Monthly Archives: November 2021

Bringing pornography use out of the shadows

By Bethany Bray November 30, 2021

Dana Kirkpatrick, a licensed professional counselor (LPC) and certified sex therapist (CST) and supervisor in Pennsylvania, is only half joking when she says she “specializes in talking about really uncomfortable things — and business is booming.”

She often supports clients as they delve into what is and isn’t working in their sex lives and how that intertwines with mental health, relationships and other aspects of life. Those discussions frequently include open and honest conversations about pornography, Kirkpatrick says.

Pornography use, like many other topics related to sexuality, can tie into other concerns that individuals and couples bring to counseling. Clients’ attitudes and beliefs regarding pornography are typically internalized based on social, cultural and moral influences. It is up to practitioners to raise the topic and create a nonjudgmental space for clients to explore the role pornography might play in their own sexuality and relationships, says Kirkpatrick, an American Counseling Association member and owner of the counseling practice Calm Pittsburgh.

This is unexplored territory for most clients, she points out, especially for couples, many of whom have never spoken out loud to each other about their use of or views on pornography. It is a complicated topic that can involve feelings of shame, hurt or embarrassment, and individuals often don’t know how to begin to talk about it.

“The important thing is [for counselors] to prompt that dialogue,” notes Robert Zeglin, a licensed mental health counselor and CST in Florida who is the founding editor of the Journal of Counseling Sexology & Sexual Wellness. “[A client] may think their partner is watching porn for one reason, but they may be wrong, entirely wrong — and they need to talk that through. … It’s a very powerful thing when people are openly allowed to talk through these things: Why am I so opposed to porn? Or why am I drawn to it? It’s really powerful to facilitate and be a part of that [exploration].”

Unrealistic expectations and assumptions

Kirkpatrick says pornography can shape a person’s sexuality much like romantic comedies do. Both set people up with unrealistic expectations concerning sex, attraction and romance, she explains.

“If [the film] Pretty Woman was your first view of romance, then that’s what you see as romance,” Kirkpatrick says. “It’s the same for porn or 50 Shades of Grey. If that’s what you see first, it’s an expectation. Both scenarios create delusions of grandeur that set you up for failure.”

“Just as with romantic comedies, we know they’re actors, but [pornography] can still lead to unrealistic expectations,” she notes. 

Pornography use can have negative effects on clients’ sexual wellness when it is used as a substitute for or an addition to sex education during a client’s formative years or when it is consumed without the intentional mindset that pornography is fictitious, with actors who are performing in scenes and stories that are created, curated and edited by a full crew of professionals.

Zeglin, an associate professor and program director for clinical mental health counseling at the University of North Florida in Jacksonville, refers to this tendency to view pornography as factual or real as “bad porn literacy.” Clients who have this mindset can struggle with body image issues and negative thought patterns as they compare their bodies to the above average (and often augmented) bodies they see portrayed in pornography, he explains.

“Body shame is a common theme when talking about pornography [with clients],” Zeglin says. “Just as not everyone looks like the cast of [the TV drama] Grey’s Anatomy, we need to emphasize that [pornography] is entertainment. There are so many bad expectations that can leak into sex and body expectation.”

Similarly, clients can harbor unrealistic expectations about what sex is or should be, Kirkpatrick adds. This can especially be true for people who started viewing pornography at a young age. Young adults may expect their partners to do certain things and respond in the same way that they’ve witnessed on screen, she notes.

Aydrelle Collins, an LPC who specializes in Black sexuality at her Dallas practice, Melanin Sex Therapy, says that pornography is where many of her clients first learned about sex or saw other people be sexual. In addition to body image issues, this can lead to a narrow or incomplete understanding of sexuality, she says.

In pornography, “the focus is on the orgasm, and if there’s not one [in real life], it can lead to disappointment,” Collins says. “That robs people of being in the moment of sex, the full experience, and can lead to the assumption that they have to have performance-type sex.”

Pornography use can also lead to misconceptions about what a partner may want in sexual situations. For example, a pizza delivery person in a pornography scene may knock on the door ready and willing to have sex with the resident, but is that realistic or accurate? Of course not, Kirkpatrick says. Counselors can help clients talk through and clear up any assumptions they’ve internalized that may be leading to frustrations or challenges in their relationships or sexual wellness.

Zeglin, an ACA member, also emphasizes that counselors can offer psychoeducation for clients who harbor unhealthy expectations or assumptions gleaned from pornography. One important message, he says, is the reality that sex is often just OK, with some really great and really disappointing experiences thrown into the mix.

Clients’ lives and relationships can also be negatively affected by pornography when it is used compulsively. If a counselor hears a client talk about their pornography usage with language that might indicate a dependence or addiction — including viewing it at inappropriate times, such as when they’re at work or school — further assessment or specialized treatment may be needed. (For more on the nuances of helping clients who use pornography compulsively, see the articles “Six steps for addressing behavioral addictions in clinical work” and “Addicted to sex?”)

Broaching and breaking unhealthy cycles 

Laura Morse, an LPC and CST in private practice in Lancaster, Pennsylvania, says her clients bring up the topic of pornography almost daily, most frequently through questions related to the theme of “Am I normal?” Clients often wonder if what they are watching and the amount of time they spend watching is “OK” or “normal”; others question whether they should be watching it at all, Morse says.

“As clinicians, we work with clients who may be struggling with unpacking the messages they receive about sex — messages which can have negative impacts on their own sexuality and their relationships,” says Morse, an ACA member and Gottman-trained couples therapist. “It’s essential that we use evidence-based tools to evaluate what role pornography serves in our clients’ lives and assess what concerns they may have about their usage. Is it impacting time away from work? [Causing them to] spend too much money? [Resulting in] loss of interest in sexual desire with their partner? All of these assessment questions help inform treatment planning.”

Morse and Collins both recommend the PLISSIT model (developed by Jack Annon in the 1970s) for prompting discussions to assess clients’ thoughts on and relationship with pornography. The model’s acronym represents its four intervention levels: permission, limited information, specific suggestions and intensive therapy. Breaking discussion into these ascending levels helps practitioners decide whether they need to continue or intensify conversations with a client and match the individual(s) with an intervention that meets their level of need. 

The model’s first level can help broach sexuality-related subjects in an open way, as the practitioner invites and gives the client(s) permission to talk about and explore issues they might have previously considered taboo, including pornography, Morse says.

Feelings of shame regarding pornography use — either self-described in individual clients or shaming language used toward a partner in couples counseling — can also indicate that a counselor needs to facilitate discussion about the topic, Zeglin says. This can include the need to unpack the assumption that because one partner views pornography, it means they don’t find their partner attractive anymore, he notes. When left unprocessed, these emotions can lead to an unhealthy cycle.

“Because of that shame, they start to hide the porn use, [and] secret-keeping and hiding things is never good for relationships,” Zeglin says. “It creates a cycle, and it’s a pretty common manifestation within couples [where one or both partners] have an overall values system that porn is taboo.”

In addition to feelings of blame, shame and embarrassment, Collins says that pornography use can lead to a disconnect between couples. This is especially so for couples who have never talked about the subject together.

“It can create a disconnect in the relationship, in multiple layers. It’s not just the porn, but everything surrounding it and the shame that can come up,” says Collins, who is fully trained but not yet certified as a CST. “It can show up as resentment, lack of sex and connection, or arguments. It can be a spiral where one person is caught watching porn and they’re not having [frequent] sex already, and then that person is shamed [by their partner]. It causes them to retreat and furthers the lack of intimacy.”

Hurt feelings surrounding pornography use are often magnified when a couple isn’t having sex regularly or as frequently as one or both partners would like, Collins adds. Blame can become intensified if one partner feels the other is choosing pornography over sex within their relationship.

In these cases, a counselor can help clients talk through not only their feelings regarding pornography but also the many complicated layers that can accompany those feelings. This can include trust issues, Collins notes.

“You don’t trust [your partner] if you feel like you’ve been misled or lied to or shamed or ridiculed for something that you feel is normal and natural and everyone does it. Once that trust gets broken, there comes a disconnect,” Collins says. “We all bring our own messages that we’ve received about sex and sexuality into relationships, and that’s the biggest underlying thing. Sex brings up a lot of feelings of uncomfortableness if you haven’t had a chance to explore your own feelings about sexuality. … We all have attitudes and biases, including around porn. We all have different feelings about what’s healthy and not healthy, whether it’s OK to watch, and how much is OK to watch.”

Collins has worked with couples who have differing views on the consumption of pornography and admits that it can be a sensitive subject to broach. She emphasizes that practitioners should validate each partner’s views about pornography and focus on repairing the disconnect between partners by helping them process their underlying emotions.

To foster discussion in sessions, Collins often creates a “sexual health plan” with couples to outline what they’d like their sex life to look like together and the role that pornography will or will not play in it.

“In cases like these, I explore clients’ views on porn watching and what that means for their relationship,” Collins says. “These conversations can be difficult to facilitate, and working with this dynamic [when partners have differing views on pornography] can be a tender topic for couples. My advice to counselors working with couples is [to] focus on the underlying emotional hurt that is there. What are their goals for their relationship? The best thing a counselor can do to facilitate these discussions is to check their own views and bias around porn in order not to take sides.”

Unpacking the complicated layers that can surround clients’ pornography use may also include talking or asking about physical problems that are affecting clients’ sex lives and debunking misunderstandings or assumptions they may have regarding their or their partner’s sexual challenges.

Collins emphasizes there is no confirmed connection between the consumption of pornography and physical problems such as delayed ejaculation or erectile dysfunction. However, client assumptions regarding this topic can lead to an unhealthy cycle, she notes.

“Many people have the misconception that masturbating or watching too much pornography can desensitize people and cause them to not be able to perform or get an erection for sex,” Collins explains. “And those assumptions can exacerbate the problem if you have those [physical] problems already.”

The counselor’s role 

Kirkpatrick notes that when working with couples who are processing their feelings regarding pornography and its effects on their relationship, a helpful first step is to invite both partners to describe what they feel pornography is. Each person will have a different definition, and couples will benefit from understanding each other’s boundaries, she says. Is it acceptable to look at Playboy magazine? Browse the website Pornhub? Watch the TV show Game of Thrones? Visit interactive mediums where the user communicates with another person (such as virtual reality or video chat)?

“Help the partners define what their beliefs are [regarding] pornography use — good or bad — and what feelings they are having presently related to [their] pornography use. The key is finding the partners’ definition of their feelings and validating those feelings,” Kirkpatrick explains. “Then [counselors] can help them work on where their views come from and if they are being kind to themselves. Do they feel betrayed? Confused? Left out? Jealous? Once we can identify what that feeling is, then we can address it.”

Kirkpatrick also suggests that counselors include a range of questions about client sexuality, including pornography use and masturbation habits, during intake. This information will provide the practitioner with more context, and it lets the client know that the counselor is interested in and open to discussing these often-taboo subjects.

The counselors interviewed for this article agree that when unpacking the topic of pornography (both with individual clients and couples), a practitioner’s role is to serve as a neutral facilitator, prompting clients to explore the values, emotions and thoughts they hold regarding its use. With couples, this includes making equal time for each partner to explain their likes, dislikes and range of feelings.

Counselors should remain neutral — “without putting their thumb on either side of the scale” — while facilitating these conversations, Zeglin stresses. This mediator role includes the exploration of differences between couples and the differences that individuals hold within themselves on the topic.

“Have frank conversations about [the client’s] comfort levels and interest, [saying,] ‘Tell me a little bit about your values about sexual stimuli and porn. Is there anything that would get in the way of enjoying that?’ It’s the same as [addressing] anything that would put them outside of their comfort zone,” Zeglin says. “We need to give time and space to all voices, all the complex and dynamic parts of the people in the room.”

If pornography has led to conflict, feelings of betrayal or other hurtful emotions between partners, it may be appropriate to have them agree to temporarily pause their pornography consumption while they unpack their feelings and thoughts during this phase of therapy, Kirkpatrick says.

Because pornography consumption is an intense subject, clients may feel more comfortable talking about it if the counselor offers to look in another direction or turn their camera off in sessions held via telebehavioral health, she adds.

Inviting clients to frame their conversations about pornography through the lens of “this is what I’m into” empowers clients and allows them to present their thoughts in an open, positive way, Kirkpatrick says. In couples counseling, this approach can also spark questions, further dialogue between partners and, in some cases, reveal that the couple shares similar interests.

Kirkpatrick advises counselors to create an open and safe place for clients to talk about pornography use because it helps take away the power of shame that often accompanies the topic. She sometimes uses a “yes, no, maybe” chart that lists a variety of sexual interests, including different types of intercourse, use of vibrators, pornography and other preferences, to encourage open discussion between couples. Each partner fills out their own chart, selecting “yes,” “no” or “maybe” for each item. Afterward, couples have an avenue to talk about things honestly with each other (both inside and outside of counseling sessions). This tool can also help with overcoming shyness, Kirkpatrick says, and reveal sexual interests that both partners share, including ones they may not have known about or considered previously.

Kirkpatrick also sometimes suggests that clients use the app MojoUpgrade, which has a similar quiz to help couples explore and spark discussion about sexual interests and desires. The app shows only items for which both partners have responded “yes,” which can also help with overcoming shyness, Kirkpatrick says. 

In couples counseling, the clinician should ensure that conversations about pornography remain respectful and refrain from assigning blame or shame toward either partner, Collins says. Society often views pornography in black-and-white terms of either all good or all bad, but it’s more complex than that. A counselor can help clients understand that it’s natural to have multifaceted feelings on the topic.

“The truth is you can put up boundaries for what you want, but you need to get there without shaming your partner,” Collins says. “Have clients really flesh out what their narrative is around sex. If they feel like porn is not the best thing for their partner to watch, explore why that is without shaming their partner. [Prompt] conversation about what they are getting out of watching porn: Is it fantasy or being curious, etc.? Everyone is allowed to have their own feelings about what is healthy and boundaries on what they want out of sexuality.”

Collins notes that using a narrative focus can be helpful in this realm. Prompting clients to explore their sexual narrative frames the conversation in an empowering way and allows them to talk through and reject stereotypes and internalized messages that they no longer feel are helpful or accurate, Collins says.

An important aspect of this work includes asking clients questions about their sexual history. Collins does a sexual genogram with clients to find out where they first learned about sex, who they have discussed sexual issues with and other details. Asking questions about when and how they began to view pornography can also give the counselor and client(s) more context on factors that influence how they feel about and interact with pornography currently.

“I go line by line, unpacking everything they’ve ever taken in about sex, and assess how that impacts how they view sex now and how they view themselves as a sexual being,” Collins says. “[This allows them to] leave the things that no longer suit them and find the things that help them define their sexuality. … Our role as therapists is to help clients [find] their own narrative — not what they’ve been told or our narrative, but what works for them.”

Allowing clients to “be present and accept that they are sexual creatures” leads to empowerment and stronger confidence and decision-making, she adds.

Back to basics 

Zeglin advises practitioners who are helping clients process their feelings and thoughts on pornography to “take the sex out of it.” Instead, counselors should draw upon the same toolbox of methods they would use to help a client who is wrestling with a nonsexual dilemma.

“Anything that distracts from the relationship can impact it negatively; it’s not the porn per se,” Zeglin says. “It’s just like anything — it’s really the use of it and not the thing itself that can cause problems.”

In fact, research has shown that the level of dopamine released by the brain when a person watches pornography is the same as when a person does other things they enjoy or find pleasurable, he adds.

pio3/Shutterstock.com

Zeglin finds that Gestalt theory is a helpful lens to use as he prompts clients to explore and “give voice” to the parts of themselves that are in competition. For example, perhaps a client is conflicted because they want their partner to be happy, but they also feel that their partner must think they are ugly because their partner chooses to watch pornography. Or maybe a client is drawn to pornography because it entertains them or brings them pleasure, but they also feel guilt and shame for watching it. 

“If you take the sex out of it, it becomes a counseling 101 values conflict,” Zeglin says.

Perhaps a counselor is working with a couple experiencing a common scenario: One person is watching pornography and is compelled to hide it, and the other partner finds out and is hurt. By taking the sex out of it, Zeglin says, counselors can flip this conversation and ask, what if the person had set a goal to lose weight and the partner found them sneaking Oreo cookies? In both scenarios, the practitioner and clients would need to explore the couple’s lack of communication, the sense of broken trust, and other thoughts and feelings related to the behavior, he explains.

“Don’t make the problem the porn. Focus on the relationship. Sex is so moralized that we get distracted by that sometimes,” says Zeglin, a co-founder and past president of the Association of Counseling Sexology and Sexual Wellness, an organizational affiliate of ACA. “Counselors already have the tools to address it, but it just feels different because sex is involved.”

When it’s a good thing

Adult couples who have talked through their feelings and preferences and are accepting of pornography may find that viewing certain things together can enhance their sexual relationship. The counselors interviewed for this article noted that some clients (consenting adults) on their caseloads have benefited from incorporating pornography into their sex lives as a way to explore new things together. This can happen organically, such as when couples come up with the idea on their own, or when a counselor suggests it (when appropriate) as a bonding exercise for a couple outside of session.

“First, you have to make sure it’s accepted by the couple and culturally appropriate,” says Kirkpatrick, who co-presented a session, “Sex Positivity: Increasing Competencies in Addressing Sexuality Issues in Counseling” at the 2021 ACA Virtual Conference Experience. “There are body-positive sites, or sites with [instructional-style videos on] things to try. It’s using it as a tool, not a replacement. It should be something to enhance your sex life, not replace your sex life.”

Kirkpatrick has a list of sex-positive websites she offers to clients who express an interest in watching pornography together. It can be a means to grow together and learn what each partner does and does not like, she says. It can also be a way for couples who have a low sex drive or sexual desire to begin thinking about sex before becoming intimate together. Depending on a couple’s interests and comfort level, Kirkpatrick’s sex-positive recommendations can include pornography that involves writing (such as erotic fiction), photographs or images, or videos.

Collins agrees that pornography can be a helpful tool for some clients. Couples who have trouble with physical issues, such as erectile dysfunction, can use it to find and explore other avenues of sexuality that may work better for them, she notes.

“A lot of people figure out what turns them on by watching porn,” Collins says. “It can be a way to educate, watch together and … explore fantasy, broaden your sexuality or get out of a rut. It can give people options, room to explore, and open up dialogue and conversation around sex.”

It can also be a way for couples to bond and even laugh, Zeglin adds. “Couples need to explore both mentally and physically, and things change over the life span. Desires change, bodies change as we age. Just like anything, porn can serve as an opportunity to see what strikes your fancy,” he says. “Or you can giggle together about how unrealistic it is [and] how bad the dialogue is.”

Counselor competency

Professional counselors must always assume a nonjudgmental lens when working with clients, especially ones who are wrestling with thoughts and feelings about the complex and sometimes uncomfortable topic of pornography. The professionals interviewed for this article agree that counselors have a responsibility not only to leave their personal feelings out of the equation but also to seek training, continuing education or consultation when they don’t understand or know how to best treat a client’s questions or conflicts regarding pornography.

“We [counselors] are licensed as health providers, and we have to remember that what is and isn’t healthy is different than what is or isn’t personally important to us,” Zeglin says.

Collins agrees, noting that the last thing she wants to do is add another voice to a client’s understanding of a topic that is already heavily influenced by cultural, societal and other factors.

“I want them to find their own voice,” Collins says. “We [counselors] need to be checking our own biases and our own narratives around sex so that we are not imposing what we feel about sex and porn [on clients]. When our stuff comes into a session, it takes away from the work that we are doing with the client. Sometimes, with sex, [practitioners] tend to forget that.”

Practitioners also shouldn’t make assumptions about clients’ views on pornography. For example, clients who come from conservative religious or cultural backgrounds may not automatically be opposed to pornography use, whereas clients who come from more liberal backgrounds won’t necessarily embrace it, Kirkpatrick points out. In addition, clients will have a range of feelings about pornography that won’t necessarily fall into binary categories of “pro-pornography” or “anti-pornography,” she says.

Kirkpatrick urges counselors not to feel that they should refer a client whenever sexual wellness issues arise in counseling work. Instead, she encourages counselors to seek training, supervision or consultation with a local sex therapist. Counselors and CSTs can also co-treat clients, when appropriate, she notes. (Find a local CST and continuing education offerings at the American Association of Sexuality Educators, Counselors and Therapists website, aasect.org.)

Counselors who find they are interested in facilitating dialogues about pornography should consider seeking certification as a sex therapist, she adds.

“Don’t automatically refer. We need more people to be able to talk about this comfortably,” Kirkpatrick stresses. “Also, ask the client. I learn more from my clients than anyone else. … They are the experts in their sexuality because it’s so complicated. They are the experts on themselves.”

 

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Pornography use during the COVID-19 pandemic

As the COVID-19 pandemic began to stretch across the globe, causing millions of people to stay home, many individuals and organizations predicted or assumed that the isolation, loneliness and boredom would result in an increase in pornography consumption. 

In spring 2020, Pornhub announced that the online platform’s “premium” content would temporarily be free to users who were on lockdown because of COVID-19. As a result, the company reported a 38%-61% increase in web traffic from regions that had lockdowns and restrictive stay-at-home orders. This usage was above and beyond the more than 1 million daily unique web visits that Pornhub reported in 2019.

However, a study published recently in the Archives of Sexual Behavior polled more than 2,000 men and women in February, May, August and October 2020 and found that pornography consumption among American adults decreased overall in 2020.

In May, immediately following the United States’ first wave of pandemic-related restrictions, there was a small increase in the number of people who said they had viewed pornography in the past month, but less so than in the baseline data, which indicated that 38% of participants — 59% of men and 21% of women — reported using pornography at least once per month.

“Among those who reported use in May 2020, only 14% reported increases in use since the start of the pandemic, and their use returned to levels similar to all other users by August 2020,” wrote the study’s co-authors. “In general, pornography use trended downward over the pandemic, for both men and women. Problematic [compulsive or uncontrolled] pornography use trended downward for men and remained low and unchanged in women. Collectively, these results suggest that many fears about pornography use during pandemic-related lockdowns were largely not supported by available data.”

 

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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.

Voice of Experience: Three rules for identifying abnormal child sexual behaviors

By Gregory K. Moffatt November 23, 2021

I explained my symptoms as the orthopedist looked at my knee, and he made a statement that I subsequently borrowed and have used many times in my work since then: “What you are experiencing isn’t normal, but it isn’t unusual.”

In other words, while my knee shouldn’t have been doing what it was, my symptoms were common and not necessarily a problem.

That line is applicable to many things we face as counselors. I have seen literally thousands of children in one forum or another throughout my long career, and I’ve talked to hundreds of worried parents.

“I found my child doing …” they often begin with awkward hesitation and then follow it with some behavior they observed that troubles them. Sometimes I am troubled too, but not always.

The childhood sexual behaviors I see can be grouped into three categories: normal behaviors, behaviors that are not normal but not unusual, and behaviors that are abnormal.

Prior to age 2 or 3, children don’t have any concept of modesty and may disrobe in the middle of Walmart if they are uncomfortable. By age 5, most children are beginning to learn modesty but still might run through the house naked even if company is present. In a way, they think that if they run fast enough, it doesn’t count as being naked.

By prepubescence, nearly all children have learned the family and cultural rules of modesty.

Likewise, nearly all children exhibit sexual behaviors at one time or another. They may self-stimulate, explore their bodies, and if other children are in the home, they might notice, explore or tease about the other child’s body parts.

As with modesty, children must learn how to use their body parts, what parts they can show and what parts they cannot, and what parts on someone else they can touch and which ones are off-limits. Learning these rules takes time and experience.

Parents rarely call me about the normal exploration they see in their children. Most of them recognize common childhood behaviors. It’s more likely I’m called when behaviors fall into the second or third category.

“I saw my 6-year-old child and his same-aged cousin in the bedroom playing. They had taken off their pants and were waiving their penises at each other,” one troubled parent said.

While not normal (not all children do this), this behavior isn’t unusual and by itself isn’t necessarily cause for alarm.

“I came into the bathroom and caught my 8-year-old son holding down his 5-year-old sister and pulling her underwear down while she was yelling at him to stop,” said another parent. This behavior is definitely troubling and falls into the third category.

There are three basic rules for distinguishing between behaviors like the second and third examples above: forced, painful, invasive.

Rule No. 1: Normal sexual behaviors in children are never forced. The exploration is mutual. While one child likely had the idea first, both children must participate. This doesn’t mean that two children might agree to engage in abnormal sexual behaviors, however. Hence the next two rules.

Rule No. 2: Normal sexual behaviors in children are never painful. When children who usually behave normally realize they have caused pain, they stop.

Rule No. 3: Normal sexual behavior in children is never invasive. Normal childhood curiosity does not include inserting objects or one’s own body parts into the cavities of others — anus, vagina, mouth, etc.

There is one other important caveat. Most normal childhood behaviors occur between children of similar age. It is highly unusual for a young child to sexually engage with a teen without violating one of the three rules above. That behavior definitely calls for further investigation. And, certainly, any sexual interaction between an adult and a child is cause for mandated reporting.

Most of the sexual behaviors parents see in the first two categories — normal or not normal but not unusual — are not necessarily behaviors we condone. But just because one of these behaviors happens doesn’t mean there is trouble.

Sexual behaviors are laden with both cultural rules and religious meaning. As a counselor, I must be able to identify sexual behaviors that are common — as well as those that may not be normal but aren’t unusual either — and put a parent’s mind at ease while also respecting their culture and belief systems.

Most importantly, I must be able to identify symptoms of abuse and abnormal sexual development, and I must comply with mandated reporting laws within my state. It was a desire to prevent child abuse and intervene where I could that motivated me to begin my career as a child therapist in the first place.

Andrew Seaman/Unsplash.com

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Related reading, from the Counseling Today archives: “Addressing children’s curiosity of private parts

 

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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.

Culture-centered counseling

By Lindsey Phillips November 22, 2021

The 2020 census revealed a growing multiracial U.S. population, with the number of people who reported multiple races increasing from 2.9% in 2010 to 10.2% in 2020. Part of this increase stems from changes the U.S. Census Bureau made to the questions about race and ethnicity to more accurately capture the shifting demographics of the nation’s population. These changes included removing the word origin on the instructions for the Hispanic ethnicity question, because this term can mean different things to different people, and adding write-in response areas for the question about racial identity. 

The counseling profession could also benefit from rethinking the way it approaches diversity and multiculturalism. Most of its foundational theories and approaches, such as psychoanalysis, cognitive theory and cognitive behavior therapy, were developed by white men, leading many counselors to ask whether these approaches still meet the needs of an increasingly diverse and multiracial clientele.  

Answers to these questions are not easy or straightforward. Some counselors want to revise or adapt these foundational counseling theories to make them more inclusive, while others argue it’s time to make room for more culture-centered theories or even create new ones.

The thought of adapting traditional forms of counseling to make the process more appropriate for culturally diverse populations bothers Derald Wing Sue, a professor of psychology and education at Teachers College, Columbia University, because “it almost assumes that no societies or other groups ever had anything like counseling or psychotherapy,” he says. Instead, he argues the mental health field should broaden its understanding of Indigenous and non-Western help-giving networks.

Broadening the theoretical perspective 

“All theories of counseling and psychology represent worldviews, primarily ones from the developer of that theory,” says Sue, the author or co-author of several books and articles on multiculturalism, including Counseling the Culturally Diverse: Theory and Practice and Race Talk and the Conspiracy of Silence. Rational emotive behavior therapy, for example, stems from Albert Ellis’ view that problems reside in the cognitive realm. In turn, these theories “represent worldviews that define normality [and] abnormality, what is therapeutic [and] what isn’t therapeutic,” Sue says. “So, the first objective is for therapists and systems of counseling and psychotherapy to deconstruct their worldviews.” 

Sue also argues that theories of counseling and psychotherapy should encompass an understanding of the social-political dynamic that affects the counseling situation. Many clients come to counseling with a worldview that is intimately linked to their status as a member of a marginalized group and the social-political dynamics surrounding that status, he notes. 

“Therapists often don’t understand that in their work, they may be encouraging clients in a forced compliance to assimilate and acculturate [and] to do things the white, Western way,” he says. “A liberated form of helping is one that recognizes strongly the social-political element and is unafraid to include that as part of the counseling session and structure that is going on.” 

Although many theories of counseling and psychotherapy attempt to do this, they have done it in a way that is not well integrated in terms of the system of counseling, he adds.

In addition, Sue, co-founder of the Asian American Psychological Association, points out that counseling theories typically study only one aspect of the human condition: the behavioral self, the feeling self, the cognitive self, etc. But human beings contain more depth; they are also cultural, political and spiritual beings, which traditional counseling can often overlook.  

Culture-centered counseling theories such as liberation psychology, relational-cultural theory and critical race theory begin to address some of the gaps in more traditional counseling approaches. These theories have basic tenets that counselors can use as a foundation for how they interact with clients, says Regina Finan, an American Counseling Association member whose research interests include multiculturalism and social justice. 

One tenet of critical race theory, for example, is that race is a social construction with real-life implications, she notes. Critical race theory asks people “to stretch and expand themselves, and bracket all the things they think they know and understand as ‘right’ and ‘true’ [about race and racism] and make space for things that they can’t understand because they haven’t lived it,” Finan says. “But isn’t [making space for clients’ experiences] what we are trained as counselors to do? … We just don’t always talk about it in terms of race, sexual orientation, gender identity, religion and all these pieces.” 

Even if counselors have never experienced depression or anxiety themselves, they don’t doubt that their clients have, says Finan, an assistant professor of counselor education at the University of West Georgia, and they set about educating themselves on those issues. That is what equity-centered theories are asking counselors to do, she stresses.  

For example, a Black client might have panic attacks whenever they get pulled over by the police. A counselor could choose to use cognitive behavior therapy to help this client because it has been shown to be an effective treatment for panic attacks. But the counselor could also approach this situation using the lens of critical race theory, Finan says. This lens can help situate the client’s fear as rationale within the broader systemic context of police brutality and racial bias. Being culturally aware will help the counselor broach this issue with the client and remind them that the problem is a systemic one, not something that is “wrong” with them. 

Broaching the topic is important, Finan adds, because although the counselor may find that there is a specific fear associated with the client’s race, it is also possible that the client fears getting in trouble. Ultimately, the counselor has more information, and then they can work together and use appropriate techniques to help the client manage the panic attacks and explore the concerns underlying the attacks.

Unlike many traditional counseling theories, Black existentialism asks counselors to broaden their perspectives and sit with the knowledge that there are multiple truths and experiences, notes Linwood Vereen, an associate professor of counseling at Shippensburg University of Pennsylvania. In the article “Black existentialism: Extending the discourse on meaning and existence” (published in The Journal of Humanistic Counseling in 2017), Vereen, an ACA member, and his colleagues explain how Black existentialism aims “to merge both individualistic and collectivist representations and dimensions of the respective self, in such a manner that the real and constructed selves are intricately bound with the social circumstances human beings find themselves situated within.”  

This theoretical approach challenges counselors to find ways of applying this notion of individual existence to clients who live and operate within communities, he adds.

Doralis Coriano Ortiz, an ACA member and licensed clinical professional counselor in Illinois, acknowledges that theories that are more culturally centered can provoke uncomfortable feelings for some counseling professionals because these theories often challenge what they have been taught in the U.S. educational system. These theories often force counselors to confront the racist origins of counseling and psychology and the ways they have appropriated and repackaged Indigenous practices, she says. 

Taking a culture-centered approach 

Culture-centered theories acknowledge that people are affected not just by interpersonal relationships but also by larger systems, notes Finan, the Association for Multicultural Counseling and Development (AMCD) vice president of multiethnic, multiracial and transracial adoptee concerns. This view allows counselors to broaden the context for clients, helping them realize that the counseling relationship involves more than just the counselor and client; it’s about the counselor’s and client’s lived experiences, which are embedded in their families’ lived experiences, as well as privileges and marginalized experiences, she says. 

If a client is struggling with how racism or poverty is affecting them, Finan suggests that the principles of critical consciousness and liberation psychology can be used to engage the client in a conversation about how systemic and historical oppression can shape them. She may have clients complete a family genogram to unpack the role that racism plays in their life. Clients can go back as far as they are able in their family tree, thinking about the experiences that their family had with racism, how that shaped them then and how it continues to shape the client today. 

The goal of this exercise is to help clients clearly understand the systemic nature of racism and realize that these experiences are not their fault, says Finan, co-author of a book chapter on intersectionality in Introduction to 21st Century Counseling: A Multicultural & Social Justice Approach. (The book is co-edited by ACA President S. Kent Butler.) In addition, this strengths-based approach seeks to center the resilience and characteristics of individuals, which in turn can be used to reject deficit narratives created by oppressive systems, she adds.

Monica P. Band, a licensed professional counselor and clinical supervisor who owns the private practice Mindful Healing Counseling Services, with offices in Washington, D.C., and Manassas, Virginia, also highlights how systemic factors affect her clients’ mental health. For example, she has worked with several women of color who were struggling with impostor syndrome. Some counselors may be tempted to focus on changing the client’s thoughts and behaviors around being an “impostor” without first considering context, Band says, but then they are leaving out a large part of the problem. 

“While the experiences of impostor syndrome are not unique to BIPOC [Black, Indigenous and People of Color] folx, the experience takes on a different tone, and cultural influences must be considered,” Band explains. “Most spaces are not created for [this client]; in fact, they often actively exclude her and, historically, have been meant to exclude her via legislation or social norms. So, some of the discomfort that the client is experiencing is not about her ‘not being enough’ but an appropriate and natural reaction to systems which have defined her as ‘not enough,’ and the client has internalized harmful narratives like this.”

She advises counselors to be cautious and avoid pathologizing the client’s distress and instead be active in observing the client’s lived experiences. “When believed, narratives associated with impostor syndrome like ‘I am not good enough’ or ‘I shouldn’t/don’t deserve to be here’ continue to perpetuate the oppressive nature of impostor syndrome by attacking the client’s self-concept,” Band says. “It is our goal as culturally competent counselors to call out and normalize these narratives by providing a broader, historical understanding for our clients by decolonizing and deconstructing their intersecting cultural identities with them.”

First, Band would normalize the client’s complex feelings of shame and pressure to succeed around being an “impostor,” and she would remind the client that the feelings associated with being an impostor, counterintuitively, helped the client survive in oppressive spaces at one point in her or her ancestors’ lives. “When I say surviving oppressive spaces, what I mean is to adapt and assimilate,” she explains. “At some point in history, BIPOC folx learned that in order to survive physically and emotionally, sometimes it was necessary to make oneself smaller, to not be seen, to not take up space, to not be [themselves] — in other words, oppress [themselves] and adapt to the legislation that has excluded [them] from these spaces.”

When these individuals enter spaces where they don’t feel like they belong or that don’t have many people with similar cultural backgrounds or lived experiences, Band continues, they begin to ask themselves, “Is this a mistake? Should I be here? Why am I here? It doesn’t feel safe.”

When Band and the client step back and begin to deconstruct the perspective of belonging considering this context, the client can then grieve the lost opportunity that resulted from intergenerational trauma and inequitable systems. The client can also learn to intentionally respond to these systems rather than react out automatically, Band adds.

“Counselors must contextualize these harmful narratives [and] understand and focus on the history as a source of strength,” Band argues. “The client has autonomy in choosing these narratives as their own once they build conscious awareness. The client and [counselor] then can build upon the strength, energies and spirits of [the client’s] ancestors as motivation and reflection. The counselor is not just working with that individual client in front of them on that couch; they are working with the ancestors and traumas the client brings with them.”

Liberation psychology means redirecting pathology away from individuals and onto systems that create environments where it is not possible for someone to be healthy, says Sarah Sevedge, a licensed mental health counselor in private practice who also holds a doctorate in counseling psychology. LGBTQIA and BIPOC clients have come to see Sevedge because of anxiety, depression and trauma — issues that can stem, she says, from the fact that they live in rural, conservative areas that may be antagonistic toward their identities. Sevedge realizes that the larger societal and systemic issues affecting her clients’ mental health work against their ability to be fully healthy, but often her clients view their mental health issues as personal failures. 

“So many clients look at mental health issues as if something’s wrong with them — they’re anxious, they’re depressed,” Sevedge says. She reminds them not to be upset with their bodies for responding appropriately in unhealthy environments. “If you have high levels of anxiety in an oppressive context, then your body is functioning properly; you’re not the problem,” she explains. “But we don’t always look at it that way.” 

Sevedge also tries to create a brave space within the oppressive environment by not being neutral about the oppression and validating her clients’ experiences. She believes clinicians must be willing to step into a therapist-activist role in the community and actively engage in the larger social dialogue on diversity and multicultural issues. Counselors can do this, she says, by attending Pride and Black Lives Matter events, participating in discussion groups about these topics, and integrating inclusive symbols into their practice (e.g., Pride flags, anti-racist and religious-inclusive artwork). Counselors can also refer clients to peer groups and other social support networks that share similar struggles to help them form community. 

Coriano Ortiz, a bilingual psychotherapist at Live Oak, a psychotherapy group practice in Chicago, often works with first-generation college students of color who attend primarily white institutions. So, if a client tells her that they have anxiety and don’t think that many people like them at school or can relate to their experiences, she doesn’t encourage them to challenge this “irrational thought.” That would only gaslight their experience, she says. Instead, she explores possible systemic issues that could be causing the client to feel this way. She asks questions such as “When did you first feel like others didn’t like you?” and “How is the transition from home to college going? Are you making friends?” These questions quickly reveal the underlying issues at play and help clients realize that their beliefs are not irrational and can be an understandable reaction to white supremacy. 

Clinical work will not always specifically be about race, gender or culture, Finan adds. Sometimes a client’s presenting issue is just about depression or anxiety, but counselors should be open to listening for when culture does play a role, she asserts. 

Decentering whiteness 

Band, an ACA member who serves on ACA’s Anti-Racism Commission, and Coriano Ortiz are intentionally decentering whiteness in their practices by asking their white clients some of the same questions that are often asked of clients from BIPOC communities.

Counselors “don’t [typically] ask white people the same questions we ask people of color,” Band says. “Some of that’s for good reason because the trauma experienced historically is felt and experienced to a greater degree by BIPOC. Counselors want to be respectful of these differences in lived experiences by acknowledging and discussing race, ethnicity and various marginalized identities within the counseling session. However [this focus] often exclude[s] accountability for white people and their lived experiences. For example, by counselors not asking how white people feel about certain sociopolitical events, they are at risk of preserving white supremacy within the space. We can so readily talk with BIPOC folx on how it feels for them as a member of their community in relation to — insert a sociopolitical event — but asking white people the same is uncommon.” 

One of Band’s office locations is near the U.S. Capitol. So, in the aftermath of the Capitol insurrection on Jan. 6 — an event she believes illustrates a buildup and continuation of hate and violence toward marginalized communities — she asked all of her clients what it was like for them to see those events unfold. She got some culturally humbled responses from her white clients. One admitted they had not considered how, as a white person, this event could also affect them. 

“They didn’t think about it because white is the default,” Band stresses. “Right now, white is seen as a monolith; it’s created that way because that’s how white supremacy maintains power. … So, if you don’t ask white people what does that mean for them as white people, then we’re not going to begin to break through the identity development that needs to occur.” 

fizkes/Shutterstock.com

This simple question allowed Band’s white clients to become more self-aware and to pause and consider how they are also a part of the community, and it challenged them to reconsider their own privilege and accountability, she says.

“Most of the white clients I work with mean well, and they are deeply empathetic to BIPOC communities, which is why most of their focus is on how that makes others — i.e., BIPOC folx and their families — feel when they are shot, targeted and taken advantage of by the system,” Band says. “They do not focus on how they enable an inequitable system. But the truth is we all must look at our own role in these systems.”

Coriano Ortiz also makes a point to ask her white clients about their cultural background. They frequently respond by saying, “I’ve never thought about it” or “I didn’t realize I had a culture.” She often eases them into this discussion on cultural identity by asking what their holiday traditions look like. This question helps them consider the diversity within white culture, which may be rooted in German, English or Swedish cultures, for example. 

Counseling resources often focus on how to work with BIPOC communities but not on how to work with white people, notes Band, AMCD vice president of Asian American/Pacific Islander concerns. She hopes that as more BIPOC counselors enter the field, the focus will be not just on ways to treat these communities as “others” but also on ways to help BIPOC mental health professionals. This means there will need to be more trainings on how to work with white clients and supervisors and within predominantly white counseling programs, she points out. 

Allowing for other viewpoints

People often equate good mental health with having a positive self-concept or strong self-esteem, says Manuel Zamarripa, a licensed professional counselor supervisor in Texas. But this leaves out the collectivist piece of mental health. 

“The [counseling] field is built on a foundation of individualism,” he says. “There’s nothing wrong with individualism … [but] we need a balance in worldviews as well.” 

When counselors encounter clients who come from a different worldview, they tend to describe the other viewpoint as a deficient version of their own worldview, says Zamarripa, a dean of counseling at Austin Community College District. Instead, he stresses the importance of seeing these different pieces as two positive, healthy and beneficial ends of a continuum. 

For example, a counselor who values autonomy may believe that their client is struggling with self-worth because they don’t have healthy boundaries with their family. Although the client also values autonomy, they place a higher importance on community. If the counselor approaches this from an individualist viewpoint, they may think the client is being difficult, Zamarripa says. But if the counselor understands that both worldviews are positive and healthy, then they can help the client find a solution that honors the client’s values. 

Coriano Ortiz also considers clients’ cultural backgrounds and their intersecting identities before determining the best treatment approach. A common client she sees is a woman of color who assumes a caregiving role in her family because she is the eldest daughter. Approaching this client’s issue with an individualist mindset would only cause more harm, Coriano Ortiz notes, because the client’s goal is not to disconnect from her family. The client loves her family and wants to be with them even though some of their expectations can be a source of stress for her. So, the client needs an approach that values her collectivist culture while also helping her find a way to alleviate the stress and anxiety caused by a caregiving role that was imposed on her at a young age because of the parentification that often happens to girls of color, she says. 

Coriano Ortiz draws on the client’s cultural values by talking about the importance of community care. She asks the client, “If you are always taking care of others, are you allowed to take care of yourself as well?” Then, they discuss how the client can show her family that she also has needs and how being vulnerable and willing to access help from her family, friends and community will ultimately create a more balanced community care dynamic. The client comes in talking about community care, Coriano Ortiz says, but sometimes she needs help realizing that receiving care herself is a part of that.

Some of Coriano Ortiz’s clients also blend their spiritual practices, such as limpias (spiritual cleansing), espiritismo (spiritism), Santería (an Afro-Caribbean religion) and other practices common in Latin America, with therapy. If a client comes in talking about recently getting a limpia, she will ask, “What were you cleansing away during your limpia?” 

“Spiritual beliefs and cultural traditions for those seeking to reconnect with their ancestral wellness practices are important to process in therapy as a valid way of sustaining mental health,” says Coriano Ortiz, co-chair of Reclamation Collective, a nonprofit that helps people who are navigating religious trauma and adverse religious experiences.

Zamarripa, with Jessica Tlazoltiani Zamarripa, co-founded the Institute of Chicana/o Psychology in Austin, Texas, and developed Chicana/o/x affirmative therapy — an approach that assumes the centralizing of culture and that a positive perception of one’s cultural background will be facilitated in therapy. When working with Latinx clients, he incorporates the “pillars of brown wellness” — identity, family and spirituality — as a means of integrating cultural relevance into the therapeutic space. 

Zamarripa also uses the four elements of nature (earth, wind, fire and water) as a way for his clients to reconnect with Indigenous practices. When doing grounding techniques, he invites clients to leave the session and find an area outside where they can take off their shoes and stand in the grass for a few minutes. Then they can let what they were talking about in session flow from them into the earth. “It allows us to appreciate more the importance of nature, the importance of the elements,” he says. “It can teach some clients something new, and for those clients that are marginalized … who have heard this in their family but they don’t practice it, it can help them culturally reconnect.”

Counselors can also draw on narrative therapy and storytelling, which has been a part of Indigenous cultures for years, Coriano Ortiz notes. During her graduate school program, where she specialized in Latinx mental health, she learned about cuento therapy, an intervention that was implemented in Brooklyn, New York, with Puerto Rican children. This therapy integrates Puerto Rican stories or folktales into therapy for children. Cuentos are a big part of Puerto Rican culture, she says. They serve as a way for children to learn lessons, feel hopeful about healing if they’ve gone through adverse childhood experiences, draw from the knowledge of their ancestors, and stay connected to their culture for those who have migrated from Puerto Rico to other parts of the world. This therapy allows children to read stories that are culturally congruent to their own experiences, which helps them build rapport with the counselor and the adults who are part of their support system. Eventually, these clients create their own life story as a way of healing. 

Preparing counseling students 

Finan believes that counselor education and counselor trainings should help equip clinicians to use a culture-centered approach in their work and engage in difficult dialogues about diversity and social justice. However, from her perspective, many counseling programs aren’t doing enough. “We are asking people to engage in really challenging conversations without preparing them to do it,” she says.

To address this issue, she piloted a counselor training workshop using Sue’s Race Talk and the Conspiracy of Silence as a framework for discussing all types of isms and social justice work in counseling. The book provides practical advice on why and how to have difficult conversations about race.

Band suggests counselor education programs help students begin to think about their own identities and biases by having them create positionality statements, which require individuals to consider how differences in social position and power have shaped and continue to shape their identities and access. The exercise asks students to describe their early life experiences of feeling “different,” “othered” or privileged, including the thoughts and emotions they experienced at the time and how they make sense of themselves now. 

As stated in the Multicultural and Social Justice Counseling Competencies, privileged and oppressed identities are contextual and socially constructed, Band notes, so this exercise highlights how someone might hold privilege in one area but may be considered a minority and experience micro- or macroaggressions in another. A positionality statement does not simply ask students to list out their identities or privileges, she says. It asks them to recall others’ reactions to them during times when they felt “different,” “othered” or privileged and how they responded to those interactions. 

With this approach, Band stresses the importance of having students not just write their statements but also share them with the class because it makes the experience more transformative. “This exercise is often deeply emotional because it is detailed and there is a storytelling or narrative aspect to it,” she adds. “It has the potential to be very cathartic.”

Vereen, editor of The Journal of Humanistic Counseling and past president of the Association for Humanistic Counseling, still teaches traditional theory from names such as Sigmund Freud and Alfred Adler in his counseling classes. But he says he does this more as a way of helping students learn from the past and figure out where the theories do and do not apply today. 

For Vereen, theory serves as a learning tool to get counseling students to think about what they would do with a client, not what Adler or another theorist would do. And then he pushes them to consider the current relevancy of these theories by asking, “Now how do you step outside of this [theoretical] framework to then be a better helper to the student or client you’re working with? … [How] does what Adler’s saying [still] apply to the work that you’re doing? And in what way does it impact the relationship that you have with this student or client?” 

Vereen recently restructured one of his graduate exams to help students see the practical application of theory. Rather than giving them a multiple-choice exam on theoretical concepts, he had the students work in groups to discuss ways to apply certain theories to client cases. 

One group explored mental health implications for a pregnant teenager who had been emancipated. They looked up state statutes and thought about ways this young woman might get lost in the system. Then they considered the mental health impacts of carrying a pregnancy to term when it was not her choice, their role as her counselor, possible theoretical approaches they might use, and the ways these approaches did or did not address the client’s needs.

Sue says that his counseling psychology program does a good job of teaching counseling students the importance of social justice. At the same time, he acknowledges it does “a bad job of arming them with the strategies and techniques to bring about change and … of immunizing them against the resistance they are going to encounter.” Often, when counselors attempt to introduce a multicultural framework to an organization or agency, they are told that the strategies they want to use don’t align with the standards of practice or ethics codes that have been established there, he explains. 

Sue recounts how one of his former students finished the graduate program excited to be a school counselor. When he noticed that underrepresented students rarely came to his office at the school where he was hired, he decided to go to them instead. He went outside and played basketball with these students, which led to some great discussion about their mental health. But the head counselor said that his actions were unethical and violated school policy. This exchange left Sue’s former student feeling discouraged. 

“It does no good for any of us to become culturally competent when the very institutions that employ us punish us for it,” Sue says. 

In his latest book, Microintervention Strategies — What You Can Do to Disarm and Dismantle Individual and Systemic Racism and Bias, Sue provides strategies people can use to combat the micro- and macroaggressions that target marginalized groups. 

An evolving profession 

Vereen challenges his fellow counselors to ask themselves a question: “If we continue to operate in the ways that we always have, are we then moving toward being unethical as a profession because we are not advancing what we’ve done to more holistically support the people and communities that we purport to be providing good work for?” 

Sue says there is no one culturally appropriate way to maintain a good system of healing. Instead, to become culturally competent, he urges mental health professionals to work toward four main objectives:

  • Being aware of our own worldviews, values and assumptions about human behavior.
  • Understanding the worldviews of those who differ from ourselves.
  • Developing culturally appropriate intervention strategies and engaging in actions that positively affect the client’s environment.  
  • Recognizing the systemic factors at play that directly and indirectly affect the policies and practices governing the mental health professions. 

Culture-centered theories are “about how we view the world and how we conceptualize who we are in the world and [who] our clients and our students [are],” Finan says. “These are foundational ways of understanding what it means to be a 21st-century counselor. If we don’t … start using some of these theories to enhance our ability to connect with, understand and support clients and students, then we’re not growing with the profession. We’re not evolving.”

 

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@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.

Helping counselors who serve sexual and gender minority youth

By Theodore “Ted” Carroll November 17, 2021

To best understand how to assist counselors, we need to address the ways that helpers are supported. The field of counselor education and supervision is composed of educators and practitioners who express support for clinical competence for practice and educational programs. The Association for Counselor Education and Supervision (ACES) is the entity that encourages program development for counseling education. ACES aligns with the 2016 Standards established by the Council for the Accreditation of Counseling and Related Educational Programs (CACREP). CACREP promotes equity, diversity and inclusion in ethical practice, advocacy, leadership and academics. Multiculturalism and diversity are broad topics with specific implications that are included in CACREP’s standards.

In a 2019 article, “An interdisciplinary ecological framework: Intervention for LGBTQ interpersonal violence,” published in the International Journal of Bullying Prevention, Sharon Bruner and colleagues suggested that CACREP-accredited CES programs intend to explore ethical considerations for serving diverse groups. Pointedly, CES promotes helping licensed professional counselors (LPCs) better serve minority populations. Bruner and colleagues asserted that one challenge CES encounters in effectively supporting clinicians and counselor educators is that the ethical views of LPCs related to serving sexual and gender minority youth (SGMY) are virtually unknown. This lack of data prevents the development of appropriate counselor and educator supports.

Jared Rose and associates, in their 2019 article “Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling’s best practices in addressing conscience clause legislation in counselor education and supervision,” published in the Journal of LGBT Issues in Counseling, contended that although CES literature speaks to SGMY views of ethical factors, current journal articles that express LPC views are missing. As the authors highlighted, SGMY harms are increasing because of an apparent lack of clinical competence and awareness on the part of LPCs.

Pointedly, discovering what LPCs are thinking about ethical consideration for serving SGMY might help clinicians and educators overcome inadequacies and increase therapeutic progress for SGMY clientele. One might wonder why this specific qualitative data is missing from the current CES literature base.

Continuing education, politics and religion

First, CES programs lack awareness and training opportunities that might better equip LPCs for serving SGMY. The abundant choices for continuing education (CE) allow precedence of preference and exclusions of convenience. In other words, as health policy specialist Sari Reisner indicated in a 2015 volume of The Milbank Quarterly, clinicians often seek out enriching CE based on their historical interests. Therefore, sometimes established therapists decline new CE options because the information is perceived as extremely unfamiliar. Paradoxical to CE purposes, new ideas for CE are ignored for decades before becoming widely embraced, despite being based on cutting-edge research findings.

Second, Reisner suggested that some clinicians are closed-minded concerning nontraditional sexual and gender identifiers. Reisner implied that some LPCs are completely refusing services to SGMY based on political and religious beliefs. Although LPCs have a right to refuse service based on scope of practice considerations and conflicting personal beliefs, the 2014 ACA Code of Ethics sets clear referral standards. Reisner purported that the problem exists because some LPCs are not referring out at all, denying SGMY counseling access and violating professional ethics guidelines. Reisner continued pointing out that some of these same clinicians are not returning phone calls, emails or similar communications from SGMY inquiring about services.

Manivong Ratts and colleagues, in their 2016 article for the Journal of Multicultural Counseling and Development, “Multicultural and Social Justice Counseling Competencies: Guidelines for the counseling profession,” discussed CES pedagogical development that would more effectively support educators, counselors and counseling students. Intriguingly, they suggested appropriate communications and referral practices as part of the need for specific counselor training and curricula topics. Notably, CACREP-accredited CES programs would benefit from hearing what a thorough cross-section of the LPC population thinks about ethics for providing services to SGMY and the implications for practice and accessibility standards.

Why and how

Ratts and team suggested that clinicians and educators would benefit from knowing more about LPCs’ views concerning ethics implications for serving SGMY. In turn, SGMY clientele might benefit too. After all, as Reisner indicated, increased counselor effectiveness often leads to individuals’ substantial therapeutic progress.

Reisner and Ratts and colleagues encouraged future studies to focus on LPCs’ views regarding ethically serving SGMY. Furthermore, Reisner and Ratts and colleagues explained that the lack of LPC data incidentally helps maintain the status quo, highlighting that some SGMY clients are underserved, neglected or ultimately denied access to counseling services. In addition, these authors implied that poor access conditions enable less than adequate clinical services and increase SGMY harms such as homelessness, substance use, severe mental health symptoms and suicides.

However, based on information from existing CES research, the above indications are primarily derived from SGMY’s perspectives, not the perspectives of counselors. Although this synopsis includes some related professionals’ views on ethics considerations for serving SGMY, it excludes LPCs’ views. Reisner and Ratts and colleagues suggested that including LPCs’ ideas about ethics and counseling SGMY might expand ethical practices for clinicians, advance CES program development, and reduce serious SGMY harms. Arguably, knowing more about what LPCs think might save lives. At the very least, counselors and educators would be assisted, thereby more effectively supporting LPCs and CES.

It is likely that the majority of ethical dilemmas and the lack of adherence to ethics standards have more to do with LPCs not being equipped with the necessary awareness and training than it is a total lack of regard for SGMYs’ needs based on extreme political or religious beliefs. For the most part, counselors become professional helpers because they really want to help others. In fact, most counselors, educators and counseling students seek to better understand people and topics with which they aren’t initially familiar.

Outliers exist, however, and it is questionable whether LPCs would admit to feeling ill-equipped regarding awareness, training, referral standards or anything else. Perhaps simply asking LPCs questions about their experience serving SGMYs would produce more qualitative data that might help colleagues and inform CES program development. Direct ethics inquiries can be avoided while still gathering valuable information from LPCs. Of course, as mentioned previously, some clinicians might benefit from a thorough review of referral standards regardless of whether they are equipped or willing to counsel SGMY.

Ethical considerations and future research

Regarding the future research and need for focused studies, Myra Parker and team in their article, “Beyond the Belmont principles: A community‐based approach to developing an indigenous ethics model and curriculum for training health researchers working with American Indian and Alaska Native communities,” in the journal American Journal of Community Psychology, underscore that clarity of rationale for conducting research is paramount for research ethics. Furthermore, Parker suggests that a sufficient need for research precludes approval by institutional review boards. Indicatively, the need for knowing more about LPCs’ views is established: Educators, clinicians and clients are likely to benefit from simply knowing LPCs’ views about ethics factors for counseling SGMY.

Basically, the lack of information — a condition of the status quo that prevents best clinical practices — can be solved by ethically and responsibly gathering that data. LPCs’ views can be acquired without any significant risks to people, especially considering that qualitative interviews can be conducted via online videoconferencing platforms. These facts are essential for research protocol, as established by a 1978 National Commission’s publication, the Belmont Report, similarly discussed by Parker.

Identifying the research need and rationale for gathering new information, one might consider the immediacy of the need. LPCs lack training and awareness, which are incidentally enabling poor counseling conditions for SGMY. Who will step up to the plate and perform the needed studies? Delaying the suggested research would perhaps be the most unethical option.

Sharon McCutcheon/Unsplash.com

Practical considerations

Above all, knowing LPCs’ views about ethics for counseling SGMY would help people. Notably, the importance of assisting helpers should not be underestimated. As Lorelli Nowell related in 2017 in The International Journal of Qualitative Methods, the nature of helping others is draining and often leads to burnout. Similarly stated, if research is left undone, then the indicated problem continues. Consequently, the established need also would persist. Ultimately, the result would be that people suffer.

Pointedly, if the need persists, then LPCs would continue to be ill-equipped for best practices for counseling SGMY, and the indicated harms would continue. Incidentally, progress for LPCs and CES would be thwarted. On the other hand, as Ratts and colleagues indicated, if future studies address LPCs’ views of ethics for counseling SGMY, then the stated harms would be likely to decrease, and clinicians and educators would be better supported than they are now.

Intervention factors

New information from LPCs regarding ethical implications for counseling SGMY would likely present new theoretical considerations. Plus, new factors for theory might produce new ways for using interventions. For example, from a social constructivist view, collaborating with peers leads to solutions for interpersonal problems and personal growth.

Additionally, mindfulness interventions such as meditation practice might prove helpful in clinical sessions with individuals experiencing social rejection or low self-esteem due to sexual or gender identity challenges. In his 2019 article in The Counseling Psychologist, Ezra Morris supported this idea, suggesting that opportunities like these might be prime opportunities for theory and intervention advancements. For example, because mindfulness-based practices originate from constructivist tenets, Morris suggested that new applications inform educators of novel program developments. Furthermore, new application opportunities would potentially help the broad human services field, affecting change throughout various helping professions and grassroots humanitarian centers.

Forward momentum

Because CES supports counselors’ competence for practice and educational programs, drawing parallels from ethics and counseling SGMY to practice standards for serving other minority groups is appropriate for the field’s growth. For example, future studies could address LPCs’ views concerning marginalized groups such as those convicted of violent crimes or those who do not have health insurance. The subjects for consideration for future research focuses are nearly unlimited.

Of course, existing CES research should continue to guide future studies. Perhaps articles such as this one will trigger renewed interest in significant research gaps. First things first: helping LPCs to help SGMY helps CES and the broad human services field. The first step is finding out counselors’ views of ethics and serving SGMY.

 

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Theodore “Ted” Carroll and spouse, Tanya Carroll, operate a private practice in Spokane, Washington, that serves individuals, couples/families and children. Ted is a CES doctoral candidate with Capella University. His research specialization is counseling sexual and gender minority youth. Contact him through the Actualize Psylutions website.

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

Life after sport

By Kris Amos November 16, 2021

I will never be the same. I have struggled with reshaping my identity after being separated from sport due to injury. 

As a track and field athlete, where overuse injuries are most common, I did not consider myself to be at significant risk for a career-ending injury. However, athletes can also incur life-changing injuries outside of their sport, as I experienced firsthand when a drunken driver traveling the wrong way down the freeway crashed into my car head-on. 

Personal background

For me, growing up on the west side of Detroit, success meant making it in sports or music. I moved out of Detroit at the beginning of high school and began competing as a track and field athlete. That’s when I discovered my love for the high jump. The thrill of competition was a sensation that brought me life. It provided me a sense of accomplishment, belonging, identity and passion. Competing as a high jumper became a career goal, and when I graduated from high school in 2007 and was offered a scholarship to compete as a track and field athlete at Michigan State University (MSU), I was one step closer to that goal.

My athletic career was promising. I earned a varsity letter my freshman year after finishing sixth in the high jump at the 2008 Big Ten Outdoor Championships with a jump of 2.07 meters. At the time, the competition level in the field events in the Big Ten Conference was very high, and I managed to have the top placement by a freshman at the meet. I barely missed the qualifying standard for the regional championship but was reassured by the fact that I was only a freshman. 

That was until Aug. 20, 2008. At approximately 1:30 a.m., I was driving 75 mph on cruise control heading back to campus when I noticed headlights traveling toward me at very high speed. I was only able to cover my face as my perception of time slowed right before our cars collided. I woke up to a woman knocking on my window, attempting to get my attention. My head was on the steering wheel, the airbags were deployed, and the windshield was crushed in toward my face. I was pulled out of the vehicle through the window and transported to the hospital for surgery. Among the many injuries I sustained were a traumatic brain injury and an extensive injury to my right knee. This was the leg I used to launch myself in the high jump event.

I learned later that the drunken driver had entered the exit ramp and begun traveling in the wrong direction on the highway before colliding with me head-on. After I was struck, a third car hit the side of my vehicle before colliding with the drunken driver. A passenger in the drunken driver’s vehicle died, and the passenger from the third vehicle had a miscarriage. I didn’t really appreciate the extent of my injuries at the time, in part because I was eager to return to competition. Concussion/brain injury protocols were not as established in the NCAA then as they are now, and although I was offered an opportunity to redshirt (to sit out a year without losing any of my collegiate athletic eligibility), I was ultimately allowed to compete. 

I was not the same. I began drinking alcohol daily, including when I woke up, before and after practice, and before I went to sleep. I finished the following semester with a 0.7 GPA, which led to me being declared academically ineligible and dismissed from the team. 

Since then, I have had five surgeries on my knee, several injections and procedures, multiple therapies, and various forms of treatment for my brain injury and chronic pain. I barely graduated from MSU in 2012 with a Bachelor of Arts in psychology and a 2.1 overall undergraduate GPA. My hopes of going to graduate school were crushed when I received a denial letter from the school to which I had applied. After explaining my situation to the program director at the University of Detroit Mercy, I was admitted to the graduate certificate program in addiction studies. After successfully completing the program, I moved to Chicago to attend the Chicago School of Professional Psychology. It was during my clinical internship at Columbia College that I discovered an opportunity to get back into sports. I graduated with a Master of Arts in counseling psychology in 2017 and moved back to Michigan to begin working at MSU.

I am currently a licensed professional counselor at MSU’s Counseling & Psychiatric Services center. I have attempted to reshape my athletic identity by providing mental health services to athletes through advocacy, education and counseling. This has helped me to re-create a sense of purpose that is aligned in sports and consistent with my athletic identity. After learning about existential psychology through my coursework, I began to research its application in sports and have found it to be helpful, both personally and professionally. 

Career-ending injuries

Career-ending sports injuries are representative of an existential crisis. They can have a devastating impact on the individual athlete, the athlete’s team, the athlete’s family and even sports fans. According to Stanley Herring et al. (2016), irritability, sleep/appetite changes, pain, depression and other adverse effects can occur following a sports injury. Not surprisingly, this can be a challenging adjustment for some athletes.

Participation in sports provides athletes with social connection and a sense of identity, meaning and belonging. Athletes are more than the tasks required of them in sports; athletes are also people. We as a species have yet to answer undeniably the big philosophical questions of life, one of which is “Why am I here?” This existential question has barely registered in the field of sports. However, from my perspective, the existential model would seem to be an appropriate fit when treating and supporting athletes who have been separated from their sport due to injury. 

According to the National Safe Kids Campaign and the American Academy of Pediatrics, more than 3.5 million sports injuries are estimated to occur each year among children and teens. A career-ending injury can encompass an unexpected injury, illness or death that prevents an athlete from participating in a sport. An epidemiology study published in 2016 by Jill Tirabassi et al. found that career-ending injuries made up 6% of all injuries captured from 2005-2014 among high school athletes. Studies published in Athletic Insight: The Online Journal of Sport Psychology have suggested that sports career termination should be viewed as a transitional process occurring from the beginning of athletic involvement through post-athletic participation. This transitional process fits well within the existential sport psychology model. 

Existential sport psychology

In a 2015 article, Noora Ronkainen and Mark Nesti discussed existential sport psychology being defined as the process of understanding the subjective reality of sport participation and the meaning assigned to experiences. They described the model as an attempt to understand and embrace the complexities of human life without attempting to “fix” or conquer them. 

Existential psychology is centered on several major concerns: death, meaning, identity, isolation and freedom. Identity and meaning are especially important for elite athletes, given that their identity is generally tied to who they are as athletes. Meaning has sociocultural influences, and the culture of sports is embedded in the value placed on it by society. This would suggest that sports participants also have value and meaning assigned to their participation in sports. 

However, consistent with themes described in 1980 in Irvin Yalom’s Existential Psychotherapy, athletes who experience career-ending injuries may experience a sense of meaninglessness, anxiety and a loss of identity. From this perspective, meaninglessness can be followed by behavioral patterns such as the misuse of alcohol and depression. This is often described as “existential neurosis.” These behaviors appear consistent with the symptomatology athletes can experience following separation from their sport. 

As discussed in Nesti’s book Existential Psychology and Sport: Theory and Application, this model encourages people to accept freedom and responsibility in their lives and to live authentically despite experiences that increase anxiety. For injured athletes, this means beginning to accept the freedom in choosing to confront their injuries, and it provides them with a framework to view themselves as people who also identify as athletes. 

Research published in 2016 by the Scandinavian Journal of Medicine & Science in Sports found that many athletes have been defined by descriptors such as age, gender, level of performance or type of sport. From an existential perspective, these descriptors are very limiting. Athletes are a diverse group of human beings who have dedicated themselves to participating in a sport. Sports participation can be an outlet for developing life skills, building community and social relationships, becoming leaders and much more. 

Furthermore, athletes belong to a culture of competitors and sport participants that is centered on a common identity. This identity is not an athlete’s only identity, but neither does this identity cease to exist following an injury. Therefore, existentialism in sport may present an opportunity for athletes to discover how their athletic identity is expressed outside of competition and sports participation.  

The Application of existential psychology in sport

The application of existential psychology in sport appears to be a model that can empower injured athletes to view themselves as more than athletes separated from their sport. Some may label themselves as “former athletes” who are still elite members of society possessing unique characteristics, talents and skills developed from participation in sports. The years of training, effort and energy expended in the process of becoming elite athletes can be transferred and applied outside of the sports context. 

Although research in this field is limited, existential psychotherapy is a well-documented approach to treatment that is gaining interest in sport psychology. This rehabilitative process involves encouraging athletes to be more authentic in the therapeutic relationship. Encouraging athletes to be more of their authentic selves may help to reveal characteristics about their identity not expressed in the sports environment. 

If an athlete is separated from a sport due to injury, their sense of identity may be lost as they transition. Practitioners can assist in this process by facilitating an environment that encourages athletes to explore their meaning and purpose. The athlete’s beliefs and assumptions regarding the injury and what it means to be separated from their sport can be discussed to continue the existential process. Uncovering beliefs and assumptions associated with being injured may also help the athlete conceptualize thoughts, feelings and attitudes that contribute to maladaptive experiences.

As athletes gain more insight, they begin to identify how their beliefs and assumptions are contributing to the distress they may be experiencing. They can be invited to confront the conflict associated with being injured, the change in their identity, the loss of meaning/purpose, and how it all fits within their role in society. Elite and recreational athletes may have their identities shaped by the daily activities associated with sports participation, the social connections made within their sport community and the cultural expression involved in the sport community. These athletes’ purpose in life was heavily influenced by the interaction of these factors, and their injuries may have completely disrupted how they view themselves in society. 

Strategies organizations can offer

The organizational sports environment influences athletes’ well-being and sense of community. In an ideal world, organizations would assist athletes separated from their sport by providing helpful resources. Offering these tools can help athletes better adjust to and deal with the uncertainty associated with career-ending injuries. Organizations can foster an atmosphere that is supportive of their injured athletes by continuing to celebrate their contributions and achievements once they are no longer participating in sports. 

Further action can be taken by recognizing that injured athletes are still athletes and that their community belonging does not change because they have sustained an injury. This could be demonstrated through messaging in the organization’s mission/vision, by offering roles to injured athletes upon separation from their sport, by providing support groups, and by encouraging the intentional development of life skills. Counselors in this role can facilitate this process by helping athletes and other stakeholders to identify how they relate to society as a whole. Preventive methods can be implemented by maintaining sport participation safety, taking steps to reduce burnout and overtraining, providing psychoeducation, ensuring a safe return to play from previous injuries, and promoting athlete wellness. 

Practitioner strategies

Athletes are often taught to accept the realization that they are no longer able to participate in sports following injury or health concerns. But life after sport doesn’t always have to be about “letting go” of the athletic identity. Being an athlete is about more than having the ability to compete at the same level experienced prior to injury. It means that one has committed to a lifelong journey of self-improvement while striving to bring out the best in others. Given the tasks required in sports, this is typically focused on the activities necessary for sport performance. 

However, many options can still exist for athletes separated from their primary sport. Practitioners can encourage options such as adaptive sports, which can provide a sense of purpose that aligns with the athlete’s sports identity. This also creates the opportunity to normalize participation in adaptive sports. Not every injury leads to permanent dysfunction, but the existence of adaptive sports challenges the idea that injured athletes are no longer able to participate in competitive sports. 

Clinicians can also continue to implement strategies and techniques that reaffirm the athlete’s identity and purpose. Athletes can be encouraged to take ownership of their freedom to make choices and transform their injury experience into new meaning. This can be accomplished through the therapeutic relationship by fostering an empathic and authentic environment that assists the athlete in confronting the choices associated with their injury. 

An additional strategy clinicians can use involves incorporating concepts of spirituality into the existential sport psychology practice. Athletes can be encouraged to define spirituality, which may provide an opportunity for them to reflect on their relationship with themselves, others and that which is beyond our understanding.

Applying the athlete’s mindset

Life after sport does not have to mean “acceptance” of a life that fails to provide the same level of renown as sports. From personal and professional experience, I can confirm that being an athlete means that you compete against the odds, and as an athlete, you recognize that you cannot allow self-defeating thoughts or negative feedback to dictate your performance. Instead, you must use it as fuel to reach the next level. 

Having an athletic identity means striving to become the best at what you do and doing what needs to be done to get there. It’s about the process. It’s about becoming a better version of yourself by exercising the determination and motivation to become the best. Because as an athlete, you know there is always a chance that you will fail or lose, but you do not let that stop you. That’s why you were able to reach the level of success that you attained — because you did not give up. You continued to be relentless in pursuit of your goal, even with the knowledge that you might have to enlist a backup plan. You may no longer be directly involved in the activity that once gave your life meaning, but the mentality you developed along the way is still a part of you and can be applied in various situations.

Regardless of whether you are still able to participate in your chosen sport, you are, and always will be, an athlete.

lzf/Shutterstock.com

 

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Kris Amos is a licensed professional counselor and national certified counselor practicing in Michigan. He works full time as a staff counselor at Michigan State University’s Counseling & Psychiatric Services center and is the founder and owner of Precision Counseling PLLC, a private practice dedicated to providing professional counseling services. Kris provides individual counseling, group counseling, couples counseling, biofeedback, neurofeedback, mental performance training and educational workshops to the Michigan State community. Contact him at amoskris@msu.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, visit 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.