Monthly Archives: January 2021

Gone but not missed: When grief is complex

By Bethany Bray January 27, 2021

The aphorism “do not speak ill of the dead” is attributed to the philosopher Chilon of Sparta. First written in Greek and later popularized in Latin, De mortuis nihil nisi bonum, the phrase perpetuates a social taboo against criticizing someone who has died.

Centuries after it was first uttered, clients in counseling may still hesitate to “speak ill” of someone in their life who has died. It’s natural, however, for human grief to involve a range of thoughts and feelings — not all of which will frame the deceased in a positive light. This is all the more true when the person who died had an abusive, rocky, strained, unsupportive, toxic or absent relationship with the client.

“Having conflicted feelings about the deceased happens more often than is discussed,” says Elizabeth Crunk, a licensed graduate professional counselor who specializes in helping clients with grief and loss at her private practice in Washington, D.C. “There’s a societal expectation that we don’t speak ill of the dead, and I think that sometimes can keep people even from seeking counseling.”

That hesitancy can be compounded when the client is worried about how a counselor might react to their situation. It isn’t uncommon for clients to assume that a practitioner will judge them negatively or expect them to forgive the deceased if they are struggling with mixed feelings about the person’s death, Crunk explains.

“It’s important [for counselors] to validate those coexisting feelings. It is possible to feel both sorrow and joy,” Crunk says. “Also, it’s important to validate [a client’s] feelings of numbness or not feeling sad. Assure them that they don’t necessarily need to conjure up sadness if that’s not genuinely what they feel.”

It’s complicated

The emotions that clients experience in response to the death of a person with whom they had an unhealthy relationship are certainly complicated. However, the term complicated grief is a specific psychological diagnosis (also called prolonged grief disorder) that involves lengthy, extended grief that often is accompanied by intense emotional pain and longing for the deceased, as well as maladaptive behaviors such as disbelief that the person actually died. (For more, see our 2014 article “The complicated mourner.”)

It is possible that clients who have lost someone for whom they have mixed feelings will experience complicated grief. However, Crunk says, the experience is perhaps more likely to fall under the definition of disenfranchised grief — a type of grief that is unsupported or unrecognized by society or culture.

Clients who don’t feel “sad” in the traditional sense about a death may believe that their experience is not socially acceptable. Such mixed feelings can be especially common when the death has a certain stigma attached to it, such as with deaths due to suicide or drug overdose, says Karin Murphy, a licensed professional counselor (LPC) who specializes in grief work at her Doylestown, Pennsylvania, private practice. Counselors who work in the addictions field or with clients whose loved ones battle addiction may hear clients disclose these types of feelings, she notes. Regardless of specialty, counselors may encounter clients using language that minimizes their loss (even when they feel the loss acutely) if they sense any stigma connected to the person’s death.

“It’s really important for counselors not to perpetuate that disenfranchisement. [A client’s grief] is supported, recognized and valid,” Murphy says.

The disenfranchised grief these clients experience “doesn’t allow room for them to express the range of what they’re feeling — especially relief,” adds Crunk, a member of the American Counseling Association and a courtesy assistant professor in the counseling department at George Washington University in Washington, D.C.

Such circumstances can spur conflict even within family networks, Crunk says. One or more family members may have had a good and loving relationship with the deceased, whereas other members of the family may not have. In these cases, family discussions about how, or whether, to memorialize and remember the deceased can be fraught with tension.

The death of a parent, spouse or other person who was abusive, neglectful or invalidating toward a client can result in a grief process that is difficult for others to understand or accept, says Mark Tichon, an LPC who is an associate professor and counseling program director at Lincoln Memorial University in Tennessee.

“The relief that can accompany the passing of an abuser is hard to discuss without seeming callous,” says Tichon, a member of ACA. “In these cases, strong contradictory feelings of longing for a [healthy] relationship and the burden of guilt at the sense of relief may result in a grieving process that is marginalized and not socially validated.”

Related emotions

Clients who seek counseling for a range of issues could be struggling with this type of unprocessed grief without being able to name it or disclose it themselves at intake. Counselor clinicians can listen and watch for a number of emotions that commonly dovetail with struggles over the loss of a person for whom the client had a complicated or unhealthy relationship.

In Murphy’s experience, shame, relief and guilt are most commonly expressed by these clients. Feeling a sense of relief that a person is gone often causes clients to question what that means about them.

“It’s feeling release, but [clients] have a very difficult time naming that. ‘What does that say about me if I’m relieved that this person has died?’ And with that relief comes shame,” Murphy says. Clients may struggle with, “What’s my part in this? What did I do to contribute to this sense of unfinished business? And the would haves, could haves, should haves that come from that.”

In addition, Crunk notes that these clients may express self-blame, anger, numbness or ambivalence over the loss. They may grapple with feeling unsettled or unresolved about certain aspects of their relationship with the deceased. They may feel grief centered not on the loss of the actual person but on the loss of a relationship that never was or of what might have been, Crunk adds.

Murphy urges counselors to remember that complicated feelings can also occur when clients experience nondeath losses, such as a change in someone who is no longer themselves because of dementia, addiction, chronic illness or other conditions. A conflicted relationship does not go away when the person begins to change because of illness, she points out. In fact, clients’ emotions may be exacerbated if they are pushed into a caregiving role.

“Understand that loss may not involve death. Life is really a series of losses, but a lot of times we don’t think about grieving, or giving ourselves permission to grieve, unless there’s been an actual death of a person,” says Murphy, who is certified in thanatology and has past experience as a hospice bereavement coordinator. “A lot of times, we have feelings about things, but we’re not really told or given space to understand that not only is it OK to feel that way, but we might expect to feel that way. That’s where the disconnect happens — feeling too much or too little. And that’s what brings [people] into counseling.”

In session, Crunk begins to explore the client’s feelings surrounding their loss with questions about the relationship the client had with the deceased. She asks the client to describe what life with the person was like. If there is any indication of conflicted feelings on the part of the client, she follows up with more gentle questioning.

“I ask them early on to talk about their relationship with the person [who died]. I try to open the door a little bit for them to share if there is some ambivalence. I don’t want to push that too hard but [simply] open the door. I want to assure them that they don’t have to speak positively all of the time,” Crunk says. “Even with deceased loved ones that we had a good relationship with, there are always aspects that we didn’t like, or things we didn’t agree with. I always try and leave room for that side of the coin.”

“Sometimes what comes up too is that we start our work and the client thinks that they had a pretty positive relationship [with the deceased], but as we begin to dig deeper into the story, other more complicated aspects arise,” adds Crunk, who co-authored a 2017 Journal of Counseling & Development article, “Complicated Grief: An Evolving Theoretical Landscape,” with Laurie A. Burke and E. H. Mike Robinson III.

This was the case with one of Crunk’s clients who grew up with a mother who was abusive. In counseling, the client needed help processing the death of her father. At first, the client identified her father as a protective figure, but as she worked through the loss in counseling, she began to voice feelings of disappointment that her father hadn’t done more to remove her from an abusive situation. At that point, Crunk recalls, their counseling work shifted to processing the client’s newly discovered feelings about her father.

Grief has many layers, but that is especially so for clients who have conflicted feelings, Tichon says. “One thing clients may need to do with a compassionate and humanistic counselor is grieve the loss of having an ideal parent, for which many clients hold hope as they grow older, or grieve the loss of hoped for reconciliation that will never come.”

Tichon once worked with a man who struggled acutely with the loss of what could have been. The client’s father, who had narcissistic personality traits, died “just as their relationship was starting to become more of an adult friendship where [the son] could exert healthy boundaries that allowed him to genuinely enjoy their time together,” Tichon says. The client’s father had died suddenly, so there was no chance to say goodbye or find closure.

“It took a long time for him to reconcile the conflicting emotions of sadness over the death of his father with the feeling of freedom from parental judgment and punitive emotions,” Tichon says. “One key goal of therapy was for this client to resolve feelings of guilt over the relief that his dad was no longer in his life. At the end of our time together, this client was able to say thoughtfully, ‘I still miss him, but I’m also relieved he’s out of my everyday life for good’ with a sense of peace.

“The tension between feelings of loss over what could have been a meaningful adult relationship, anger and resentment over emotional neglect during his childhood and adolescence, and guilt over feelings of relief that the relationship was finally over had resolved to … greater clarity and peace as he became more fully accepting of these intense and contradictory feelings.”

Unwrapping

Grief work should always be tailored to the specific needs of the client, but that becomes especially important with those who are navigating mixed emotions about the deceased. As a counselor who specializes in grief and loss, Crunk may have five clients who are experiencing the same type of loss — the death of a parent, for example. But as Crunk points out, each client will have different aspects of the loss that they struggle with and need to process.

To narrow the focus, Crunk encourages clients to identify what is “most troubling” to them about the loss. If the loss was traumatic or unexpected, that may be the aspect that is most troubling to them, she explains. But for other clients, it could be feelings of guilt or shame surrounding a person’s death.

One of Crunk’s clients was mourning the loss of her grandchild. The client had experienced a troubled upbringing herself, but as an adult, she had endeavored to create healthy and safe family dynamics for her own children and grandchildren. As their work in counseling progressed, it became clear that the client was grieving the loss of her identity as a loving grandparent as much as the death of her grandchild.

“I had assumed that losing her first grandchild was the worst of it. But when I asked her what was the most painful, she said, ‘I worked really hard to cultivate a healthy, stable life, and now I’ll never have that perfect life.’ She had lost that part of her narrative: She no longer had a ‘perfect’ life,” Crunk recalls. “It’s important [for counselors] to put personal assumptions aside. What you assume is the most troubling [aspect] may not be. Let the client dictate, and spend the most time on that.”

Helping clients give voice to the complicated feelings that accompany a loss is among the most important things that a counselor can do, says Tichon, who is scheduled to co-present a session, “Complicated Grief: Treatment Stories and Experiential Exercises,” at ACA’s Virtual Conference Experience in April. Tichon has past experience as a geriatric counselor and would sometimes hear clients express a range of feelings that they had held on to for years regarding a loss.

One client, a woman in her 80s, had lost her husband two decades prior but still harbored resentment because he had been emotionally punitive, controlling and physically abusive early in their marriage. In counseling, she needed to process both the loss of her husband and the pain he had caused her.

“She grew up in an era when people often did not discuss their marital problems outside of the home. At the beginning of addressing this topic in therapy, she had a lot of guilt and shame about ‘talking bad about him,’ as she had some religiosity about needing to honor her husband,” Tichon recalls.

As their counseling work progressed, the client grew in her ability to verbalize her feelings of hurt and sadness and, in turn, process the abuse her husband had perpetrated. Only then was she able to focus on some of the more positive feelings she had toward her husband, Tichon says. As a result, her depressive symptoms lessened, and her life narrative became much more positive.

“He had been dead for 20 years, but her unexpressed resentment had [been] pent up in her all those years. … She made a breakthrough in the process of grief when she was able to voice that although the physical abuse had ended when she was in her 30s, she held contempt and emotional distance [for her husband] through the end of the marriage. At 83 years old, she wound up owning her own part in a bad marriage, and in a faith-based, spiritual way, asked for forgiveness for not accepting his remorse and validating that, in some ways, he was a changed man [while] he was still alive,” Tichon says. “In short, grief needs to happen, and when we allow the depth of the process to work through in what is often long-term therapy, we deeply heal.”

Making meaning

Expressive therapies can be particularly useful in helping clients make meaning of losses that involve mixed feelings. Exercises such as writing a letter to the deceased can be especially helpful when clients feel that things were left unfinished or unhealed in the relationship. However, work should be client led, and interventions must be used only when appropriate.

“Writing a letter to the deceased person — highlighting the happy moments, the resentment, anger and sadness that the relationship caused, and unrealized dreams and hopes — and reading that letter using empty chair work can help integrate these emotions into the personality,” Tichon says. “I find that when using the empty chair technique, if I have the client mindfully visualize the person sitting there, down to remembering mannerisms and clothing of the object of their grief, it makes the experience particularly impactful. I would rule out this depth of visualization, however, if the deceased was particularly abusive. I would not engage the client in this level of visualization of the abuser, as the intervention is significantly deep. In cases like this, venting strong emotions and giving voice to unresolved anger and hurt is, in itself, very cathartic.”

Bernadette Joy Graham, an LPC who specializes in grief and loss at her Maumee, Ohio, private practice, uses a similar technique, prompting clients to use their imagination to create a space where they can visualize meeting the person who died and speak with them to find closure. This can be a real place, such as a room in their childhood home, or a setting that holds meaning for the client. Graham lost her mother when she was a teenager, and she uses this technique herself, imagining a front porch where she can sit down with, see and speak with her mother whenever she feels the need to.

Crunk also uses various correspondence exercises, including letter writing, journaling, the empty chair technique and other imagined dialogue techniques, with her clients. She says this work allows clients to say things they wish they had said while the person was still alive, apologize if they feel that is needed, work through complicated emotions and process unresolved conflict.

“The end goal is about revising their self-narrative and their narrative of the relationship with that person that brings a little more repair and helps things feel a little bit more integrated,” Crunk says. “I use a lot of attachment-informed meaning reconstruction techniques to help them create a coherent grief narrative.”

In sessions, she also looks for nonverbal cues that might indicate that a client needs to explore something further. If a client shows signs of agitation, for example, she’ll ask them to name what they’re feeling.

“If I see tears, I ask, ‘If these tears could talk to you, what would they be saying?’ If they say, ‘I feel a heaviness in my chest when I talk about this person,’ I might ask them to put a hand on their heart, and I might mirror that with my own hand,” Crunk says. “Then, I’ll ask them to describe that heaviness. Does it have a shape? Does it have an image? It’s all with an aim of them being able to tolerate that.”

Crunk is using telebehavioral health with her entire caseload during the coronavirus pandemic and acknowledges that picking up on nonverbal cues from clients can be more challenging. However, she believes that “it’s all the more important to show that I’m present, that I’m there with them, offering a place to cry or feel anger or relief, whatever it is.”

Some grief counseling techniques may need to be adjusted slightly when used with clients who did not have a good relationship with the deceased, Crunk notes. This is the case with empty chair, letter writing and other expressive techniques. The goal of these techniques is not to have clients reimagine their narratives regarding the person — for example, by pretending that the abuse never took place or that the person never lapsed into addictive behaviors. Rather, the goal is to help them reconstruct their narrative of their relationship with that person and, potentially, accommodate any new insights about the person who died or their relationship with that person into their current awareness or schemas. Sometimes, Crunk explains, when “conversing” with the person who died, the client stumbles upon a new insight about that person or their life that helps the client see their relationship with that person from a different perspective — one that can potentially help the client make more sense of their loss or bring them some calm.

These techniques are meant to offer clients a pathway “to revise the relationship in a way that they can carry it with them but that does not put pressure on the client to transform it into something that is unrealistic or fictional,” Crunk explains. “It helps the client imagine a world where there is an opportunity to receive an apology or hear words that they yearned to hear the person say.”

Clients sometimes express doubt about whether the deceased person loved them or struggle with things that went unsaid or undone while the person was alive, Murphy notes. She urges counselors to help clients find creative ways of expressing or completing what was “left undone.” For instance, counselors can leverage anything that a client enjoys as a hobby — writing poetry, painting, making collages — to help them communicate thoughts that are uncomfortable or to explore things that went unfinished between themselves and the deceased.

The simple act of writing down a thought, even if it gets tucked away in a desk drawer or journal, validates what the client is feeling and acknowledges that they are working through it, Murphy says. She sometimes recommends that clients read licensed mental health counselor Stephanie Jose’s book Progressing Through Grief: Guided Exercises to Understand Your Emotions and Recover From Loss, which features journal prompts throughout the text.

“Getting the thoughts and feelings out of your head and having a container for them is going to bring relief. It allows clients to process these feelings but also separate themselves from them and put them in a separate place than their mind,” Murphy says. “There is a common misconception: If I just give it enough time, I’m going to feel better. In reality, it’s time plus what you do that will help.”

In addition to encouraging expressive therapies, Murphy often suggests that clients seek out grief support groups so that they can connect with others going through similar experiences. Doing volunteer work can sometimes help clients address things that they feel they didn’t accomplish with the person who died, she adds. For example, they may not have been able to reconcile with an older relative before that person passed away, but they can forge connections with other older adults by volunteering at a nursing home or similar setting.

Similarly, counselors can help clients create new rituals to mark the passing of someone for whom they have mixed feelings. This can be done privately on their own, or with the practitioner in session. It can involve anything from making a donation to a cause that is important to the client or was important to the deceased, to eating at a restaurant that the client associates with good memories about the deceased.

Tichon agrees that expressive and creative therapies can be particularly helpful with clients who are “stuck” or need to process hurtful feelings regarding a loss. In one technique, Tichon has clients rip off a piece of paper for each emotion or painful memory that they express in session regarding the deceased.

“At the end of this exercise, the client is often in tears and staring at a shredded pile of paper, deeply in tune with the feelings of pain and brokenness. We then process how this piece of paper won’t look like what it did before we started, but we can use it to build something new. And in grief, things won’t be the same [either], but they can be good again,” Tichon says.

Tichon then directs clients to take their shreds of paper home and use them to create something that speaks to their hopes for the future. “This has been a particularly powerful experiential intervention, and clients have brought back art and murals that serve as metaphors for moving forward and building new meaning in life,” he says.

Leaning in

Counselors might find themselves experiencing the urge to comfort clients who are struggling with difficult emotions related to the death of someone who inflicted pain upon them, Crunk notes. While these clients need support, they also need to gradually work through the discomfort they feel regarding the loss.

“Grief, as painful as it is, it’s my belief that it needs to be felt. It can become complicated, but in general, for the vast majority of people, it’s not a disorder. [It’s] an emotion that needs to be felt and honored. I try and create a space for the person to emote and hold that grief [in a] container for them. I don’t want to press too hard, but I encourage them to lean in to it, to be able to expand their tolerance and sit with their grief,” Crunk says. “It’s a delicate balance because, as much as I want to provide comfort, if that’s all that I do, then nothing will change. … We want so badly to help [our clients] and provide support and comfort. It can feel counterintuitive in grief counseling, but sometimes the most helpful thing to do is to help them increase that capacity to feel their grief. As painful as it is, it’s a necessary part of healing.”

That delicate balance involves helping clients access and sit with their feelings of grief and find ways to take respite from their grief, pursue restoration or give themselves permission to feel positive emotions, Crunk adds.

Clients who are struggling with a painful, complicated loss sometimes ask how soon they will feel better or get through it. Making promises to these clients that everything will eventually be fine is not appropriate, Graham asserts. Although it is natural for counselors to want to “fix” these clients, practitioners must push back against that urge, she says.

“Be honest with the client and say, ‘This will never be easy, and you might never have [complete] closure,’” Graham advises. “I give them as much support as possible, but I never say, ‘It’s going to be OK.’ I say, ‘I don’t know how long this will take. Everyone’s different and everyone’s unique. There is commonality in grief, but no two experiences are the same.’”

Murphy acts as a gentle guide for clients as they lean in to their uncomfortable feelings related to grief. “I often tell clients, ‘We’re doing this in bite-size pieces … because it’s too big to do all at once.’ I hear this a lot from my clients: ‘It’s been three months, and no one wants to hear me talk about this [anymore]. Why aren’t I over it?’ A lot of [this] is realizing that grief has no timeline.”

Murphy says clients often need to give themselves the following permission: “I have every right to grieve this. It matters to me, and it’s going to take as long as it takes.”

Instilling self-compassion and focusing on self-talk can make an important difference for clients struggling with disenfranchised grief, she says. “Finding the self-compassion to sit with what you need to allows you to move past it,” Murphy says. “I often hear from clients, ‘If I let myself cry, I’m never going to stop.’ I [say to clients], ‘Let’s test that out. When was a time when you allowed yourself to feel something, and did that last forever?’ It’s a lesson that feelings come and go, but they’re not here to stay.”

Forgiveness and compassion

Clients who harbor feelings that go against cultural norms — such as feeling relief that a family member has died — need a safe space to voice those feelings. Tichon urges counselors to “wear their best Carl Rogers hat” when working with these clients and to remember the principle of unconditional positive regard.

“Allowing the client to experience the full range of conflicting emotions, and providing the depth of a supportive, nurturing and nonjudgmental environment — which the client often has not experienced — can allow deep healing to occur. … Clients may have feelings of longing and sadness, but also betrayal, anger and contempt. It is helpful to extend compassion and allow clients to explore and express the fullness of those conflicting emotions and grieve the loss of the ideal parent, spouse or significant attachment figure who they never had. [This can result] in validation of feelings [that are] contrary to cultural messages on grieving.”

Murphy also emphasizes the need for practitioner compassion with these clients. “Maybe they’ve never had anyone ask them how they’ve felt about the loss. That can go a long way, and it opens the door to get them to talk about it,” Murphy says. “Validation [of the client’s feelings] is the important first step.”

“A big concern [that clients voice] is ‘What’s wrong with me? Why am I feeling this, and why can’t I get over this?’ And the answer is because you’re human,” Murphy continues. “When we’re doing this type of work, the relationship — that therapeutic alliance — is the most important. We can talk about tools, but the most important thing is that the person is feeling heard and acknowledged. … What we [counselors] can bring is to be present during that pain and allow the space [to process it]. That’s what it’s all about: Just being validated is the most important thing, and then figuring out from there what tools are needed, because it’s so individualized.”

Graham says that “empathy goes a long way” with these clients and also stresses the need to keep the work client led. Prior to intake, she explains to clients that the assessment process will take the entire session and that she will be asking about subjects that may stir up difficult feelings. “Don’t assume that they know what assessment is and how it works,” Graham says. “They may not realize that they’re going to have to disclose past trauma, assault” or other painful issues.

A gentle approach on the part of the counselor can prevent clients’ anxiety from spiraling, Graham says, especially if they aren’t familiar with the therapy setting. This can mean the difference between a client returning to counseling or dropping out, she says. “I tell the client, ‘There will be a lot of serious questions that are going to take you back in time. If it gets too emotional, we can stop and take a break,’” says Graham, who previously worked at an inpatient rehabilitation center for clients with substance dependence. Graham also stays mindful during sessions and steers the conversation to lighter topics toward the end, while leaving time for questions from the client. If appropriate, she finishes with a joke to get the client laughing. “They are going to have to go home and function [after session],” Graham says, “[so] I try and close the wound back up a little.”

Another aspect of this work with which counselors must tread lightly is the issue of forgiving the deceased, Crunk says. This too must be client led. Forgiveness is sometimes an outcome of grief counseling, but it should never be imposed by a counselor, she stresses.

“I would never pressure a client or use that type of language unless they bring it up. If, through the work, they find more compassion or empathy toward the person, [that can be a positive outcome], but I just don’t feel that should come from me. It’s not a goal that I would impose on the work,” Crunk says. “There are ways that positive psychology can lead to growth and positive outcomes, but we also have to be careful how we use them. Clients can react, understandably, negatively if they feel their counselor is trying to get them to find beauty in their grief or goodness in their relationship. We have to be careful that it doesn’t feel forced [by] us.”

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Grief and doing your own work

Counselors are human, which means that they will experience personal losses throughout their career. Hearing clients talk about the different painful emotions related to the death of a loved one can be triggering for practitioners if they haven’t fully processed their own feelings regarding a loss in their life.

“It’s hard,” acknowledges Karin Murphy, a licensed professional counselor (LPC) with a practice in Doylestown, Pennsylvania. “Counselors have to do their own work [to process loss]. Oftentimes, counselors are not able to talk about it [a client’s grief or loss] because of their own history. It’s an important component of grief counseling: We have to do our own work so we’re able to let that come into the room.”

Ohio LPC Bernadette Joy Graham recently experienced the death of someone close to her, and she stepped away from her counseling practice for a brief time to mourn and process the loss.

“The counselor really has to have themselves rooted with all of their losses,” Graham says. “No matter how well-trained you are as a grief counselor, grief in your own life will be hard.”

As it relates to counselor grief, the 2014 ACA Code of Ethics cautions against practitioner impairment. Professional counselors are called to “monitor themselves for signs of impairment from their own physical, mental, or emotional problems and refrain from offering or providing professional services when impaired.” See more at counseling.org/knowledge-center/ethics, particularly standards C.2.g. and F.5.b.

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Action steps for more information

Search for articles with the tag “grief and loss” at CT Online
Read Counseling Strategies for Loss and Grief by Keren M. Humphrey, published by ACA (imis.counseling.org/store).
Join the ACA Grief and Bereavement Interest Network (counseling.org/aca-community/aca-connect/interest-networks).

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

Far away, so close: Negotiating relationships during COVID-19

By Laurie Meyers January 26, 2021

COVID-19 has taken away many of our in-person interactions. Office chitchat by the coffee maker. Happy hour with friends. Holiday celebrations. Friends, co-workers, extended family — since the pandemic began, many of us have seen them only virtually. In many ways, it’s like we’re all stuck on our own desert island — closed off from the outside world yet sometimes desperately wishing to vote our “fellow inhabitants” off.

The people we live with. We love them. We’ve treasured the extra time with them. But sometimes we just want them all to go away.

The never-ending togetherness; the uneven distribution of household responsibilities; the challenges of balancing work, child care and virtual schooling; and the career sacrifices that many people (women primarily) have had to make are all creating new stress and tension, while also exacerbating pre-existing conflicts in couples and families. In other words, couples and family counselors are very much in demand.

Seeking moments of solitude and respite

“Time and space are just different this year,” says licensed professional counselor (LPC) Christina Thaier. “We no longer divide our roles and tasks into different spaces, and that means all of who we are has to exist within less space. This is tough for kids and adults alike.”

Work, school, family, intimacy, socializing and relaxing are all wedged into the home.

Esther Benoit, an LPC with a private practice in Newport News, Virginia, points out that many parents are really struggling with roles they never expected to play — such as teacher and tutor when their children encounter difficulties with virtual schooling — while still trying to work from home. Other clients are working outside the home but spending substantial time on the phone providing “tech support” to their adolescent children who are at home alone, Benoit says.

Thaier notes that clients are floundering to find a way to balance everything in the absence of real-life connection to their communities and support networks. “It’s limiting. We miss a lot, and if we live with others, we are taking this on without any real break from our family or roommates,” says Thaier, a couples counselor who is the founder and director of Terrace House, a group practice located in St. Louis. “It’s a strange feeling to feel lonely and cut off from our usual life and, at the same time, never feel we get a break from others.”

“We [also] miss the versions of ourselves that exist in our usual spaces — our co-worker self, our happy-hour self, the version of us that shows up at the gym or the part of us that sings in the car after dropping the kids off at school — and the natural breaks and alone time that were previously built into our day,” she continues.

Thaier, an American Counseling Association member, helps clients envision alternative ways to be their different selves. “Maybe I can access the part of me that comes alive during time with friends by moving our time together to the park with masks,” she suggests. “Or I can plan a 10-minute Zoom call with my favorite co-worker at a time we would usually stop by one another’s desks.”

Thaier and her clients also seek simple ways to re-create those moments of solitude with activities such as taking a walk in the middle of the day, running errands, completing a solitary trip to the store to pick up groceries, or taking a bath or shower. “We’ve also talked about meditation apps and making the most of the early morning or late evening time when most of the house is sleeping,” she says.

Megan Dooley Hussman, a provisional licensed professional counselor and clinical supervisor at Terrace House, says many clients have found not just alone time but also a way to stay centered by engaging in daily rituals such as meditating, walking or even making and drinking tea mindfully.

Some clients also seek quasi-solitude by establishing family reading or movie-watching times, Thaier notes, adding that “quiet is almost alone.”

But with the multiple roles that parents are playing, stolen moments of solitude often aren’t enough, Thaier asserts. She helps parents map out the logistics of making sure that each partner gets their own break at some point during the week. That often involves one parent — or a family member within the household bubble — “hanging” with the kids while the other parent gets some time to themselves, she says. Thaier describes it as a “big win” for parents when everyone else leaves the house — even if only for an hour.

Sharing the struggle

The pandemic has been overwhelming for everyone — in unique but also universal (or at least common) ways. For parents and couples, the biggest contributor to distress and conflict is often unequal distribution of the “mental load,” says LPC June Williams, whose specialties include couples counseling. The mental load, she explains, is everything that needs to be done to keep the household moving. And much of it seems never-ending.

As Williams, a private practitioner in Cedar Park, Texas, points out, everyone is eating all the time when the kids are at home due to virtual schooling. Meals need to be planned and scheduled because family members aren’t necessarily eating at the same time. The dishes seem to self-replicate, requiring multiple dishwasher runs per day. It isn’t uncommon for one parent to manage this process — in addition to keeping the children engaged in online schooling and attempting to perform their “regular” job duties from home. In such cases, the parent spends the day constantly switching focus from their work laptop to their children’s screens. One of Williams’ clients is working and managing the family’s three children while their partner is in another room with the door shut.

When the distribution of household responsibility is not equal, it is often because much of the mental load is invisible, Williams says. She helps make it visible to her couples clients.

Williams will sit with the couple and task the partner carrying the uneven load to walk her through their day. Williams asks the other partner to listen without interrupting. Often, the partner who has been contributing less is shocked to learn the full mental load that their loved one has been carrying, Williams says.

It isn’t always possible to achieve a 50-50 split, Williams says, but she helps couples distribute the load more equitably. They discuss all of the tasks that make up the mental load and talk about how to handle them as a team. Williams asks the partner with the lesser load to think about what areas they would be willing to take over. She then asks the other partner to decide where they are willing to relinquish control. “What’s something you are willing to give away, knowing that it’s not going to be done your way?” she asks. If the partner offloads dish duty, they have to accept that the dishwasher may not be loaded “correctly,” Williams counsels.

Williams also has couples take responsibility for different areas of the house. Once that’s done, each partner’s domain is sacrosanct. “No micromanaging,” she says. “If the trash is your partner’s deal, you don’t say anything — it’s in their lap.”

ACA member Paul Peluso agrees that cooperation and flexibility are essential for navigating home life during the pandemic. He recommends that couples come up with a practical, workable schedule that allows each partner some time off. Unlike Williams, he recommends that couples switch off tasks such as bathing the children, taking out the trash and cooking. This cooperative effort creates a sense of fairness that allows a partner who has had a particularly bad or busy day to ask the other partner to take over a task that the tired partner feels too tapped out to do. The understanding is that the same grace will be extended to the other partner when needed, says Peluso, a professor of counselor education at Florida Atlantic University and a former president of the International Association of Marriage and Family Counselors, a division of ACA.

Peluso also recommends that couples cut themselves and each other some slack, especially during the pandemic. For instance, perhaps the routine has been to fold and put away clothes immediately after they come out of the dryer. “Give yourself a break and let it be in the basket for a few days, and use that time to watch a show together or to talk,” Peluso urges.

Sometimes, an unevenly distributed responsibility cannot be transferred from one partner to another, Williams says. The couple with one partner working and managing school for three kids is doing it out of necessity because the partner with the closed door is constantly in meetings.

In cases such as these, Williams typically encourages couples to explore possible outside resources that can be brought in: “Can we talk to family [about providing help]? Do we have a COVID-safe nanny? A COVID pod so that two days a week the kids are going to another parent’s house?”

Sharing the load becomes more difficult when one partner is working outside the home and the other works virtually or has put their career on hold. This scenario can easily lead to resentment, Benoit says. To the partner who stays home, it can seem as though the partner who works externally has experienced a return to business as (almost) normal, she explains. Meanwhile, the “inside” partner feels like their life has been completely upended because they are either trying to work from home while also providing child care or may even have felt it necessary to leave their job, Benoit says. Resentment builds because the partner at home feels trapped.

Benoit finds it helpful to externalize these conflicts for couples, emphasizing that it is the situation that is the problem, not the person who is working outside the home. Adopting this perspective, it becomes something that the couple can address as a team. The goal is to avoid recrimination and accusations, Benoit says, and to ask instead, “How do we get through this together?”

Although the essential circumstance cannot be changed, the level of resentment can be lowered dramatically, Benoit says, by something as simple as the partner working outside the home acknowledging that the other partner has the tougher end of the deal and asking, “What can I do to help?”

Benoit also emphasizes self-compassion. “I tell a lot of clients that what we’re aiming to do is get through,” she says. “We’re not aiming to thrive, but to survive.”

Couples also must learn that they are not responsible for each other’s moods, Williams says. A felt need to “fix” everything is often present in the partner who feels “overloaded,” she says.

“I work with that person who is trying to fix and [I] help them get more comfortable with everyone’s discomfort,” Williams says. This is doubly beneficial because the person who is underfunctioning may be hanging back as a result of receiving the message from their partner (directly or indirectly) that they never do anything right. Williams wants to help the partner carrying the lighter load to take on more of the burden not because they are being nagged but because it is important to the family.

Williams also asks the “overburdened” spouse about the feelings they are living with. Do they feel the need to fix, rescue, save and control? Do they feel anxious and resentful? If the client acknowledges these patterns, Williams asks whether they like feeling that way.

The usual response? “No, I am mad all the time and tired.”

Possessing a sense of responsibility does not mean that the client is responsible for everyone in the world, Williams counsels.

She gives clients a scenario: Your husband comes in and is in a terrible mood. He sighs heavily and drops his bag. As his wife with an overdeveloped sense of responsibility, you may flutter about and try to step in and take over. The end result? You haven’t fixed anything. He’s still irritated, and now you are too, Williams says.

She tells clients that they can still be compassionate, check in with their partner and ask how their day was. But if the partner responds that their day was terrible, clients need to ask themselves whether they have the emotional energy to carry that burden with their partner, Williams advises. If not, “It’s OK to say, ‘Here’s a soda water,’ give them a hug and move on,” she says.

When clients feel that tension in the pit of their stomach that is pushing them to step in, Williams urges them to do something calming in another room, such as belly breathing, stretching or taking a quick shower. These strategies also have the advantage of physically separating the person from the partner and their bad mood.

“Offer them compassion and allow yourself to remain separate,” Williams advises.

The price women pay

Williams doesn’t generally like to make assessments along gender lines, but she says the consequences of the pandemic are clearly delineated. Women are typically the ones expected to put their careers on pause — to be the caregivers and nurturers, to be more in tune with the children and to meet the family’s needs — even if they are the family’s highest wage earner, Williams asserts. She references a pithy and pitch-perfect quote from sociologist Jessica Calarco: “Other countries have safety nets. America has women.”

Thaier agrees. “Women already tend to take on more of the emotional, social and household roles, and that has not changed despite those tasks further multiplying,” she says. “In my practice, we talk a lot about our humanness, and that no one human can do all the things. We work on asking for help, prioritizing and eliminating what we can, establishing boundaries, and making time for ourselves.”

Women have absorbed a tremendous number of losses but haven’t had time to properly acknowledge those losses, Thaier says. “It’s hard to grieve within the experience of trauma,” she continues. “If we use the definition of trauma as too much, too fast, all of 2020 has been that. The quick reorganization of our lives has required [clients] — especially women — to move into crisis management mode. In crisis management, we do, we don’t get to be. In that way, therapy itself invites a chance for being, even if, after the hour, we revert back to survival mode a good portion of the time. We begin to carve out moments, which build on each other, for something different.”

“In some ways, because everything is different, there are opportunities for everything to be different, and that means families can brainstorm and strategize together on how to take care of the home and one another,” Thaier says. “It’s not easy, and there are lots of challenges. But I see a lot of great conversations happening, and with that, a lot of change too.”

In therapy, clients get to recenter themselves and their experiences, Thaier says. “They can voice resentments, frustrations, fears and anxieties, and their fear that feeling this way makes them a bad mother, partner, employee or friend.”

Thaier encourages clients to question these assumptions and where they came from, and then begin to redefine what is important to them about the roles they play. “For example, if we are redefining being ‘good’ at a relationship from an old definition of trying to not let anyone down to a new definition of being present and authentic with the people we love, we can begin to think about what this might look like,” she explains. “We can notice when the old definition is guiding our behavior and patterns, and we can start to practice new ways of relating.”

Reimagining clients’ relationships and roles often involves rejecting parts of the past by breaking patterns driven by cultural assumptions. But the past can also inform the future. Thaier uses narrative therapy to help clients grieve their losses and find ways to preserve elements of what was lost. “I think a lot about telling the stories of the people and experiences we have loved and that have significantly influenced our lives,” she says. “For a woman who has made the sacrifice of a current work role that is a significant part of her identity, we explore that.

“How did the job bring you alive? What did it make possible? What were the best parts of your day? Where did you imagine this would take you next? How did this role fit into an imagined and cherished future?”

“We can actually strengthen that story even as we grieve the space it has left in the present,” Thaier says. “And we can begin to narrate how the client can access her relationship to her work — or [what] she found possible there — and bring that into the present. In other words, the people and experiences we love become a part of us, and we can continue to take them with us into our futures. Our relationship with them gets to continue, if we want it to.”

An existential pause

The pandemic-induced global slowdown has provided people an opportunity (even if unrequested) to examine their lives and reevaluate their priorities, Peluso says. A number of people are asking themselves if they want to get back on the treadmill of constant activity and productivity, “or do I want to start thinking about what I was saving for someday and do it now?” he says.

Regardless of whether they choose to return to the treadmill, stepping off of it even temporarily has granted many people clarity about their relationships, Peluso observes. Some have grown closer to their partners during the pandemic, whereas other couples who were gritting their teeth and staying together for the sake of the children beforehand are asking themselves whether it’s worth the price they are paying.

Some couples are reassessing how they were choosing to spend their time prepandemic, he says. “I think especially early in the pandemic, when there was a hard stop to a lot of activity, it created a window of opportunity to just build some new rituals for connection,” Peluso says. “Couples were able to do things together — tasks, projects around the house.”

This ability to slow down — rather than charge through a list of chores — allowed some couples to rediscover pieces of each other that may have been subsumed in the daily grind, Peluso says. “For a lot of them, it forced them to look at some places where they had been neglecting relationships,” he adds.

“While this year has been incredibly challenging, it has also been an invitation,” Thaier says. “An invitation to slow down, to be together more, to take stock of what we’re doing and how we spend our time. To be at home more. To rest. To see our limitless creativity and resilience and strength. To acknowledge that our lives really could look different at a moment’s notice. To learn to be together in new ways. To be outside more. To take less for granted.”

“I wouldn’t say it’s been ‘worth it,’” she continues. “That would disrespect all of the loss and tragedy and, frankly, just wouldn’t be true. But there’s good here too. And there’s invitation in every holding pattern to see something that is waiting to be acknowledged. There’s a mirror here, if we’re willing to look into it.

“I’m thankful for the invitation, and I’m hopeful about what’s next.”

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Additional resources

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

Counseling Today (ct.counseling.org)

“Identifying and addressing competing attachments with couples” by Anabelle Bugatti
“For such a time as this: A plan of action for couples and individuals” (online exclusive) by Esther Scott
“Relationship management” by Laurie Meyers
“The relationship as client” by Laurie Meyers
“Retaining family focus” by Laurie Meyers
“Exploring the ties that bind” by Bethany Bray
“Speaking to the needs of women in counseling” by Bethany Bray

Books & DVDs (imis.counseling.org/store)

Theory and Practice of Couples and Family Counseling, third edition, by James Robert Bitter
Mediating Conflict in Intimate Relationships (DVD) presented by Gerald Monk and John Winslade

Continuing Professional Development (https://imis.counseling.org/store/catalog.aspx#)

“Creative Counseling for Couples: Using the Integrative Model” (webinar) with Mark Young
“Imago Relationship Therapy” (podcast) with Susan Hammonds-White

International Association of Marriage and Family Counselors (iamfconline.org)

IAMFC is a division of the American Counseling Association that embraces a multicultural approach in support of the worth, dignity, potential and uniqueness
of families.

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Laurie Meyers is a senior writer for Counseling Today. 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.

Voice of Experience: Violations of trust

By Gregory K. Moffatt January 19, 2021

Trust is the foundation on which relationships of any kind are built. Think about how much we depend on trust in our everyday lives. We trust that our teachers are telling us the truth. We trust that a check from someone won’t bounce. Even the cash we exchange requires trust in the value of the currency in our hands. We trust that the products we buy will function properly and feel betrayed when they don’t.

And with every secret we share in confidence with another person — no matter how big or small the secret — we trust that it will be protected.

Trust comes easily for children in almost all relationships. Whether it’s with parents, siblings, teachers, coaches or sometimes even with counselors, children generally are quick to trust. “My teacher said …” “Coach told me …” “My dad told me …”

Sexual perpetrators take advantage of the ease with which children trust by “courting” — pushing boundaries a little at a time so their victims don’t ask too many questions. Con artists do the same thing to adults, preying on our natural human instinct to believe in one another. But once trust is violated, it will never come naturally again. A violation of trust compromises not only that relationship, but all relationships.

So, to protect ourselves, we must learn, by necessity, that not all people are equally worthy of trust.

In the field of ethnography, the term incorrigible propositions refers to beliefs that are so fundamental to our existence that we don’t even question them. The most serious violations of trust involve incorrigible propositions. When these beliefs are called into question, it shakes all of our beliefs. In a way, we say, “If I can’t trust in this, then what can I trust?”

For example, most people are familiar with statistics on divorce, but upon getting married, almost no one assumes that they will experience divorce themselves. They trust their spouses. But when the belief that they will always stay together is shattered — by infidelity, for example — their entire world is shaken. The incorrigible proposition that people are trustworthy comes into question. Distrust can generalize to all spouses, everyone of a given gender, or to people in general.

Marriage and family therapists see this kind of shaken trust almost every day. The abused children who come through my office have had their trust violated as well, and I have to work hard to prove myself worthy of their trust. This is often a monumental task. Their childlike gullibility is long gone by the time they come through my office doorway.

I have written before in this column that confidentiality is the foundation on which most of our ethics are built as counselors. This is so important because it relies on a client’s trust that we won’t betray secrets.

Sometimes, however, trust must be betrayed. We must act, for example, if clients are a threat to themselves or to others. Mandated reporters have no choice but to violate confidentiality when they suspect abuse or neglect. Even the sharing of therapeutic information with parents or guardians can potentially compromise our clients’ trust in us. These violations of trust cannot always be avoided.

But perhaps most damaging is when counselors — those of us entrusted with the scariest and most embarrassing secrets carried by clients — violate that trust in an unethical manner.

Unethical violations of trust can come in many forms. Unfortunately, carelessly using a client’s name while talking to a colleague or failing to adequately disguise a client’s identity in consultation with a supervisor are not uncommon occurrences.

Most serious is the violation of trust that takes place when a therapist engages in blatant boundary violations with a client. Inappropriate touching, inappropriate social relationships and other egregious boundary violations with clients always destroy trust in the long run.

Those of you who have been in the counseling profession very long have likely seen your share of clients who have had bad experiences with previous therapists. Therefore, you have almost certainly experienced the painstaking job of trying to prove that you are trustworthy (and that the profession as a whole is worthy of trust) to someone whose personal experience has taught them otherwise.

Even more painful to me is the knowledge of all of the clients who will never risk going to a counselor again. These clients will not seek help because of a violation of the trust-based relationship that is at the heart of our profession. Whether these violations were careless or intentional, the effects are the same. These are the people we have lost.

An ethical “oopsie” that violates trust might never be known to anyone else. But then again, it might. Even the slightest breach might damage a client’s trust to the point that they will never seek counseling again. And that, my dear colleagues, is unforgivable.

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

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

Using the ‘tap in dedication’ technique

By Nicholas Salazar January 13, 2021

Emma quickly checks her watch as she turns her key in the lock. It’s 9:57 p.m. She sighs as she pushes open the door and quickly moves to her room to drop off her bags before heading to the kitchen to make dinner, her second meal of the day since leaving at 6 that morning. She fills up a pot and turns on the stove, dropping in some noodles before opening her laptop to check emails and begin working on her course readings. It’s 10:03 p.m.

Emma’s eyes glaze over as she skims through the endless screens of text, and her head nods until she is awoken by a text from her boss: “Hey Emma, I just had someone call off. Can you open tomorrow morning?”

Emma immediately replies, “Sure thing, see you tomorrow!”

She glances at the time on her phone — 11:13 p.m. She panics and runs to the stove to turn it off. Greeted by a pot devoid of water, she throws away the burnt noodles and closes her laptop. She has finished only one of her five readings, but she needs to be up early tomorrow morning for work. She has six hours of classes after that and internship the following day.

It’s 11:30 p.m. Emma lies in bed with closed eyes and an empty stomach. Her mind races thinking about the different clients she has been working with and how they are holding up. She considers which clients might have which urges — and what she could do to help them, if anything. She thinks about the classes that she didn’t complete readings for and wonders whether she can get by without doing the readings. She thinks about herself as a counselor and questions whether she can ever be successful if she is already struggling.

It’s 12:25 a.m. Emma is asleep, but she will wake up in three hours to get ready to do this all over again.

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As a second-year graduate student who is also working on-site at a residential treatment program, I have discovered it can be difficult to not let every piece of life bunch together and form one massive challenge. It seems that everything of which I am a part is geared toward becoming a mental health counselor. It can be hard to engage in clinical experiences and separate the emotional intensity I experience on-site from my schoolwork, personal life and all other aspects of life.

In our field, being emotionally present and available and working through the sensitive topics of other people’s lives is our daily bread. But being able to stay engaged with a client can be a challenge, especially when you are burned out from the day before, or the events of that morning, or the previous client — not to mention school, work and other life tasks. Taking time to check in with yourself, support yourself and separate one facet of life from another is a skill I have found to be useful when applied in a genuine and purposeful manner.

Overview

“Tap in dedication” is a technique adapted from theater creators when dealing with highly intimate work on stage. It has been used for scenes ranging from a staged slap to simulated intercourse, and the intended purpose is to allow the actors an opportunity to establish their readiness to engage in sensitive and potentially harmful work.

My experience with this technique stemmed from my theater work during my undergraduate studies under the direction of Carin Silkaitis and Gaby Labotka, the latter being a certified intimacy director with Intimacy Directors and Coordinators. They introduced the technique of “tapping in” to those of us in the show, focusing on respect, safety and well-being for ourselves and for those with whom we were working. We used this technique regularly during scenes of overt sexuality, abuse, trauma and death.

We would physically tap each other’s hands, like a “high-ten,” as a way to say to one another, “I am ready to engage in this work with you.” When work on that scene or sequence had been completed, we would perform this action again to provide a physical symbol that communicated, “We did the work, and now we are stepping outside of it to be ourselves.”

Adapting this technique for counselors to use is a nice fit because of the themes of respect, safety and well-being — something that we helping professionals are adept at offering to clients but may not always apply to ourselves. In the counseling profession, it is important to find ways to respect ourselves and our work because if we do not, it can become all too easy to face burnout, experience vicarious traumatization or even fail to respect our clients.

I coupled the technique I learned in theater with aspects of dialectical behavior therapy to allow helping professionals to engage in mindful participation in their careers while providing them the time to check in with themselves before and after a day’s work. In the case of a particularly difficult session, counselors can also use this technique quickly between clients. Depending on site regulations, it may even be used with some clients.

The goal of the technique as I describe it here is to provide a way for counselors, counselors-in-training and other helping professionals to deal with sensitive subjects, to be present and engaged for the difficult work they take part in daily, and to be able to “leave work at the door” when they reach the end of the workday. It can be detrimental for helpers to bring troubling work home with them because it can impede their self-care and have a negative effect on the relationships they have outside of work. Ideally, using this technique will make it easier for clinicians to allow themselves to be engaged fully in their work life while helping them to separate this time from their personal life.

The technique

Practice self-care: Begin by entering or coming to the place where work will be done for the day. Next, take a moment for yourself by performing some action that is soothing and regulating for you. This could be making a cup of coffee or tea, enjoying a snack, reading a few pages of the newspaper, doing a crossword puzzle — anything you find that helps you feel relaxed or calmed. If this is a technique that you would like to use several times per day, between sessions or simply as it feels necessary, an activity that takes less time may serve you better.

Engage in mindfulness: Once you complete your self-care activity, it can be helpful to become grounded in your work environment. For example, take a few minutes to use a “five senses” grounding technique: Identify five things that can be seen, four that can be heard, three that can be touched, two that can be smelled and one that can be tasted.

Skills for distress tolerance can also be beneficial. An example is radical acceptance — taking time to accept one thing that you cannot change about how your day may go, while acknowledging that you can affect your own presence in the day. A technique such as one-mindfulness could be used to promote purposeful attention by focusing on one thing and allowing yourself to see, hear and appreciate it, whether it is physical, emotional or something else (e.g., a plant, a feeling, a thought). Any activity that helps you feel mentally at ease and instills feelings of calm and preparedness can be used for this activity.

An important consideration is to decide where and when you will engage in this process daily. For example, will you do it before you leave home? In the car or on the bus while traveling to work? Once you arrive at your office? From my experience of using similar techniques in theater, once the actions have been set, it is helpful to always do them the same way or as close to the same way as possible to preserve the integrity of the actions and process.

With practice, you will likely be able to engage in your self-care and mindfulness processes anywhere, although a change in environment or process initially could make it difficult to establish and maintain the mindfulness you hope to achieve. If you are in a position where you must travel regularly for your sessions, it can be helpful to have one specific action that you engage in prior to each session. It can also be useful to practice that action several times in settings that are calming before engaging in the activity in a more fluid and potentially stimulating environment.

Literally tap in: After you complete your grounding activity, you will literally tap in. This means to physically tap your hands on a surface or object. Your physical tap in signifies that you are mentally, emotionally and spiritually ready to be 1) devoted and engaged in the activities that follow in an effortful and conscientious manner, 2) fully present in your interactions and 3) aware of the effect that your effort and presence can have on clients and others.

Your physical tap in action serves to signify that your day has begun, and you will give conscious attention to all that occurs from that moment forward. Importantly, tapping in marks the time that is about others (rather than about one’s self), while the preceding actions were exclusively for the individual performing them (i.e., you). This can allow you to engage and deal with more demanding emotions and experiences by allowing you to acknowledge that this time is about being wholly devoted to another, just as the actions before were devoted to taking care of yourself. And in essence, you are taking care of yourself while caring for others because you have intentionally prepared yourself for your service.

Literally tap out: After your sessions, work or treatments are completed (or between sessions if content was particularly difficult), it is time to tap out — literally — just like you tapped in. This is a physical action in which you physically tap the same surface or object you used to tap in. It is important to use the same object every time if possible to symbolize the ending of the specific dedication to your work.

This tap out provides a physical action to close out of what has been occurring during your workday and allows you to engage with the nonwork you again. Additionally, this action signals that the feelings and emotions that may have come up during your work are meant to be kept in that specific time; they are not necessarily meant to exist beyond the scope of that session or that day.

Enjoy your post-tap-out activities: At this point, it is time to go about the doings of your personal life and nonwork time. This means to do anything you would normally do after work — exercising, playing with your children, grocery shopping, attending to your home, spending time with friends and so on — without interruption from what occurred during your work time.

Additionally, some people find it incredibly helpful to engage in some kind of self-care at the end of the day, similar to what they did at the beginning of the day. This might involve watching a specific show, enjoying some ice cream, doing another crossword puzzle — anything that can help you to decompress and relax. This activity can be done at any time but may be more useful to do soon after tapping out so that it can serve as a nice, calming cap to your workday.

Technique considerations

This technique was adapted from a theater practice used in scenes in which violence or intimacy was approximated that could cause effects similar to reliving traumas or increase actors’ emotional discomfort. It is important to recognize when something goes beyond the scope of dedication to work. It is up to counselors to use their best judgment to determine when an event may need further intervention to protect their well-being. Some subjects may be difficult to “leave at work,” and if this circumstance arises, it may be wise to seek support. If a counselor has a troubling response to a client’s trauma, it may be useful to discuss this in the clinician’s own therapy sessions or to process it with trusted colleagues or supervisors so as not to shoulder the burden alone.

Using this technique can take up a fair amount of time depending on the self-care actions the counselor chooses to use. Given that reality, it can be useful to find a quick-and-easy action, or to incorporate parts of the technique into one’s daily routine so that it does not become a burden to the user. However, taking the time needed to prepare for one’s day is imperative to staving off burnout and to increasing wellness.

Although this technique is not intended as a catch-all for reducing stress, it may prove useful in helping to establish firmer boundaries between personal life and work life, which is a common stressor among counselors. The goal is not to fix every stressor that clinicians may experience, but rather to provide an opportunity for clinicians to have a solidified and intentional process of entering and exiting their daily work in a demanding field.

In the event that a counselor must travel between environments during the workday, it may help to tap in and tap out before and after each client and to use travel time for a bit more mindfulness. Especially because of the variety of possibilities, such as traffic or accidents, that can occur when traveling between places, practicing mindfulness during the journey may be helpful in terms of keeping travel stress separate from your work. Additionally, using this technique can allow helpers to reduce personal stressors that often are carried over into work with clients, thus enabling a fruitful and intentional work experience.

Suffice it to say there are many situations that may not benefit from the ability to tap in and tap out. Using this technique ultimately comes down to each person’s discretion. It is simply meant to give them increased autonomy in how they choose to handle their time in a helping profession.

Getting started

Ask yourself the following questions to get started with the tap in dedication technique:

What would it be like for you to intentionally tap in to your workday and tap out of it? Do you have any hesitations? What can you do to resolve those hesitations?
What self-care routines would you like to use to start your day? Which ones are you doing already?
Mindfulness is an integral part of preparing to tap in. What mindfulness practices do you have established on which you can draw? If you do not participate in mindfulness, do you have other religious or spiritual practices that you might use (e.g., prayers, religious texts, songs)?
Where will you tap in at the beginning of your work and tap out at the end?
What does it mean to you to practice your work in a conscious way?
What practices do you want to establish if your work life enters your personal life after you have tapped out?
What resources do you possess to process particularly difficult clinical workdays? Jot them down and use your list when you need it.

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Nicholas Salazar is a second-year master’s student at Marquette University in the Department of Counselor Education and Counseling Psychology. He works part time and is an intern at Rogers Behavioral Health in Oconomowoc, Wisconsin. Contact him at nicholas.salazar@marquette.edu.

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.

‘But my clients don’t get eating disorders’

By Laura H. Choate January 11, 2021

Almost all counselors encounter clients who engage in behaviors such as extreme dieting, excessive exercising, fasting, emotional overeating and binge eating. These symptoms can be initially mild and overlooked or even viewed as normative in our thinness-and-appearance-obsessed culture. Sometimes it is hard to tell the difference between a client who is experimenting with the latest fad diet and a client who is quickly spiraling downward on the path toward a destructive eating disorder. There are two reasons this can happen.

One reason is a lack of counselor awareness. Few counselors receive much training in the area of eating disorders treatment, so they might not be aware of the need for further assessment when a client has initial problems related to eating, weight and body image. The problem is that without effective assessment and treatment, these types of symptoms have the potential to escalate into full-syndrome eating disorders such as anorexia nervosa, bulimia nervosa and binge eating disorder.

Once eating disorders have developed, they frequently become serious, complex, chronic disorders with significant biopsychosocial consequences, including potentially lethal medical complications, poor treatment outcomes, high rates of remission and high mortality rates. Anorexia nervosa in particular is associated with the highest mortality rate of all psychiatric disorders, and both anorexia nervosa and bulimia nervosa are associated with suicide attempt rates that are considerably higher than those for the general population. Suffice it to say, even the most highly trained, seasoned counselor is not equipped to work with this population alone; all clinical guidelines call for a team approach to the treatment of eating disorders. Therefore, regardless of whether we are specialists, we need to establish relationships with other providers in our communities and know when to make referrals for specialized services.

The second reason that initial symptoms might be overlooked or dismissed is that we are not just counselors, we are also individuals who live in a society in which we are all bombarded daily with messages about weight and appearance. We are all exposed to cultural ideals that equate thinness with beauty, happiness and success and that dictate strict standards regarding an ideal body shape. We all have to manage these pressures for ourselves, and few of us are exempt from developing biases and blind spots around these issues. Because of countertransference reactions in this emotionally charged area, we might unintentionally misjudge a client’s pain due to our own struggles and experiences. Therefore, when working with clients who present with issues such as body image, chronic dieting and pressures to be thin, it is extremely difficult to separate our own personal values from what is best for our clients.

So, even though you might never intend to work as an eating disorders specialist, all counselors need adequate preparation to recognize disordered eating symptoms in their clients, to know when and how to provide appropriate referrals, to understand the importance of a multidisciplinary approach to treatment, and to effectively manage personal values. To illustrate, I include three scenarios that highlight some of the complex concerns that can arise for counselors when working with clients who have problems related to eating, weight and body image.

Scenario 1: April’s intermittent fasting goals

April attends an initial session with Karyn, a licensed professional counselor with three years of experience. April reports that she has been on an extreme intermittent fasting diet for the past six months, allowing herself to eat only during a two-hour window per day. She adheres to a vegan diet because she believes it is the healthiest option for keeping a low weight. She also engages in binge/purge episodes three or four times per month (during which she does not adhere to a vegan diet but eats anything she wants). Her body mass index (BMI) is in the low to normal range.

Although April is reporting occasional dizziness, she does not want to give up her diet because she still has not reached her weight loss goal. Instead, she wants to get rid of her binge/purge behaviors, improve her body image and improve her self-esteem. She wants to work exclusively with Karyn even though Karyn does not have a specialized background in treating issues related to weight or binge eating.

Karyn believes April’s goals seem reasonable for individual treatment because she does not appear to be underweight. In addition, because April’s symptoms do not meet criteria for a diagnosis of anorexia nervosa or bulimia nervosa, Karyn does not consider April’s problems to be severe. In fact, Karyn knows a bit about intermittent fasting and its current popularity, so she believes that she can help April evaluate her diet plan.

Implications for counseling practice:

The ACA Code of Ethics states that counselors must know their scope of competence and practice within their areas of training and experience. Karyn is taking a risk in her agreement to treat April because without additional medical assessment, she has no way of knowing the extent of April’s disordered eating behaviors or how her symptoms are affecting her physiologically. It is likely that April is experiencing medical complications even though she does not appear to be underweight.

American Psychiatric Association practice guidelines state that in treating eating disorders, we should always work as part of a treatment team that includes at minimum a therapist, a dietitian and a medical professional. By agreeing to work in isolation and ignoring the need for collaboration, Karyn would not be able to adequately address the medical components of April’s weight loss — and without a medical referral, she would be working outside of her scope of competence, which could cause potential harm to April. In addition, she seems to ignore the fact that April’s behaviors could possibly be progressing to a severe eating disorder.

One way to address these potential problems is for Karyn to inform April that in order to begin treatment, she will need to agree to see a medical professional for evaluation. Based on these results, Karyn might also need to work with a nutritionist, in addition to possibly making a referral to a mental health professional who has more expertise in treating emerging
eating disorders.

Scenario 2: Nila’s secret and Asha’s dilemma

Nila is a 15-year-old who is in counseling at her mother’s insistence. Nila tells her counselor, Asha (a child and adolescent counselor in a general private practice), that her mother is too intrusive in her life, is always telling her that she should lose weight, and tries to control all of Nila’s food intake.

A few weeks into therapy, Asha notices that Nila has swelling in her neck area and has a large scrape on the fingers of one hand. When asked about this, Nila reveals that she has been trying to diet according to her mother’s demands but “just can’t stick to it.” Subsequently, she has engaged in binge eating by sneaking food from the pantry and eating it quickly so her mother will not know. She hides the wrappers in her book bag and throws them away later. Nila then uses self-induced vomiting, a technique she learned from watching YouTube videos, to try to “get rid of the calories.” She begs Asha not to tell her mother because she does not want her mother to become even more controlling of her food intake.

Asha isn’t sure of the next best step to take because Nila is in a normal weight range and seems to be healthy overall. Asha decides not to inform Nila’s parents and keeps working with Nila individually because she wants to respect Nila’s privacy.

Implications for counseling practice:

In resolving the issue of whether Nila’s parents need to know about her binge/purge behaviors, Asha has to balance the parents’ legal right to know what is disclosed in sessions, Nila’s ethical right to privacy and autonomy, and the counselor’s duty to provide effective treatment and protect Nila from future harm. In making this decision, Asha recognizes that Nila does have an ethical right to privacy and could possibly be harmed if her mother becomes even more controlling over her food intake.

However, Asha should also be very concerned about Nila’s emerging diet/binge/purge cycle because this is a potentially high-risk behavior. While the binge/purge behaviors are not currently life-threatening, Asha needs to consider the serious and potentially lethal nature of eating disorders, the chronic and compulsive nature of the diet/binge/purge cycle, and the medical and psychological consequences of any emerging eating disorder. Because Nila is an adolescent, her health could deteriorate quickly due to weight loss and purging behaviors.

American Academy of Child and Adolescent Psychiatry practice guidelines call for a comprehensive medical examination, working with a treatment team, and family involvement in the treatment of eating disorders. For any of these treatment aspects to occur, the parents would need to be informed of Nila’s disordered eating behaviors; Nila can’t arrange for them herself. In this case, therefore, Nila’s parents would need to be informed, even if this goes against Nila’s wishes.

In order to respect Nila’s right to privacy and minimal disclosure, however, Nila should be involved as much as possible when her parents are informed. If feasible, the information should be shared in a family session. If Nila can be in the session when information is disclosed, she is less likely to feel betrayed by Asha. If Asha can establish an alliance with the parents while also maintaining trust with Nila, Asha can start to work with the family system to create better communication. The parents need assistance in allowing for increased, developmentally appropriate autonomy and privacy for Nila. At the same time, Nila will have to accept her parents’ assistance in helping her manage her disordered eating symptoms.

The entire family would benefit from education about the harms of dieting, particularly for children and adolescents, and how food restriction is directly linked to binge eating and
is often the trigger for binge/purge cycles. With Asha’s help, the family can start to focus more on overall health and communication and far less on control over Nila’s eating, weight and body shape.

Scenario 3: Jamie’s diet advice

Jamie is a female counselor who works for a community counseling agency. Jamie’s client Dan reports frequent binge eating that causes him a great deal of distress, guilt and shame. Dan is a 45-year-old man who is in a higher-weight body. Jamie assumes that Dan needs to eat less and lose weight to feel better about himself because of his larger body size. She does not assess for an eating disorder but rather persuades him to pursue weight loss as his treatment goal.

In contrast with what she deems as Dan’s “weaknesses,” Jamie is highly invested in maintaining her own weight, daily exercise routine and “clean eating.” She feels a certain pride in her own self-discipline and thinks that Dan’s problems result from a lack of willpower and effort on his part. She is quite uncomfortable with Dan’s body size and tells him he would be better off in his career and relationships if he were to lose weight.

Dan reluctantly agrees to restrict his calories and to exercise more, even though he has tried “hundreds of diets” over the years. As time progresses, he feels discouraged and even worse than he did prior to treatment with Jamie because he can neither adhere to the weight loss plan nor stop his binge eating. He drops out of treatment, believing he is a failure.

Implications for counseling practice:

Even though binge eating disorder is by far the most common eating disorder (occurring in 3.5% of women and 2% of men), it was overlooked by Jamie in this example because her client is male and has a larger body size. In addition to neglecting assessment for binge eating disorder, Jamie seems to lack awareness of effective treatment for binge eating.

American Psychiatric Association practice guidelines for the treatment of binge eating disorder state that dietary restriction is actually contraindicated; in fact, dieting is known to trigger and sustain binge eating. There are biological and psychological reasons for this relationship. When Dan (or anyone on a diet) restricts food, he begins to deprive himself of the energy needed to maintain his current weight. As a result, the brain sends out warning signals telling his body to slow down because it thinks it is entering a time of famine. It also tells Dan to take in more fuel to prevent what it perceives as starvation. In an effort to preserve energy and fight against weight loss, his body’s metabolism will decrease, he will have more thoughts about food, and he will become increasingly hungry.

Second, the more Dan imposes restriction and deprivation on his life, the more he will experience psychological reactance — an internal battle that ensues anytime we perceive that our personal freedoms are being restricted. He will start to think about, crave and, eventually, overeat the very foods that he has ruled “off-limits.” He will likely eat more, not less, because of dietary rules. And for Dan, who has a long history of binge eating, his hunger, deprivation and dietary rules will most likely serve as triggers for continued binge eating. This will lead to a cycle of guilt/shame, dieting, broken rules, binges and more guilt/shame.

In addition to pushing a potentially harmful treatment plan, Jamie seems to be having difficulty managing her countertransference reactions. Like so many people in today’s culture (including many mental health and medical professionals), Jamie appears to have a bias against people in larger bodies. Because she believes that losing weight is the “answer” to Dan’s problems, she imposes this value on him even though he is seeking treatment not for weight loss but for reducing his symptoms of binge eating. Jamie’s discomfort with her client’s body is a form of weight-based discrimination that can cause Dan to feel judged and further marginalized.

Research indicates that weight stigma actually demotivates, rather than encourages, health behavior change. In response to weight stigma, people tend to eat an increased amount of food and are less likely to adhere to a diet plan. To avoid further stigmatization, they tend to avoid exercise, fearing additional judgment from others. They also tend to delay medical care to avoid stigmatization from medical professionals who may further criticize, blame or shame them for their weight. Jamie’s personal values in this case are causing her to display a lack of respect for Dan’s dignity and welfare. In sum, her biases and lack of knowledge of effective treatment for binge eating disorder are actually causing her client harm.

Key takeaways

The following list is a summary of considerations for counselors when they encounter clients who experience problems with eating, weight and body image:

Remember that anyone can develop an eating disorder. Do not assume that only underweight white women have eating disorders. For example, binge eating disorder is the most common eating disorder, and it occurs in people of all sizes and cuts across both gender and race/ethnicity.
During the intake process, ask questions about the client’s attitudes and behaviors toward eating, weight and body image. Remain aware that initial symptoms can potentially progress to full-syndrome, complex eating disorders.
Regardless of your treatment setting, be aware of resources, and be prepared to make proper referrals so that clients can receive specialized care when needed.
Effective eating disorders treatment involves a multidisciplinary approach.
Counselors, like all people, can have strong biases in the areas of eating, weight, body image and the importance of appearance. We have to be careful about imposing these values on our clients.
Weight stigma is a form of discrimination that serves to marginalize and shame people. It is not a value supported by the counseling profession.

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Recommended resources:

“Ethical Issues in the Treatment of Eating Disorders” by Laura H. Choate (in The Cambridge Handbook of Applied Psychological Ethics, edited by Mark M. Leach and Elizabeth Reynolds Welfel, Cambridge University Press, 2018)
“Assessment and diagnosis of eating disorders” by Kelly C. Berg and Carol B. Peterson (in Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment, edited by Laura H. Choate, American Counseling Association, 2013)
American Psychiatric Association practice guideline for the treatment of patients with eating disorders (2010): tinyurl.com/APAEatingDisorders
“Practice parameter for the assessment and treatment of children and adolescents with eating disorders” by James Lock, Maria C. La Via and the American Academy of Child and Adolescent Psychiatry Committee on Quality Issues, Journal of the American Academy of Child and Adolescent Psychiatry, 2015
National Eating Disorders Association: nationaleatingdisorders.org
Academy of Eating Disorders: aedweb.org/home

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Laura H. Choate is the Jo Ellen Levy Yates endowed professor of counselor education at Louisiana State University in Baton Rouge. She is the author of five books, the most recent of which is Depression in Girls and Women Across the Lifespan: Treatment Essentials for Mental Health (2020). She has 40 publications in journals and books, most of which have been related to girls’ and women’s mental health. She is a member of the ACA Ethics Committee. Contact her at lchoate@lsu.edu.

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