty through Administration on Aging grants. She also won approval from the National Board for Certified Counselors (NBCC) for a national certification in gerontological counseling. Sadly, neither of these specialties exist today within CACREP or NBCC.

Chi Sigma Iota (CSI): In 1985, Tom and Jane established the first counseling honor society chapter (Alpha) at Ohio University. Both served as president and executive director of CSI. CSI has more than 130,000 initialed members, has chartered more than 400 university-based chapters, and is the third-largest active membership organization in the counseling profession.

Since its inception in 1985, CSI has returned over $1.7 million to university chapters and members through rebates, awards and grants. Its goal is “to promote a strong professional identity through members … who contribute to the realization of a healthy society by fostering wellness and human dignity.”

CSI’s leadership style is based on Robert Greenleaf’s philosophy of servant leadership — i.e., one serves to benefit the greater good of others rather than for self-interest.

Wellness: Jane and Tom began their work related to wellness in the 1980s. Through their research, writing and teaching, they helped provide a foundation and focus that increasingly defines what it means to be a professional counselor.

A gallery of portraits of American Counseling Association presidents is featured in a hallway at the ACA headquarters office in Alexandria, Virginia. Jane Myers is visible in the middle row, second from right. Photo by Bethany Bray/Counseling Today

An excerpted interview with Tom Sweeney

Allen Ivey: Could we turn to those basic important struggles you had in the early days?

Tom Sweeney: Looking back, sadly, I had thought that we could be both collegially professional counselors and psychologists. As background, I have a minor in counseling psychology, belonged to the counseling psychology Division 17 [of the American Psychological Association until the mid-1970s], and was a licensed psychologist because we had no Ohio counselor licensure yet. I worked early on, and even as president of ACES (Association for Counselor Education and Supervision) and ACA, to build cooperation and dialogue with Division 17, AAMFT (American Association for Marriage and Family Therapy) and other groups. Jane did as well during her term as ACA president. Cooperation was not forthcoming, and psychologists have consistently fought to stop or limit counselor practices. Many still do today.

ACA supported starting NBCC because we knew the battle would be long and hard fought. Now all states have counselor licensure, but the battles in the marketplace continue.

Mary Bradford Ivey: You and Jane have been central in leading and supporting state-by-state licensing, CACREP and Chi Sigma Iota. These are awesome contributions that have made counseling a full profession. How did all this start for you?

Tom: The short answer is I learned in my doctoral studies that counseling was an “occupation,” not a profession. From my early leadership years, I sought to bring counselors into the family of helping professions through counselor credentialing, standards of preparation, ethics and accreditation.

When I wrote the first article on “Licensure in the helping professions: Anatomy of an issue” (1974) for the APGA journal, we were far behind psychologists. The Ohio state psychological board was new and aggressive in asserting its authority. The next year, I was commissioned to write what became the APGA Governing Council-adopted position paper on counselor licensure. I chaired both the first SACES (Southern Association for Counselor Education and Supervision) Licensure Committee (1972) and then the APGA Licensure Committee (1975-77). As a consequence, I networked with counselors all over the country who were being impacted by psychologists’ efforts to advance their members’ practices. I traveled, spoke and testified on occasion at legislative hearings.

I can still recount the aggressive actions of psychology licensing boards. The most notable case for me was the state of Ohio psychological board having an African American Ed.D. counselor arrested on felony charges for providing assessments for parents whose kids couldn’t get tested for special ed placements. I got personally involved, and we (APGA) sent a friend of the courts brief. The judge dismissed the case but made no ruling.

Another case in Virginia got a favorable review by the judge, and Virginia became the first state to have counselor licensure as a result. A member of our licensure committee, Carl Swanson, was instrumental in both of these cases. Every state attaining licensure was different thereafter, and literally hundreds of counselors made it possible.

Allen: And then there is CACREP, a necessary foundation for our profession. You and Jane were central here.

Tom: As president-elect of APGA/ACA, I knew that without accreditation, licensure efforts would be even more difficult. I am pleased to say that I made the APGA motion to adopt the ACES Standards for Counselor Education for the first time ever. Until then, there were no recognized APGA-endorsed standards.

As President, I wrote the position paper establishing CACREP. Joe Witmer was CACREP’s first executive director, and I was the first chair for CACREP’s initial, critical, formative six years. Lots of stories associated with these early years. Deans of colleges openly opposed us.

One of our most important tasks was revising standards in those early years. CACREP is accountable to the members of the profession and the public that we serve through the process of standards revision and implementation. Change in higher education moves slowly because of tradition, expense and reluctance to create unintended consequences. I don’t think we as a profession are unique in this regard. Of late, some might argue that change has gone too quickly in some regards, especially related to online education and its entrepreneurial rise to power in higher education. Not just in our field but in the medical field and others as well.

Nevertheless, the role of CACREP is critical as a foundation for helping to define our scope of practice. In some ways, CACREP helps us define what is meant by “professional counseling.”

Mary: Why was NBCC started?

Tom: NBCC was established because those of us immersed in the licensing efforts knew it would take a long time to establish professional counselor credentials in every state. The Federal Trade Commission was pursuing other professions with too closely enmeshed membership, accreditation and national credentialing bodies, so we opted to keep CACREP and NBCC apart from ACA, even though ACA (APGA) supported each startup with funding and office space.

As APGA president at the time, I remember my Governing Council subcommittee wanting to delete a budget for continuing such an effort. I intervened and got it reinstated by having the committee conduct a survey asking members what they thought. It got the largest mail survey result of anything AGPA had attempted before — and members wanted their membership association to support their accrediting and credentialing bodies.

Mary: What does NBCC do for us professionally?

Tom: When we first conceived of what then was called national “registers of service providers,” we thought it would fill in as a credential for those members who had no prospect of a state license for years to come. Once licensure was established in all jurisdictions as it is now, we thought the national credential would fade away.

I’m probably not the one to ask, as my involvement over the last decades has been limited to some collaboration between CSI and NBCC. Under the leadership of Tom Clawson, NBCC’s advocacy and outreach programs have gone far beyond whatever we could have imaged in 1982. As with Carol Bobby’s CACREP leadership, they have advanced counseling as an important partner in promoting professional counseling throughout this country and abroad.

Allen: And along with all that, you and Jane founded our profession’s honor society, Chi Sigma Iota.

Tom: Yes, Jane had started the Rho Chi Sigma rehabilitation counseling honor society. It was small, modest numbers, of course, but she made those students feel special through her style of mentoring. When I say her mentoring, a few years ago, the winter edition of the Journal of Counseling & Development (JCD) had articles by six of Jane’s graduates. Last year, five received various national awards. We all learned from the very best! This is the kind of mentoring that she helped model in CSI.

So, witnessing Jane’s honor society chapter spirit, I saw its potential for the profession as a whole. Many faculties in other programs were struggling for a professional identity, so I decided to create a way for students, faculty and graduates to claim their professional identity through an honor society dedicated to all counseling specialties, all degrees, etc. We mailed one letter of invitation to counselor educators across the country, and we never needed to send another.

Today, programs seeking CACREP accreditation also want CSI chapters since we are known to be co-curricular partners within counselor education programs. For example, the CSI Executive Council recently adopted a position of leadership and advocacy for counselor identity and wellness that will find its way into all of our chapters and beyond.

Mary: I recall clearly Jane’s 1990 presidential address on wellness over the life span. It was exciting, as I was once a physical educator in the Madison, Wisconsin, schools, where health had been central to my work. And on hearing Jane’s address, I immediately understood what needed to be done to support her direction. My work with Allen on therapeutic lifestyle changes was reinforced by her ideas.

Tom: Yes, Jane was a visionary. As president-elect (1989-1990), she got a resolution passed to state unequivocally AACD’s “support for the counseling and development profession’s position as an advocate toward a goal of optimum health and wellness within all of our society.” It was about this time that our wellness research was just getting off the ground. With our Ohio University colleague Mel Witmer, we developed the WEL inventory and began collecting data for Jane’s database.

Allen: Tell us more about your and Jane’s solid research and work on wellness and assessment instrumentation.

Tom: With substantial help of a world-renowned statistician, John Hattie, we used Jane’s database of several thousand subjects to conceptualize an empirically derived Indivisible Self Wellness Model (ISWEL) and to create the Five Factor Wellness Inventory (5F-Wel). With Jane’s help, I was able to use Adlerian theory to provide practitioners and researchers with concepts and means to advance their clinical and scholarly work based upon a practical theory and sound empirical model. The instrument has been translated into over a dozen languages.

An article in JCD (2020) with Laura Shannonhouse as senior author affirms the usefulness of the adult 5F-Wel. After a rigorous screening process of over 100 studies down to 59 that met their criteria, the authors reaffirmed that it is suitable for both research and clinical practice. There were insufficient reports as yet for teenage and elementary reading levels.

I continue to receive what had been Jane’s correspondence from individuals from all over this country and abroad in counseling, education, psychology, nursing and medicine. Our instruments and empirically based Indivisible Self Wellness Model are cited far and wide beyond our field.

Mary: The four of us had the pleasure of writing a book that brought counseling, wellness and development into an integrated package. As we conclude our discussion, it might be helpful if we talked about the “how” of a developmental/wellness-oriented counseling and therapy practice.

Tom: Like you folks, Jane and I became convinced that holistic wellness was a better construct from which to define counseling goals and outcomes.

Our Indivisible Self Model has 17 factors (e.g., positive humor, thinking, nutrition, etc.) that practitioners can incorporate into any client’s treatment plan regardless of the presenting issues. Rather than focus only on problems, we focus on client strengths and what they can do now to take steps toward optimizing the totality of their quality of life as much as possible.

Counseling has long been a wellness and positive development profession. Both developmental counseling and therapy (DCT) and Adlerian practice focus on the strengths one finds in all clients. Both are fully aware of social influences in the session. Wellness is central to both and has its own proven system to encourage demonstratable therapeutic lifestyle changes. One does not need to embrace all the tenets of Adlerian or DCT to effectively implement a wellness counseling approach, but if you do, it certainly will help.

 

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Allen and Mary Bradford Ivey have written, keynoted, and presented workshops throughout the world for nearly 40 years. Allen is distinguished university professor (emeritus) at the University of Massachusetts, Amherst. Mary has been recognized nationally as having developed one of the top 10 guidance programs in the United States. Both have been honored as fellows of the American Counseling Association. Allen and Mary were also founders and former president and vice president of Microtraining Associates, an educational publishing firm focusing on counseling and therapy skills and the first in the nation to present educational videos on multicultural approaches to counseling and therapy. Contact them at allenivey@gmail.com.

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

Life after cancer

By Laurie Meyers April 29, 2020

To the uninitiated, a favorable cancer prognosis may appear to follow a challenging yet relatively linear path ending on an upward trajectory: diagnosis, treatment, elimination, champagne.

After all, what’s not to celebrate? Treatment is over! You’re cancer-free! Everything is great! You may now return to your regularly scheduled programming.

You are ecstatic, right?

For most people completing cancer treatment, the answer is: It’s complicated. And bewildering, because almost no one talks about the messy reality of “after.”

These are some of the unspoken truths about life after cancer:

  • The end of treatment is a cause for celebration and a time of uncertainty and fear.
  • The end of daily, weekly or monthly medical visits can leave patients feeling as though their safety net has been removed.
  • The emotional support that patients receive from those around them may shrink — sometimes dramatically — once their cancer is “gone.”
  • Surgery, chemotherapy and radiation may be over, but treatment is not; patients still require regular scans and, in some cases, pharmaceutical maintenance regimens.
  • Pain, neuropathy, fatigue, mental fogginess, physical restrictions and other side effects often last long after treatment is completed.
  • After months or years of focusing on cancer, survivors can struggle with a sudden loss of structure and purpose.
  • Physically or metaphorically, cancer patients have lost pieces of themselves.
  • Scars, hair loss, skin changes, bloating, weight gain or loss, medical devices such as intravenous ports or ostomy bags, and other changes in appearance frequently have a negative effect on body image.
  • The physical and psychological effects of treatment can cause lasting intimacy issues, both physically and emotionally.
  • A professional clinical counselor can be the one person who never tires of hearing about the individual’s cancer experience and helps the individual make meaning of that experience and find their new “normal.”

Seeking solid ground

Cancer patients are often surprised by their reaction to the last day of treatment, says licensed professional clinical counselor Cheryl Fisher, a private practitioner in Annapolis, Maryland, whose specialties include counseling clients with cancer. Most cancer clinics have some kind of ceremony — a bell to ring or a certificate to present — so there is a feeling of celebration, she notes.

But then? Fisher says these patients often have a sudden realization: “Oh, crap. Now I’m on my own.”

The medical support group that has sustained those in treatment week after week, month after month, suddenly is no longer there, notes Fisher, a member of the American Counseling Association. Yes, the physicians and nurses are still available, but those reassuring regularly scheduled visits that provided a consistent sense of forward momentum are over, leaving patients unsure of what comes next and whether they’ll truly be OK.

During treatment, patients are essentially swept along, focused on navigating the tasks placed in front of them, Fisher explains. “What do I do next? What do I do next? OK, tell me what do I do next?” she says. “You’re just going through the motions almost on autopilot.”

And then, suddenly, the merry-go-round stops, and survivors are left standing still, yet psychologically awhirl with everything they’ve lived through. “Your body, your mind, your neurology is still trying to catch up with all that has happened,” Fisher says. “You’re still processing it.”

ACA member Mary Kathryn Rodrigue, a licensed professional counselor who specializes in psychosocial oncology with a focus on young adults, agrees. Many of the clients who come to her practice after completing cancer treatment are just beginning to process their grief, she explains, because they felt compelled to put everything else — financial worries, job concerns, questions about fertility, relationship concerns — on the back burner during treatment.

Rodrigue, founder and co-owner of The Wellness Studio, located in Baton Rouge and Covington, Louisiana, uses the Functional Assessment of Cancer Therapy-General, a scale that measures physical, social/family, emotional and functional well-being, to help determine her clients’ needs. In addition, she administers standard depression and anxiety assessments.

Many of her clients present with anxiety surrounding “what if” scenarios. Rodrigue describes exploring these fears as “peeling back layers of an onion.” Follow-up tests are a frequent source of anxiety. “I have a scan coming up. … What if the doctor doesn’t call right away? How will I cope?”

Rodrigue frequently uses journaling with her clients and says that “worry journals” can be very effective. “It’s allowing you to tangibly take that worry that feels like it’s on a ticker tape and put it somewhere else,” she says. Clients might also use their journals to play out the worst-case scenario, imagining that a scan shows evidence of cancer, taking stock of their support systems, and attempting to formulate a plan. Examining that fear and planning possible responses keeps clients from “back burnering” their fears and letting them build momentum, Rodrigue says.

She also teaches clients mindfulness and grounding techniques such as environmental awareness — noticing the temperature of a room, focusing on the feel of clothing against the skin, and identifying the textures and tastes of the food they are eating, for example.

Fisher, who is also the director of the online master’s program in clinical counseling for the California School of Professional Psychology at Alliant International University, says scan anxiety is a constant concern for many of her clients, some of whom face scans every three months. When the first scan comes back clear, Fisher says, clients begin “just testing the toe on the water, trying to gain some semblance of this new normal. What does it look like?” But then, as the next scan time approaches, their anxiety amps up again. Fisher helps clients develop tools to manage their fears without derailing the process of reengaging in life.

She recalls one client whose scans indicated a small recurrence of cancer on the lung. “There’s this little, teeny, tiny spot. It’s not growing fast. They’re actually not going to do surgery. They’re just going to watch it,” Fisher explains. And, so, the client had to make peace with the unknown.

Fisher asked the client what she was feeling.

“I’m afraid,” the client said.

“OK, great,” Fisher responded. “Acknowledge that you’re afraid. Call upon it, sit down, have a conversation with it [through journaling or self-talk]. What’s the fear about? What’s the greatest aspect of the fear? What is it telling you, teaching you? How would it ask you to live your life differently now, with the unknown? What would that look like?”

The client was anticipating the birth of her second grandchild and was afraid that she wouldn’t be around to experience it. So, Fisher asked the woman to think about how her plans might be altered by knowing there was no guarantee she would be in the child’s life. The client decided to make some preparations for the birth of the child. She had previously been putting off her plans, paralyzed by fear of the unknown. As it turned out, the woman’s follow-up scan showed no sign of any growths.

“What we do with fear,” Fisher says, “is tell fear, ‘OK, I know you’re going to co-journey with me around this. I know you’re going to be there, but you cannot lead it. You cannot be the leader of my life. What I’m going to do is … to pull you out periodically. We’re going to have a conversation. I’m going to allow myself to experience you, cry, be angry, journal, do some work around it. Then I’m going to tuck you back in and tell you [that] you have to walk beside me, not in front of me.’”

Fisher emphasizes that this intentional practice allows clients who have experienced cancer to decide what is essential — the nonnegotiable things they want to experience no matter what.

All that you can’t leave behind

As clients learn to negotiate their fears and reengage with life, they will inevitably need to reevaluate. Everything. But especially the people in their lives.

“Your whole world turned upside down,” Fisher asserts. Clients’ perspectives are altered — sometimes radically — by what they’ve been through. “Now you’re really evaluating people, places, things, and how they’re serving you in your life,” she explains. When assessing relationships, clients are seeking reassurance that the people around them are able to allow them to move forward while still understanding — and respecting — the radical life changes cancer has brought on.

Rodrigue was struck by a presentation she attended in 2019 on issues affecting young women with breast cancer that described three different categories of relationships and the need — particularly in times of significant change — to do an inventory of the people in one’s life and where they fit. The first category comprises the closest relationships — those built on unconditional love in which people willingly make sacrifices for each other. The speaker emphasized that it is essential not to have too many of these relationships because it is easy to spread oneself too thin. The second category consists of reciprocal relationships — people who do things with you and for you, Rodrigue says. And the third category of relationships includes people in your life by default — family members, friends you’ve known for a long time, individuals with whom you were brought together by a crisis or a project, etc.

Major life changes and shake-ups tend to call attention to those relationship lines, Rodrigue says, explaining that it is not uncommon for people who have recently gone through cancer treatment to feel anxious about their relationships. She encourages clients to ask themselves several questions: What is driving their anxiety? How are relationships not meeting their expectations? Is there a lack of reciprocity? A tendency to be unavailable or unsupportive? Perhaps a previously unnoticed pattern of negative and undermining comments and behavior? Is the pattern a new development caused by a change in friendship dynamics, or was the relationship never based on equal footing?

In many ways, cancer survivors have an even greater need for support once they’ve finished treatment. Not knowing whom to count on or being betrayed by someone who seemed like a trusted ally can have a significantly detrimental effect on clients’ emotional and physical health. Taking a relationship inventory that allows clients to recognize the need to “refile” or even release a relationship can reduce anxiety and help eliminate unnecessary conflict.

Both Rodrigue and Fisher say another significant challenge cancer survivors encounter in their relationships is everyone else’s need for them — the patient — to be “OK.” But they’re not. At least not all of the time.

This inability on the part of others to consider the person as anything less than “good as new” sometimes comes from a place of selfishness or ignorance, but it can also come from fear, Fisher says. Those close to the client have endured months or even years fearing the loss of their loved one, so they desperately want to believe the person will be fine, she explains.

And cancer survivors often want to ease that burden, to say they’re fine even when they’re not, Fisher continues. “Oftentimes, we still are in that protective role, where we’re like, ‘Yeah, yeah. I’m good. I’m fine,’ rather than saying, ‘You know what? I could still use a weekend away,’ or ‘I don’t know if I can take on my full life right now in one swoop.’ … So, now it’s like, OK, on your mark, get set, go. It’s too much. It’s overwhelming.”

This is where counselors need to step in and educate their clients. Fisher tells her clients that their A-game no longer looks the same; that there is no “back to normal” — inevitably, it is a new normal; and that finding secure footing on the path forward takes time. People will want to assume that the person who went through cancer treatment is fine, so it is up to that person to set boundaries, to let others know when they need time off or to say, “I can’t deal with your bull,” Fisher asserts.

Sometimes, helping clients manage others’ expectations requires bringing in the third party. Fisher had a client who was a cancer survivor and a widow. The woman’s daughter would come to town to visit and had a hard time hearing that her mother had bad days. During one of these visits, the client asked Fisher if she could bring her daughter to a counseling session so that they could work on expectations together.

“That was where, of course, the daughter was able to break down and say, ‘I’m scared. I can’t stand the idea of seeing Mom vulnerable. I have to see her as super mom,’” Fisher recounts. “Mom is crying, saying, ‘I would love to be that super mom, but that’s not my M.O. anymore. I learned that trying to be super mom actually was killing me. I need you to know honestly that some days are great, some days are not great. I need to have the ability to do what I need to do on those not-so-great days without worrying that it’s upsetting you.’”

The elephant in the room

Life after cancer treatment means reengaging not just in platonic relationships but in intimate ones as well — if and when the survivor is ready, Fisher says. Again, it’s complicated.

Survivors are scarred and often not comfortable in their bodies, Rodrigue explains. It’s hard to reclaim your body when part of it is missing, especially in cases with mastectomies, she continues. Survivors need a safe mental health setting in which they can express their rawness and grief over the loss.

Fisher notes that breast cancer survivors with hormone-positive cancer grapple with an additional complication — hormone-blocking pharmaceuticals such as tamoxifen or aromatase inhibitors. Tamoxifen usually forces women into early menopause and the physical aspects that come with it, such as hot flashes, dryness and discomfort.

Many survivors aren’t even ready to think about a sexual relationship at that point, but if they have a partner, the topic comes up sooner rather than later, Fisher says. For women who don’t have partners but are interested in a sexual relationship, the process of finding one may feel more complicated. Fisher quotes one client as an example: “The next time I’m going to be sexually intimate with somebody, I’m going to have to feel safe enough to tell my story.”

“It really requires trust to be able to expose the scars, talk about the scars, experience a relationship with somebody in the scars,” Fisher says.

Too often, survivors struggle alone with reestablishing their sexuality. Even clinicians are often hesitant to address sexuality after cancer, Fisher says. She asserts that counselors should be asking these clients about their body image and their identities as sensual and sexual persons.

“Talk to me about what you’re experiencing now. What are your fears? What would you like it to look like?” Questions like these will open the door and allow clients to talk about their sexuality, Fisher says.

Counselors should also make sure they are up to date, comfortable with and educated about the aftermath of cancer treatment and reengaging in sensual, sexual, and body image components, Fisher says. “Sexologists, sex therapists are excellent resources,” she suggests. “The interesting thing is, finding them is kind of challenging at times. [Find] out who’s in the area so you can refer clients. Then, hey, you know what? Normalizing [with clients]. This is really normal stuff.”

She also recommends that counselors consult with physical therapists who are knowledgeable about pelvic rehabilitation. “They educate you from A to Z in terms of what could possibly be interfering with both physical and sexual functioning.”

Again, it is about getting clients back into contact with their “new bodies” and embracing the changes — not just in terms of sexuality but in redefining their own beauty, Fisher says. She finds yoga and breathwork to be particularly effective ways for clients to reconnect with bodies that they may feel betrayed them.

Rodrigue has had many clients tell her that they no longer feel beautiful or even functional. It was such a common refrain that when it came time for her to open her practice, she made a specific request of the interior designer — a friend and former Project Runway winner. “Everything is made from repurposed materials, stuff people threw away,” she says. Rodrigue encourages her clients to see themselves in the materials — not broken but rather remade with a new purpose.

Fisher has a similar view of the healing process. “When is it over? I don’t think it’s ever over,” she says. “I think you just get to the other side of it, and it’s repositioned and informed your life. … Just because the treatment is over doesn’t mean the processing and healing are over.”

 

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Laurie Meyers is a senior writer for Counseling Today. She was diagnosed with breast cancer in February 2019 and finished active treatment this past January. Her discovery that there is no survival guide for life after cancer inspired this article. Contact her at lmeyers@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.

The psychosocial impact of COVID-19 on Asian Americans: Counselor interventions and considerations

By Adrianne L. Johnson April 27, 2020

April is Counseling Awareness Month, and every year, counselors dedicate efforts to promoting our profession through evaluation of service delivery, community promotion, and increased legislative advocacy efforts. This year, counselors are faced with an unprecedented challenge: to promote mental health while transitioning to telehealth session delivery, modeling physical distancing while closing cultural mental health gaps, and connecting clients with services from their own homes.

This is a critical time in our profession’s history, and we are needed now more than ever. Treatment is now largely shifting to a triage approach as counselors move to the front lines in psychosocial stabilization amid fear, isolation, anger, anxiety and depression.

One population being alarmingly affected is the Asian American population. The novel coronavirus global pandemic has observably spurred a stark increase in violent attacks on people of Asian descent. Xenophobic racism against Asian Americans has surged as the coronavirus sweeps the U.S., with reports of hate crimes averaging approximately 100 per day, according to Rep. Judy Chu (D-Calif.).

Counselors are now called upon to address the concerns of this population in our practice. Knowing the multicultural considerations of this population, and prioritizing culturally sensitive treatment approaches, has become an essential service now and for the foreseeable future.

Counselor advocacy

Through advocacy, we are able to influence the creation and delivery of transformative initiatives and programs that offer immediate and long-standing benefits to our clients. For example, we may lobby legislators to implement targeted mental health screening of at-risk populations, including clients with prior mental health diagnoses. The psychosocial needs and responses of Asian populations will be unique, and interventions should be trauma-focused, including components of building social support and community resources.

Address terminology: On March 20, the U.S. Commission on Civil Rights voted to issue a statement expressing “grave concern” regarding “growing anti-Asian racism and xenophobia” related to the coronavirus pandemic. The commission suggested that using terminology such as “Chinese coronavirus,” “Wuhan flu” and “Yellow Peril” was fueling xenophobic animosity toward Asian-Americans. Using racially based language to describe a pandemic attaches ethnicity to a viral outbreak and contributes to the instigation of race-based assaults.

We have an ethical obligation as counselors to redirect the language of our colleagues and to address this language with our clients as our approaches and frameworks allow. Using proper, professional terminology for this pandemic and directly addressing defamatory language with clients can expand a culturally humble dialogue and allow clients to explore their fears and anxieties in the safety of our offices.

Offer trainings: We may also use our expertise to offer site training in trauma and crisis response to help educate the public and health care workers about how best to deal with the immense pressure and anxiety of Asian American families. This may help minimize the detrimental psychosocial response in these times of crisis.

The American Counseling Association has compiled a comprehensive database of trauma resources and continuing education opportunities for counselors. ACA states that “disasters tend to stress emotional, cognitive, behavioral, physiological, and religious/spiritual beliefs.” Among the tools provides are external trauma and disaster resources, disaster mental health resources, sheltering-in-place resources, and trauma-related articles from Counseling Today. The database also offers information on resiliency, grief, and helping survivors manage skills and healing.

Educating our colleagues on the disaster impact and recovery model has particularly relevant and important applications at this time. This model incorporates several phases of assessment and identification of trauma stages preceding anticipated grief.

Client interventions

Asian Americans are experiencing exhaustion from elevated fears of harm beyond microaggressions outside of the home. Stress-based responses to dramatic environmental changes often lead to a dissolution of coping skills that previously have served as protective factors for Asian American clients.

As global attention is largely focused on the active physical treatment and recovery of patients on a medical level, the cultural considerations of specific populations have largely been left unaddressed. Many symptoms of post-trauma will not present for several months. Until then, we can rely only on our knowledge of disaster models to meet the needs of these clients.

Currently, our focus should be on intervention and prevention through building resiliency, developing community support, and encouraging social connectivity during physical distancing. Consider the following suggestions:

  • Encourage individuals of Asian descent to reach out to one another through social media and other technologies to share experiences and feelings related to these fears and exposure to aggressive acts. It would be helpful to suggest joining an Asian American online community or advocacy organization to build feelings of self-agency and empowerment.
  • Introduce mindfulness. When our clients notice sensations in their bodies such as a tightening in the chest or quickened heart rate, the observation of these feelings can build insight into the triggers. This helps clients develop awareness and a heightened sense of mind-body connection. Introduce mindfulness activities such as breathing, body mapping, and concentration to help clients focus on emotional balance. When in public, clients are more likely to access rapid-action options when they are calm, instead of habitually relying on immediate defensive or avoidant impulses.
  • Directly address symptoms related to depression, anxiety and hypervigilance. Discussing these symptoms and suggesting evidence-based practices to aid in restoring rituals, connecting with family and friends, and incorporating spirituality may offer critical tools to prevent symptom-related impairment.
  • Prompt clients to lean into literature, such as Grace Lee Boggs, Maxine Hong Kingston and Thich Nhat Hanh. Understanding how others of Asian descent have persevered through pain and difficulty is emboldening in a time of isolation and disenfranchisement.
  • Be ready to discuss and disseminate resources on financial help, vocational disruption or academic distress, and maintenance of a cohesive family environment. Have handouts and weblinks prepared, phone numbers for emergency help and response, and community locations that will aid clients if they are in active crisis and cannot reach authorities or hospital treatment centers in their areas. As this public health crisis escalates, it is critical that Asian American clients have multiple resources on which they can rely for a sense of needed safety and security. 

Suicide prevention

The potential for suicide cannot be overlooked in this vulnerable, targeted population. Suicide screening should be done early and often. In Asian American clients, warning signs of suicidal ideation are often ignored because of stereotypes associated with Asian ethnicity. Counselors should approach the issue from a culturally informed perspective and consider intergenerational influences, pressures of perfection, collectivistic values, and the attributed image of being a “model minority.” The pressure of cultural expectations is elevated in times of severe stress and trauma exposure, and counselors should be direct when assessing risk factors, protective factors and treatment options.

According to the U.S. Department of Health and Human Services Office of Minority Health:

  • Asian American females in grades 9-12 are 20% more likely to attempt suicide compared with non-Hispanic white female students.
  • Southeast Asian refugees are at risk for posttraumatic stress disorder (PTSD) associated with trauma experienced before and after immigration to the U.S. One study found that 70% of Southeast Asian refugees receiving mental health care were diagnosed with PTSD.

The American Psychological Association offers additional data:

  • Suicide is the second-leading cause of death for Asian Americans ages 15-34, which is consistent with the national data across all racial/ethnic groups (the second-leading cause for those 15 to 24 years old and the third-leading cause for those 25-34).
  • Among all Asian-Americans, those ages 20-24 have the highest suicide rate (12.44 per 100,000).
  • Among females from all racial backgrounds between the ages of 65 and 84, Asian Americans have the highest suicide rate.

Counselors should remember the importance of confidentiality and informed consent as a delicate balance between rapport and mandated reporting. Two tools to consider using in suicide screening are the Collaborative Assessment and Management of Suicidality model and the Suicide Intervention Response Inventory−2.

Other counselor considerations

Compassion fatigue. Effectively managing our own emotional responses to trauma has been a focus of training and continuing education for professional counselors. As of today, the majority of counselors have transitioned to providing online telebehavioralhealth services to their regular caseloads and have taken on additional responsibilities in their communities, including providing crisis intervention for individuals whose exposure to sudden violence has superseded their ability to cope effectively.

This presents unique challenges for counselors who are experiencing multiple pressures to fulfill additional responsibilities for decompensating clients and new referrals. It is not uncommon for counselors to feel physical, emotional and psychological fatigue daily due to our deep concern for the safety and well-being of our Asian American clients during the current circumstances. Dennis Portney (2011) described compassion fatigue as “burnout plus the accumulation of stress resulting from empathizing with clients over time.” Compassion fatigue may appear suddenly and feel pervasive, interfering with normally ascribed self-care routines. To combat compassion fatigue, counselors need to affirm for themselves that commitment, not perfectionism, is the key to maintaining energy during this time.

Self-care. Counselors should consider the work they do as essential, necessary and sacred. And we cannot minimize, trivialize or dismiss our own emotional trauma-based reactions through overidentification and countertransference. We should commit to honor ourselves and our mental health, just as we do with our Asian American clients, and monitor our investment in their care within this framework. As our resilience wears down, we may see our usual compartmentalization skills regress into exhaustion, anxiety, impaired sleep, and reduced investment in client care.

Another important application of self-care is diligently reminding ourselves to practice what we preach. We need to apply our prescribed coping skills to our own daily routine during this time. Yoga, breathing techniques, visualization, and staying connected with positive, supportive groups builds our resiliency and reminds us of Irving Yalom’s key principle of universality. The incorporation of coping skills that Asian cultures embrace are applicable to our own lives and will ease our own trauma-based reactivity during this time.

Promoting posttraumatic growth for ourselves and our clients In the Counseling Today article “The transformative power of trauma” (2012), Lea Flowers and Gerard Lawson suggest that positive psychological change experienced as the result of a struggle with highly challenging life circumstances can lead to personal transformation as a by-product of the traumatic experience itself.

Focusing on the client’s growth, and not just the circumstances of xenophobically based violence, can help Asian American clients deliberately build a repository of demonstrated strengths and skills to help them reframe their experiences. These reframes will shape their reactions to future traumatic events and build emotional, psychological and mental resilience.

In the words of Lawson, “This is right in our wheelhouse as counselors. What are the strengths that this person continues to demonstrate despite their traumatic experience? We need to be deliberate about highlighting those for our clients.”

And ourselves as counselor.

 

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Adrianne L. Johnson is a licensed professional clinical counselor supervisor and an associate professor at Wright State University in Dayton, Ohio. She is the past president (2018-2019) of the Ohio Counseling Association and the executive editor of the Journal of Counselor Practice. Contact her at adriannejohnson@gmail.com.

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

Exploring the ties that bind

By Bethany Bray April 24, 2020

Family therapy pioneer Virginia Satir famously said, “If we can heal the family, we can heal the world.”

Satir believed the family to be the “factory” where all people are made. She was among the first to champion an idea now commonly acknowledged among counselors: A person’s family of origin and family relationships influence that individual’s health, personality and life patterns — and, when explored in therapy, provide a fuller picture from which to help the client. That understanding can be expanded even further when the individual consents to involving family members in counseling sessions.

When considering whether it is appropriate to involve a client’s family in counseling sessions, “I look at what the primary focus of our work will be,” says Esther Benoit, a licensed professional counselor (LPC) with a private practice in Newport News, Virginia. “If the primary focus is on relational [issues], I want to bring in as many people as can possibly show up to sessions.”

Regardless of whether professional clinical counselors work with family groups, couples or individuals, an exploration of family issues can provide a more holistic picture of clients and what is contributing to their presenting issues.

Heather Ehinger, a licensed marriage and family therapist in Connecticut, urges practitioners to ask questions that dig into the traditions, boundaries and roles in the family systems in which clients operate. For example, perhaps clients perceive their role within their family to be that of the troublemaker or the placater. How did they arrive at that role? Is it a role that they desire
to inhabit?

“Using a family systems lens to treat anyone is very important,” Ehinger says. “Even if all you do is treat individuals … [using] a holistic lens, a family systems lens, in their assessment … will enrich any counseling that did not include that already.”

Trauma and transitions

Although discussing a client’s family background or involving family members in counseling sessions can enhance work with clients regardless of what brought them to counseling, there are a number of issues for which family work can be particularly helpful. The counselors interviewed for this article report that issues related to trauma and transitions — such as blending two families after a second marriage — come up repeatedly in their work with families.

Trauma, including past sexual, physical or emotional abuse, can often lead to problems with attachment in families, notes James Robert Bitter, a counselor educator who supervises graduate students at East Tennessee State University’s (ETSU’s) on-campus community counseling clinic. There is also the trauma of separation. Bitter says several students he supervises are counseling young clients who are in foster care or being raised by grandparents because their parents are incarcerated or struggling with addiction.

“[In] family therapy these days, in our area, we’re not working so much with children and families because they are structurally misaligned or have difficulty with psychiatric disorders. We are much more working with trauma and working with families to be more effective in how they raise children,” says Bitter, a professor of counseling and human services who specializes in family counseling and the Adlerian method. “When there’s been a rupture in attachment issues, helping clients [relearn attachment] in a compassionate way is hard. The people who have been traumatized are way outside the natural bond.”

Kristy A. Brumfield, an LPC at a group practice in Philadelphia, finds that working with families in groups can often help those who are struggling with transitions such as the arrival of a new baby, a move, or the particulars of co-parenting after a divorce.

Transition challenges can also crop up naturally as families grow and age, Benoit adds. For example, families may find that formerly established patterns that used to work well around the areas of discipline and boundaries begin to cause friction as children turn into teenagers. Professional counselors can serve as valuable sources of support and guidance as families take a step back and examine the patterns within their systems, says Benoit, who specializes in relational work with individuals, couples and families across the life span.

“Working through developmental things is huge [with families], as well as attachment and focusing on relationship patterns,” Benoit says. “Also transition points. Anytime there’s an expansion or contraction of a family system, that’s when people often seek help. It can be a birth, a death, a divorce or a blending of a family. Sometimes, what was working before is no longer working.”

Getting together

The term “family counseling” may invoke thoughts of the traditional nuclear family, with juvenile children and parents sitting together and talking with a clinician. This arrangement can and does happen, but family counseling also encompasses groupings beyond the immediate or traditional family unit. It can involve any constellation of family members willing to participate who are relevant to or involved in the family’s presenting issue and who could benefit from work on communication patterns and relationship issues.

When involving multiple people in counseling sessions, counselors must first identify who the client is and what that entails, including privacy issues. In some cases, the individual who first sought counseling will be the client; in others, a couple or the entire family group will be the client. (Find out more about this essential conversation in the 2014 ACA Code of Ethics, including Standards A.8. and B.4.b., at counseling.org/knowledge-center/ethics/code-of-ethics-resources.)

Benoit says she always begins counseling with family groups by fully explaining and defining the therapy relationship and letting the family decide if they would be comfortable with a group format. “I like to put the ball in the client’s court and give them a chance to decide if this modality feels right and will address what they want it to in counseling,” says Benoit, a member of the American Counseling Association.

Recently, Benoit received a call from a couple seeking counseling for their twin teenagers struggling with stress related to being in high school. The twins were both gifted and very bright. Benoit first met with the parents, without the twins, to learn more about the situation and to explore the family dynamics. She quickly saw that the family’s relationship was strong and healthy, which meant that wasn’t the issue of concern. Instead, the twins needed space to process some complicated emotions — feeling close and supportive of each other and yet sometimes simultaneously competitive with each other in academics, sports and extracurricular activities.

When Benoit had her first session with the twins, she talked over several options with them: individual work with different counselors, seeing her together for sessions, or having the entire family involved in counseling. Benoit stressed that if the twins decided to come to her together for therapy, they would need to stay together for sessions. She gave the twins time between their first and second sessions to think it over.

“Because of the uniqueness [of their situation] and how connected they were to each other, they felt it was most appropriate to be seen together,” Benoit recalls. “Ultimately, they decided that this felt like the best option [for them].”

Benoit emphasizes that this process will look different for each client and must be tailored to fit each client’s needs and presenting issues. For example, she has another set of juvenile siblings on her caseload who see her separately as individual clients. Their presenting issues are very different, and their counseling work does not overlap, so individual sessions work best for them, she explains.

The symptom carrier

Ehinger owns a group family counseling practice with two locations in Connecticut. Her staff of therapists is able to collaborate and co-treat family groupings and individuals within families who need counseling on separate issues simultaneously.

Frequently, in families, there is one identified person who is symptomatic and causes the family to seek counseling, such as a teenager with an eating disorder or a child with attention-deficit/hyperactivity disorder. Even so, the problem often runs deeper and affects the entire family. “The idea is that one person is holding the symptoms, but it’s not the only problem within the family system,” says Ehinger, an ACA member with a doctorate in counseling education and supervision.

This is especially common when couples have an unhealthy relationship or are going through a divorce, she says. Their child may be the one who is symptomatic, but the issue is rooted in the parents. “The child may be afraid to go to elementary school and has a lot of anxiety. The parents have talked with the school and find that it’s not anything academic, and the child is not being bullied,” Ehinger says. “Then we might find out from the parents that the father moved out two months ago, there’s a lot of fighting and there are lawyers involved. They may say, ‘We’re not fighting in front of the kids.’ [But] whether they’re fighting in front of the kids or not, this child is absorbing the energy and knows there’s something going on.”

Ehinger and a colleague at her practice co-treated a family in which a teenage son was identified as symptomatic. The parents initially sought counseling for the 16-year-old because they said he was grumpy and defiant, staying out past curfew, skipping classes and experimenting with substance use.

The teenage son started individual counseling with a male clinician at Ehinger’s practice. Because the practice specializes in family systems issues, the clinician viewed the teen’s troubles from a systems perspective and soon uncovered a larger challenge. The answers the teen gave to questions about his family life indicated there was tension in the home and that his parents were having trouble.

The family also had a daughter who was a freshman in college. When she came home for holiday break, she refused to return to school and started displaying defiant behavior and some of the other symptoms her brother had shown. As these challenges unfolded, Ehinger began working with the parents, while her colleague worked with their children. Sometimes they would all convene for sessions together, with four family members and two clinicians in the same room.

Ehinger’s conversations with the parents in counseling revealed that the couple had experienced an issue with infertility and that both of their children were adopted. The couple hadn’t resolved their grief over their infertility, and that contributed to them struggling with their adopted children gaining their independence and beginning to “launch” from home, Ehinger says.

Within a few months, the symptomatic teenager was no longer “the problem” — the couple’s marriage was, Ehinger says. The son’s symptoms dissipated as counseling helped him find autonomy, and he subsequently stopped acting out as often.

This family’s presenting issue was due to problems with attachment, Ehinger explains. “The parents hadn’t really grieved the loss of having the ability to have their own children. They were extremely sensitive to being ‘perfect’ parents. They felt they would be failures if they weren’t perfect parents to these adopted kids and were pointing fingers at each other out of frustration.”

The issue was exacerbated, Ehinger recalls, because the parents had large extended families with lots of children, so they felt inadequate and insufficient compared with their relatives.

Ehinger worked with the mother to boost her self-esteem and process her infertility grief in individual sessions. With the couple, Ehinger also focused on grief processing, as well as finding safety within their relationship. They talked about “how to be intentional with each other, how to relate to each other, what their idea of marriage is, and how they [could] be more intentional to get to that,” she says. She also provided psychoeducation on why transitions, including child development during the teenage years, are so hard for families.

Ehinger often uses narrative therapy with families, and in this case, it was particularly helpful. In this family, the narrative was that the husband and wife felt like “bad parents,” the son was the “troublemaker,” and the daughter had always been the “good one,” although she later struggled when she came home from college.

“We worked to change that story: The parents were not bad but hypervigilant. We taught them about attachment, normal teenage rebellion and helped them recreate the narrative of their family,” Ehinger says. “We talked about roles: How did [the son] get the role of the troublemaker? Did he want to keep it? Did he ask for it? Who would resist him shedding that role? What other role could he [and other family members] become?”

Uncovering patterns

Benoit finds structural family therapy and experiential family therapy helpful in her work with family clients. Both modalities focus on interaction patterns within family groups.

“A family’s whole systemic interaction pattern can be shifted by changing small behaviors. That’s why it’s so important to identify those patterns,” says Benoit, a full-time faculty member teaching online at Southern New Hampshire University.

One way counselors can encourage families to shift long-held and unhealthy patterns is to raise family members’ awareness of the roles they play within the system. “For example, sometimes one member will be the family’s harmonizer, smoothing over all conflict,” Benoit says. “Those roles often dictate how members interact in day-to-day interactions, but also during conflicts and transitions. Understanding the roles that are played and how those influence interactions can help challenge family members to explore alternatives and to try on new roles as their family systems grow and change over time.”

Benoit’s focus on patterns involves careful listening and close observation of the ways that family members talk and interact, both verbally and nonverbally, in sessions. This includes body language as well as the tone and subtext of what is said verbally. “I’m taking it all in,” she says.

Perhaps the family members always sit in the same order for each session, for example, or one child always sits with one parent and distances themselves from the other, or the children always look at their mother before saying anything. Often, families don’t even realize that these patterns are happening or that there might be deeper meaning behind them, Benoit says.

Her method is to gently point these patterns out to the family, framed by curiosity. Her approach doesn’t paint the behaviors necessarily as being bad, but rather just as something to ask about and gather more information on.

“With family counseling, families are coming to us to get information and feedback, so pointing out patterns can help,” Benoit says. “Over time, I might point [a pattern] out to the family and say, ‘This is what I’m seeing. Help me understand where this comes from, and how it helps in your relationship. … Tell me about what this behavior means to your family.’”

For example, a child may always sit between his mother and stepfather in session. What might this symbolize? Is it a physical representation of the bridge-building role the child plays in the family? Benoit would bring up this observation, framing it as a question or a “tell me more” prompt.

“It’s something to explore. It doesn’t always mean something, but it’s worth asking,” she says. “And I get it wrong all the time. Sometimes the family will say, ‘Gosh, no!’ and then it just helps me to learn more information” about the family system.

Behavior patterns within families can also be rooted in culture or context, Benoit adds. For example, a young child who always defers to his or her parents or waits to speak in counseling sessions can be exhibiting a sign of respect taught within the family or culture.

Uncovering patterns and the meanings behind them demands that practitioners be present and focused on each moment in session. It also requires keeping a curious mindset, Benoit says. “One of the reasons I love relationship counseling so much is that instead of working with one person, you’re working with multiple people. But more importantly, you’re working on the space between people,” she says. “It’s really dynamic and powerful work.”

Processing trauma

Bitter counsels clients with the internship and practicum students he supervises at ETSU’s on-campus counseling clinic, which offers free services to members of the community, many of whom have minimal or no health insurance coverage. Bitter says he starts thinking about other family members who could be involved in counseling work within the first session with a client. From his perspective, all issues that bring clients to counseling are family issues in one way or another.

“Everything is a family issue,” says Bitter, who will be publishing a third edition of his book, Theory and Practice of Couples and Family Counseling, with ACA this fall. “Instead of family or couples [counseling], a broader term might be relational counseling. From the moment we are born, we are in a relationship. We can’t survive without them.”

Bitter recalls one client whom he has counseled for multiple years (beginning when the client was 14), with various counseling interns also being involved in one-semester intervals. Initially, the client’s aunt contacted ETSU’s counseling center to request help for her nephew.

The client’s mother struggled with addiction and had been married four times, in addition to having multiple other relationships, all of which had been immersed in drug culture. The youth — the second of his mother’s five sons — had seen “a constant stream in his young life of drug dealers and men with whom his mother was having relationships,” Bitter says. By the time the boy was 5 or 6, he had taken on the role of unofficial parent and caretaker for his younger brothers. He would get them up and dressed in the mornings and make sure they had food to eat, and he would clean the house.

When he was 9, the boy and his older brother went to live with their father, who had alcoholism. There, the client also took on caretaking tasks for his brother and, to an extent, his father. Bitter notes that the boy would have to ask his father repeatedly for money to buy food for the household.

At one point, the youth called his aunt and asked if he could stay with her. The aunt took him in and called the ETSU counseling center for help. Initially, Bitter saw the teen as an individual client (at the teen’s request). But in sessions, the youth would claim that he was “fine” and never bring up anything to talk about.

“The trauma and neglect in this boy’s life led him to be depressed but also led him to be very secretive. He had a very, very hard time telling me what was going on in his life,” recalls Bitter, an ACA member. “When you grow up being a little boy who has to take care of everyone else, you have to present a really good face to the rest of the world and learn to act as if everything is fine, until it is not.”

Eventually, Bitter worked with the youth to involve his aunt and grandmother — the most supportive family members in the client’s life — in counseling sessions. In their work together, Bitter focused on ways to rebuild the teen’s broken family while removing the caretaking role he had shouldered for so many years. “I asked the adults to be a family, and the aunt and grandmother were willing to do that,” Bitter says.

A year and a half later, counseling began to include a focus on the teenager transitioning from living with his aunt to moving back in with his father, who had worked to get sober and secured a job as a landscaper. “The counseling center helped with that transition and rekindled relationship and also reversed the pattern of trauma [in the family],” Bitter says. “We helped him to live as a child again and rely on the adults in his life. Now he has an aunt, grandmother and father who are functionally caring for him.”

The teen will soon turn 17. He’s doing well but is “still careful and cautious in relationships,” Bitter says. “He has two good friends and can’t really handle more than that.”

The teen and family’s recovery came “after two years of [counselors] constantly seeing this family, encouraging them and literally teaching them how to talk to each other, helping them with how to respond to each other,” Bitter says.

Effective parenting

In addition to working through unresolved trauma, much of what Bitter focuses on with families in counseling is changing unhealthy parenting patterns. Parents often come to the counseling clinic at their wits’ end because of behavior problems with their children.

The world has changed dramatically over the past century, but parenting styles, on the whole, have not, Bitter contends. With what counselors know about attachment and the benefits of using boundaries rather than punishment with children, practitioners are well-equipped to offer psychoeducation to parents who are struggling, he says.

“The majority of people parenting today, when we’re at our best, we sometimes parent better than our parents did, but when we’re at our worst, we all parent at about the same level our parents did — and we have to assume they did the same thing,” Bitter says. “Most of parenting is teaching [clients] how to form really good bonds with children and help them grow and develop.”

Bitter says a counselor’s role is to offer guidance rather than explicit instructions or commands to parents. “I wait for the client to say what they did and then ask, ‘Did that work for you? How did it go?’ If you had to spank your child [multiple] times per week, then it’s not working. Let’s talk about what might work [instead].”

Counseling can also normalize parents’ challenges, sending the message that they aren’t alone in their struggles. “They get to see that they’re like every other family — if you have children, you’re going to make a mistake every day,” Bitter says. “Often, parents are doing a pretty good job but just need [extra] help. But those who are dealing with trauma, or dealing with a bond between a child and parent that has to be reconnected, that takes some time and patience.”

Bitter draws on a number of methods to help parents, including Jane Nelsen’s positive discipline approach, Michael Popkin’s active parenting system, the Systematic Training for Effective Parenting (STEP) program, and James Lehman’s Total Transformation trainings for parents. However, Bitter emphasizes the “natural consequences” concept when it comes to child discipline.

As a child, Bitter says he hated Brussels sprouts, but his father loved them, so the pungent vegetable often appeared on the family dinner table. This circumstance frequently escalated into verbal battles, with his father insisting that Bitter was going to eat Brussels sprouts and Bitter insisting otherwise. Use of the natural consequences philosophy can circumvent such parent-child power struggles.

“Now we know that if parents serve a variety of things and a balanced diet, over time a child will make good choices,” Bitter says. “If you make [healthy] food available, a child will eat it. I recommend that parents model good eating habits but not get into fights over what the child is or isn’t eating. [When a child refuses to eat something], say ‘OK, don’t eat that.’ The natural consequence is that the child will get hungry. If they say, ‘I’m not eating breakfast’ [with the rest of the family], a parent should say, ‘OK.’ The child will come back at 10 a.m. and say, ‘I’m hungry.’ The parent can respond [by saying], ‘OK, lunch is served at noon, and you’ll make it until then.’”

If these types of patterns are repeated often enough, children will learn from their experiences and realize the natural consequences of their choices, Bitter points out.

He gives another example: Perhaps a mother who is struggling with a defiant adolescent finds that the child pushes back on her instructions to come out of the mall to be picked up at 3 p.m., despite having been dropped off for shopping with friends hours earlier. Bitter says he would ask the client, “What would happen if at 3 p.m. [when the child isn’t there], you just pressed on the gas in your car and drove away?” When the child calls to ask why Mom isn’t there to pick him or her up, she can calmly explain that she was there at 3 p.m. but the child wasn’t. Now, Mom has other things to do but will return to get the child when she can, Bitter says.

The crux of this method is for parents to learn to control themselves, Bitter says. Once they learn and find control, their child (or children) will follow.

“This is not difficult stuff. It’s hard to put into practice but easy to understand. Part of this is just helping couples and families get there,” Bitter says. “It takes patience on the part of the parent. The parents we are seeing are extremely frustrated because what they’re doing isn’t working. … If you put these [concepts] into practice, [parents] will have a more harmonious life with their children. It’s just a question of getting started.”

Playing together

Brumfield is a registered play therapy supervisor and has used play therapy not only with children, but with adults and families, for 18 years. While play therapy with children is mostly unguided, Brumfield provides prompts and gentle guidance for the adults and families on her caseload, often in the form of games and activities. This can include asking a family to create a puppet show or to play out a story using puppets in session. Among the many benefits of this approach, Brumfield says, is helping adults “reconnect to the playful parts of themselves.”

Brumfield, a member of ACA, also uses music and art in her work with families. For instance, she might ask family members to draw their answer to a counseling prompt. Or she’ll pass out rhythm instruments and have the young children beat a pattern, while the parents are encouraged to add to it or to repeat it back to the children on their own instruments.

Observing how the family interacts during these activities tells Brumfield a lot about the relationships, patterns and roles within the family. For example, is one person dominant and leading the entire plan for the family puppet show? Or does everyone work on drawing on their own, almost as if no one else were in the room? “While watching them interact, I see the gaps and places where the family might grow,” explains Brumfield, who is also a counselor educator at Immaculata University in Pennsylvania.

In addition to in-session activities, Brumfield encourages families to make time for activities together at home. These can run the gamut from a game of hide-and-seek or a family bike ride to board games and puzzles. She recommends games that encourage conversation and that are cooperative rather than competitive. One of her personal favorites is the Ungame, a board game that directs players to answer various questions to encourage conversation but has no winner. Similarly, families can use a conversational card deck — a number of which are available online — to spark healthy discussion at mealtimes.

When it comes to “assigning” families activities to do outside of session, Brumfield likes to have each family member think of three things they would like to do together. “Children often have ideas readily, and the children are really the ones teaching the parents. I ask the parents to think of their own childhood and what they enjoyed or things they wished they were able to do when they were a child,” Brumfield says. “The primary goal is connection and helping them be more cohesive and work together.”

Boosting family connection typically involves taking a break from technology, Brumfield adds. She often requests that clients try to unplug during family activities. An exception is when technology prompts bonding, such as when a teenager invites his or her parent to play a nonviolent video game together.

Playful activity — inside and outside of counseling sessions — helps families to be less guarded with one another, Brumfield notes. It also boosts communication, joy and vulnerability. Parents might feel silly at first, and that’s a good thing, Brumfield asserts. She reassures parents that letting their guard down to play does not lessen their authority or diminish boundaries.

“When family members are more vulnerable, they’re more able to be seen. It can increase [the family’s] understanding of one another,” Brumfield says. “The children can see their parents differently — as more human. The parents are able to feel reconnected and able to have fun with their children, which can help balance more challenging times for families. … For younger children, mastery can be learned. It can be a confidence boost to be able to participate and learn to be a part of their family. For parents, they’re able to see the things that their children are capable of. Parents often want to do everything for a child, [and play] helps them discover what they can do for themselves.”

Brumfield encourages counselor practitioners to remember the power of play, regardless of whether they specialize in play therapy. “We all — counselors and clients alike — need to be connected with the playful parts of ourselves,” she says. “Remember the importance of humor in our work. It can even be a form of self-care. Think of play as a way to release, stay centered and help in other facets of life.”

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Families and technology

Heather Ehinger, a licensed marriage and family therapist in Connecticut, says conflict over technology use comes up over and over again in her work with families.

This includes fighting between parents and children (and among couples) about which technology is being used and how often. In addition, a couple may have differing views over the age at which their children should have access to technology (such as their own cellphone) or whether they should be allowed to have a computer or video game system in their bedroom.

The conflict that arises over one or more family members’ use — or abuse — of technology can be a flashpoint or an indicator of deeper issues. Technology isn’t necessarily what brings a family in to counseling, Ehinger says, but it’s often a contributor to their presenting issue.

“Technology is not the problem exactly, but it is part of the problem. It feeds into authority issues and discipline,” Ehinger says. “Technology is like a thorn in the family’s side, but it actually turns into the lens through which we see whether the family is functioning or not.”

Ehinger worked with one family who had a son in fourth grade. He was acting out at home, having tantrums and pushing back against boundaries with his mother, who was a stay-at-home mom. He wanted to play Fortnite all the time and would sneak his mother’s cell phone away from her to do so. She would find her son upstairs, still in his pajamas, playing the online video game when it was time to leave for school in the mornings.

This was partly a problem of overstimulation and obsession on the son’s part, but there was also a disconnect on the part of the mother, Ehinger says. Sometimes, disagreements over technology use are generational. In this case, the mother didn’t realize that her son was using the game as a way to socialize and communicate with peers. Adding to her frustration was the fact that she had previously worked in a corporate environment and was used to people listening to her, Ehinger observes. Now, as a stay-at-home mom, she was locked in a battle of wits with her young son.

When it comes to addressing issues of technology use, Ehinger says that psychoeducation about family roles and setting boundaries can be particularly helpful for families in counseling. She often talks with parents about setting limits, taking televisions out of children’s bedrooms, and establishing regular “no tech” nights, when the home’s Wi-Fi is switched off for the evening, to spend time together as a family.

Ehinger also moderates conversations with couples in counseling to get them on the same page regarding their family’s technology use.

“Often, it turns out to be a couple’s problem,” Ehinger says. “They need to define roles when it comes to discipline and boundary-setting — which is all affected by their family of origin. They have to create an ‘our way’ [instead of ‘my way’] and stop bickering and fighting with each other.”

 

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Contact the counselors interviewed for this article:

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Find out more about family counseling from the International Association of Marriage and Family Counselors, a division of ACA, at iamfconline.org.

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Adjustment disorder in the time of COVID-19

By Laura Sladky April 21, 2020

The inability to leave home; constantly accessing the 24-hour news cycle; fervent hand-washing and disinfecting; increasing anxiety; sleeplessness. These are just a few facets of the world’s new “normal.”

Doubtless, the COVID-19 pandemic has highlighted the necessity of personal hygiene and the fragility of life. But while projections of decreased mental health states have been rolling in aside a slew of seemingly never-ending bad news, the media have generally failed to normalize the struggle for (nearly) everyone to adjust to this new way of life.

As professional counselors, we are braving telehealth, juggling our own mental health needs amid those of our clients, and helping friends and family members adjust to uncertainty and unemployment, all while trying to pepper in some self-care and generally navigate this unprecedented time for ourselves.

To begin, I would like to normalize adjustment disorder for ourselves as professionals. Depending on the timeline of our geographic location’s response to COVID, we may be relatively early in the process of testing, diagnosing and surviving this pandemic. As a result, most of us (understandably!) meet the criteria for emotional and behavioral symptoms in response to an identifiable stressor occurring within three months of the onset (read: the genesis of COVID-19 and adjustment disorder). Furthermore, we are remiss if we do not acknowledge our own social and occupational impairment as a result of this pandemic.

I share this not to wallow in the current reality but to normalize it. I see my friends and colleagues pouring out their every waking moment to address the needs of clients and families alike. Most counselors have seen a rise in their caseloads as the result of COVID-19, many times taking on new clients without having met them in person. Given these circumstances, truly, when are counselors given the space and time to not be whole? To not “have it together”? To not have the “answers”?

On a personal level, I have consumed more coffee, slept more disruptedly, worked out more, and nibbled on more snacks than I care to admit. I have unceremoniously become a school counselor who works from home (with a 12-step commute) and shares “office space” with my spouse. My cat is thrilled by the constant access to affection, but I cannot help but view my life in terms of discontinuity and extremes.

To you, my dear friends, comrades and colleagues, I say that we are in an unprecedented time with no predictable end date. We are responsible for ourselves both personally and professionally. We must take care of ourselves before we can help others (similar to the guidance we give to our clients). We must practice self-care. We must resist the urge to assuage our lack of control with overexposure to the news. We must resist the downward spiral.

A favorite text to which I often return in trying times or times of uncertainty is The Upward Spiral: Using Neuroscience to Reverse the Course of Depression, One Small Change at a Time by Alex Korb. In this accessible text, Korb highlights how seemingly everyday behavior can improve our neurochemistry and continue to spiral us upward toward healthier levels of functioning. Lately, the aspects of this text I have found most salient are:

  • Work it (out): “Movement increases the firing rate of serotonin neurons, which causes them to release more serotonin.”

Fortunately for those of us quarantined at home, there is an endless supply of free streaming content from major workout companies, live workouts from trainers, and general gym enthusiasts who are willing to share their routines online. Whether you are a novice or a natural, make sure to get your body moving daily.

  • Set goals: “We are often under the impression that we are happy when good things happen to us. But in actuality, we are happiest when we decide to pursue a particular goal and then achieve it.”

This may seem counterintuitive in a crisis, but setting goals for ourselves can help increase our personal happiness. Personally? Running a marathon on my balcony won’t spark much joy, but for you, it might.

  • Get outside: “Bright sunlight helps boost the production of serotonin. It also improves the release of melatonin, which helps you get a better night’s sleep. So if you’re stuck inside, make an effort to go outside for at least a few minutes [in the middle of the] day. Go for a walk, listen to some music, or just soak in the sun.”

I cannot stress this enough: Whether it’s in between seeing clients or on your lunch break, if safety allows, please get outside. Nature provides us one of the most natural ways to improve our mood and connect to something larger than ourselves. This also might be an excellent time to assist your local animal shelter by taking some furry friends out too.

  • Maintain a sleep/wake schedule: “[Q]uality sleep is essential for learning and memory. In particular, sleep selectively enhances memory for future-relevant information, which helps you be more effective at achieving your goals. Furthermore, sleep enhances the learning for rewarding activities, which means you’ll have an easier time focusing on the positive.”

The best thing about sleep is that it resets reality and let’s us try again tomorrow; the worst thing about sleep is that it seems harder to attain in times of high stress. One of the best ways to ease your way into REM is to develop and uphold a sleep schedule that creates predictability for your body between night and day. Resist the urge to check your phone, consume caffeine or alcohol, work out, or engage in emotionally stimulating activities before bed. When we sleep at regular intervals, we are able to do our best thinking.

  • Practice gratitude: “Gratitude is powerful because it decreases envy and increases how much you value what you already have, which improves life satisfaction.”

This one hits differently, doesn’t it? We encourage our clients to practice gratitude and mindfulness often, but how much do we really practice it ourselves? I have recently encouraged myself (OK, maybe held an intervention with myself after a COVID-centered news binge) to begin the practice of physically writing down what I am grateful for on a daily basis. In my “regular life,” I often dismiss this practice on account of time and because it is something I “practice in my head.” Now that I am swimming in nothing but time, I am honing my practice.

While I cannot offer my friends and family members a timeline for this pandemic, I can offer them hope. While I cannot change each aspect of the world that is hurting, I can render psychological first aid to my corner of the world, help clients improve their mental health, and continue to grow despite hard times. Finally, while I cannot (and will not) offer my colleagues empty platitudes about how we can “live, laugh, love” our way through this, I will remind each of you that you are not alone. Your struggle is not a weakness, but rather a sign of your humanity. You are allowed to embrace your adjustment disorder to your new normal, and when you do, I’ll be right alongside you.

 

 

 

 

 

 

 

 

 

 

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

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