Monthly Archives: May 2022

Voice of Experience: The mean dog

By Gregory K. Moffatt May 25, 2022

“When will this go away?” my client asked me.

So many times, I’ve seen the same desperate look in the eyes of clients. With this 45-year-old man, the look was caused by grief at the sudden loss of his closest friend — his father. Every morning after a restless night, he woke only to be greeted by the ever-present hole in his heart created by his loss.

“This kind of pain doesn’t go away,” I said softly. “It fades, but unfortunately, it will always be there.”

And then I shared a metaphor with him that I’ve used a thousand times.

“Suppose you live next door to someone who has a mean dog. Let’s also suppose that you will never move and your neighbor will never move. Wishing for your pain to go away is like wishing for the neighbor with the mean dog to move. It won’t happen.

“But instead of wishing that the dog would go away, we can confront our fear of the mean dog. If we pretend that it isn’t there, it very likely might hurt us if we carelessly stray too close to the property line. But if we are aware of the mean dog and the length of its chain, then it can never hurt us no matter how much it growls or how loud it barks.”

This metaphor works for addictions — the mean dog is the lust for chemicals. Pretending the mean dog isn’t there (or hoping it has gone away) can trick the person to stray too close to the party with alcohol or the reception where former methamphetamine acquaintances are likely to be congregating.

The metaphor works for trauma — the mean dog is the event or the perpetrator. Pretending “I’m OK” can allow the mean dog to slip closer and closer, maybe over years, as the client represses fear, hurt and pain. Then, one day without warning, the mean dog can bite.

The metaphor works for sexual addictions. So many men and women have been drawn into this secretive and shame-laden world under the illusion that “I’ve got this under control.” In the privacy of their homes, they swim in their addictions, sometimes straying too close to the property line. The dog bites in the form of spouses or children who catch them or in the form of illegal activities that land them in jail, forever branded as sexual offenders.

Recognizing the mean dog isn’t novel. The idea has been around in other forms for many years. Alcoholics Anonymous got us started in 1935 with the concept of 12-step programs. The very first step is admitting your powerlessness over the addiction. By admitting one’s powerlessness, in a sense one is admitting that the mean dog will be around for a while — probably forever. I just added the metaphor.

But even before Step 1, we admit who we are. “Hello, I’m Greg, and I’m an alcoholic.” In a way, I’m saying, “Hello, I’m Greg, and I see that mean dog over there. I respect it and know its dangers, but I also know its limitations.”

One last truth about the mean dog: It will never be our friend, but we can co-exist with it. So, in addition to the above, we can vocalize, “Even though I know the dangers of the mean dog, I won’t allow it to cause me to live in fear, shame or pain. I am well aware of my limits and the things that compromise my safety.”

Whether used with a 7-year-old child who has been sexually abused, a 40-year-old man struggling with grief or a middle-aged woman challenged with addictions, this metaphor has been a regular and helpful tool for me.

And one last way to utilize this metaphor: Sometimes we can move away. When we hold on to our resentments and anger and we wallow in our hurts, we are electing to live next to the mean dog when we don’t have to. In such cases, maybe it is within our power to find a quieter place to live.

As for me personally, as may also be true for you, I know the mean dogs in my history, and I practice this myself. I have moved away from the mean dog a few times, but there are other mean dogs that will always be with me. As much as I’d love for the guy with the mean dog to move, I know that in some cases, we are neighbors forever. But as time moves on, the hedges grow taller and the barking gets quieter.

That, my friends, makes for much more peaceful nights and restful days.

Don Agnello/Unsplash.com

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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.

Statement of the American Counseling Association on the School Shooting in Uvalde, Texas

May 24, 2022

Today, our nation has begun learning about yet another mass shooting, this time at an elementary school in Uvalde, Texas, where 19 children and two adults were shot dead by an 18-year-old high school student.

In the days, weeks, months and years to come, professional counselors working in schools and communities will be called upon to help those who were impacted by what our country has witnessed all too many times. These victims were innocent children whose life potential will never be realized. They are gone. And, sadly, we know that the impact on those who were part of their life orbit will also face challenges.

While we expect to hear a renewed debate about the access that people have to guns in our country, there also needs to be discussion, discernment and action focused on societal issues that set the stage for these tragic events. Racism, classism, oppression and the lack of mental health resources are just some pieces of a puzzle that has now led to more than 200 mass shootings in the United States since the start of 2022, according to the Gun Violence Archive.

“I’m tired of the rhetoric passed on by political figures who won’t stand up against this violence,” ACA President S. Kent Butler said following the news of the shooting. “I sent my child to school today happy about her excitement to go. Now I’m anxious about sending her tomorrow. We are all forever affected by this madness.”

As an association comprising 58,000 professional counselors, we know that the platitudes of “our hearts and prayers are with you” ring hollow to those who were looking forward to summer vacation, but now must bury their elementary school-age children. Compassion for others and spiritual strength are shared with the best of intentions, however, we also encourage communities and public policy officials to find the internal fortitude that supports and implements what is needed to prevent, rather than always respond to, events that have lifelong and tragic impact.

ACA provides resources to educate counselors and stay vigilant during these horrific times on our website. We also offer resources for counselors and the public to help address all the ripple effects that trauma has on our collective well-being when violence like this occurs.

 

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If you or someone you know is experiencing mental distress in the wake of the Uvalde tragedy, call or text the Disaster Distress Helpline at 1-800-985-5990 for crisis counseling and other resources.

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The American Counseling Association offers free resources to help counselors and those affected by mass shootings: https://bit.ly/2HXfH7F

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Relevant articles from the Counseling Today archives:

Sex-positive counseling

By Lindsey Phillips

Sexuality is a core aspect of the human experience, yet it is often a topic clouded in shame and secrecy. Some people can’t even bring themselves to say the word “sex” out loud, resorting instead to euphemisms such as “the birds and the bees,” “the horizontal tango” or “getting to know someone in the biblical sense.” 

Mental health professionals who consider themselves sex-positive providers are hoping to change the way that people — including other helping professionals — think and talk about sex. In a recent Healthline article, sex educator Goody Howard defined sex positivity as “the idea that people should have space to embody, explore and learn about their sexuality and gender without judgment or shame.” 

Counseling already provides clients with that safe, nonjudgmental space. So, why aren’t more professional counselors talking about sex? 

Steve Ratcliff, a licensed professional clinical counselor in New Mexico and a licensed professional counselor (LPC) in Oregon, believes that too often clinicians avoid discussing sexuality and sexual wellness with clients out of their own fear or shame around the topic. Sometimes counselors incorrectly assume that sex is a topic reserved only for sex therapists, Ratcliff says. Although sex therapy does involve talking about sex, it’s much more than that. As he explains, sex therapists are trained to treat sexual disorders and concerns such as vaginismus (i.e., the involuntary tensing or contracting of the vaginal muscles out of fear of vaginal penetration) or erectile disappointment. 

“Some counselors consider talking about sex as tantamount to having sex with the client,” continues Ratcliff, a member of the American Counseling Association. “There’s this fear that if I talk about it, I’m running a risk ethically or in terms of liability. But if there is a significant clinical issue that we’re not addressing because of our own discomfort that might raise a larger liability and malpractice issue — are we not treating a client’s shame just because it’s sexual?”

Clinicians don’t have to specialize in sex therapy to broach the topic of sexual wellness with their clients. “Sexual issues and mental health go hand in hand, and they influence each other in very distinct ways,” says Angela Schubert, an LPC at Brightside Counseling Services in Greenwood Village, Colorado. For example, growing up in a household where homophobia is present could cause stress, especially if one of the family members is attracted to people of the same sex. And someone who lost their partner of 35 years may be depressed at the thought that they will no longer be able to have sex with this person. But as Schubert points out, clinicians don’t often ask or consider how sexuality may play a role in a person’s mental health. 

Clinical sex education (or a lack thereof) 

Ratcliff is a private practice therapist at Liberated Counseling and a sexual diversity researcher at The Alternative Sexualities Health Research Alliance (TASHRA). He says broaching sexuality is a skill that all counselors should have, yet most clinicians receive little to no training on the topic in graduate school.

“It is unethical how we approach sexuality in the field of counseling right now,” argues Schubert, an associate professor and director of the online master’s program in clinical counseling at Central Methodist University in Fayette, Missouri. Only two states — Florida and California — require counselors to take a human sexuality course to be licensed. And human sexuality is mentioned in just two CACREP standards (rehabilitation counseling and marriage, couple and family counseling), she adds. 

On top of that, sex education varies widely in state public schools in the United States, with many providing inadequate information. As of April 2022, the Guttmacher Institute reported that 26 states and Washington, D.C., mandate both sex education and HIV education, and only 18 states require these education programs to be medically accurate. 

“You’re born and raised into an environment where there’s no formal sex education,” Schubert says. “So, you come into the counseling field as a master’s student already with your arm behind your back in terms of your knowledge and understanding of sexuality in a formal way. [However,] what you [do] have … are all these biases, values and assumptions related to sexuality. … And then you have a counseling program that does not require you to take a human sexuality course and may not even address human sexuality. How does this reality align with our ethical obligation to do no harm? We can do much better.”

Ratcliff would like to see CACREP add at least one required course on human sexuality to its standards. “One three-unit course in human sexuality in graduate school is not enough to become a sex therapist,” he says. “But it might be enough to provide a little bit of education, a little bit of exposure to different sexualities and a chance to work on our own stuff [biases] … and give us a chance to grow as well.”

Until that happens, the onus of finding training is placed on the counselor. Ratcliff and Lily Gonzalez, an LPC and sex therapist who is the co-founder of Moving Mosaic Therapy & Counseling in Chicago, suggest that counselors look for trainings through sex-positive associations such as the Association of Counseling Sexology & Sexual Wellness (ACSSW), which is an organizational affiliate of ACA, and the American Association of Sexuality Educators, Counselors and Therapists (AASECT). In particular, they both recommend attending a sexual attitude reassessment class, which involves process-oriented trainings that challenge attendees to evaluate their own beliefs and values toward sexuality and sex-related topics. These trainings provide clinicians with an opportunity to learn more about sexuality, explore any potential biases or conflicts, and practice their ability to self-regulate when exposed to things outside of their comfort level, Ratcliff explains. 

“You will be triggered” during these classes, Gonzalez says. “But you need to be because you need to know what’s going to trigger you [in session]. You need to understand what your limits and discomforts are and work through those. If we’re not comfortable with our own sexuality, we’re going to be really uncomfortable helping someone navigate theirs.”  

Giving and getting permission 

Consent is a crucial part of not only sex but also sex therapy. Clinicians can underscore the importance of consent by first asking and obtaining the client’s permission to discuss sexuality and sexual behavior, Gonzalez notes. She says that can be as simple as stating, “I’ve noticed you struggling with this problem related to sex. Can we go there?”

Counselors can also broach the topic of sexuality even before meeting clients, says Schubert, co-founder and president of ACSSW. This can be done in how they introduce themselves or through the language they include on their paperwork and intake forms, she explains. For instance, a clinician could note that they are a “sex-positive counselor” on their website. 

Cheryl Walker, an associate professional counselor and sex therapist at GlobeCoRe in Atlanta, creates a safe, welcoming environment in her clinical practice by forgoing binary systems of classification on her intake forms. “Folks who struggle with sexual wellness are [often] fighting these labels that are placed on them,” she observes. She includes blank spaces so clients can fill in how they want to be identified rather than forcing them to check a box, and she makes a point to ask about pronouns.

By engaging in binary thinking (“Are you this or that?”) or making assumptions, “counselors censor and close off conversations that the client either wants to have or needs to have,” says Walker, moderator of the ACA Sexual Wellness in Counseling interest network. “As clinicians, we can make sure we have this open space, this ambiguous space, so that the client can fill in the blanks.” 

Ratcliff, a member of AASECT, often works with sexually and racially diverse populations. He makes it known on his website and clinical paperwork that he is an LGBTQ+, kink-, polyamory- and consensual nonmonogamy-affirming provider and a sex-positive counselor. Using inclusive, affirming language and asking questions about sexuality on intake paperwork will cue clients that the counseling office is a safe place to discuss sex and sexuality, he says. 

Even if counselors are cautious in how they broach conversations around sex and sexuality, mistakes can happen. When they do, Ratcliff advises counselors to take ownership and apologize for their misstep. 

Barriers to sexual wellness

Sexuality is a significant part of who we are as human beings, but it is something that “we’ve been taught to hide, to be ashamed of and to not bring into the room,” Gonzalez notes. She says much of her clinical work involves providing psychoeducation related to the human body, culture and the origins of one’s sexual knowledge. Because counselors are often helping clients navigate something internal and hidden, it is helpful to have a trauma-informed background when doing sex therapy, she adds. 

Ratcliff notes that many people learn about sex from their peers or through the internet or television, and this inadequate education frequently leads to common misconceptions. People may incorrectly assume that older people or people with disabilities don’t enjoy or have sex, for example. 

Any sexual desire or preference that does not align with society’s accepted “norms” often results in feelings of shame, Ratcliff continues. Men may be embarrassed if they enjoy prostate massages because they have been conditioned to believe that the penis is the major sexual organ. And women might not feel the freedom to enjoy their sexuality because, as Ratcliff notes, female sexuality is highly pathologized in American culture. He says it is common for women to report not having an orgasm until much later in life when some of that shame has been dispelled. 

Religion often influences how people view sexuality. Gonzalez finds that it sometimes results in the overlap of sexual shame and self-shame. If someone is taught that being good involves being a “clean,” moral person, then that spills into their perception of their sexual self, she says. As a result, enjoying sex or being aroused by pornography may make them feel like a “bad” person. 

Walker, who is part of the University of Michigan’s sexual health certificate program 2022 cohort, also works with clients who are conflicted about sexuality because of their religious beliefs. Some are taught that touching themselves sexually makes them bad people, so they never learn what feels good to them physically, she says. 

One’s understanding of sexuality is also shaped by media — in this case, referring to all movies, TV shows and social media, not just pornography. Walker points out that television often perpetuates the fallacy that all people are equally desirable and that the path to love is simple — it just requires dinner and flowers, she jokes. So, when people experience in real life that love and sex aren’t simple and straightforward, they often wonder what is wrong with them. 

Counselors will often need to help clients realize how these external and internal factors affect their understanding of sexuality. “People do not often talk about sex,” Schubert observes, “yet it narrates a lot of our worldview, whether it’s something we are conscious of or not.” 

Schubert often has her counseling students and clients explore their sexual scripts — the narratives they have formed about sex based on embedded cultural beliefs, social messaging, biology, personal experiences, and formal or informal education about sexuality. She says counselors can begin to unpack these internalized messages by asking clients questions such as “What messages about sex did you receive as a child? Did anyone say, ‘I love you’? What did you learn about gender roles growing up?” 

Schubert often introduces the concept of a sexual script by having clients visualize it as an umbrella. Sexuality is the tip of the umbrella, and the parts of the umbrella connected to the tip all form one’s sexual script. The umbrella panels represent one’s identities and experiences; the ribs running along these panels are the beliefs, biases and assumptions; and the shorter ribs that hold the umbrella open are one’s values, she explains. 

Schubert, co-editor of the forthcoming Handbook for Human Sexuality Counseling: A Sex Positive Approach, published by ACA, provides a hypothetical example of working with a male client who struggles to say the word “masturbation.” Instead, he repeatedly says “that thing we do” rather than using the word in front of the clinician because he fears they would think less of him if he verbalized it. In this scenario, Schubert would prompt this client to explore the possible reasons behind his hesitation to say sexual words by using the sexual script exercise. She would ask him questions such as “Where did you first learn it wasn’t OK to say masturbation? Did your caregivers ever talk about sex with you? What did your religion or culture say about masturbation?” 

Gonzalez finds the bio-psycho-social model beneficial in helping clients understand the way that their life experiences affect sexual wellness. She explains that clinicians can explore any physical limitations or illness that might be hampering the client’s sexual wellness (biological), the client’s emotional reactions to sexuality such as past traumas or current stressors that affect it (psychological), and societal influences and expectations around sexuality such as the client’s religious views and the gendered roles they were taught as a child (social). 

For example, Gonzalez describes how a Latin American woman who is born into a religious and patriarchal environment may have certain expectations around sex. This woman may feel the need to be chaste in the way she presents herself to society yet also be sexually pleasing to her husband (what is referred to in psychoanalytic literature as “the Madonna-whore complex”). This woman wasn’t taught how to enjoy sex but instead views it as a service or act that she must perform, Gonzalez explains. Applying the bio-psycho-social model would help the client process this internalized messaging around sexuality and allow her to start working on her own sexual wellness, Gonzalez says. 

She finds this model particularly helpful when she’s working with partners who come from different cultures or religions. Counselors can use it to discuss each person’s cultural upbringing and models of love and how this affects what they expect and want sexually from each other, Gonzalez says. 

Reconnecting to our bodies 

One key aspect in helping clients achieve sexual satisfaction is broadening the definition of what sexual wellness means. “Our society has done a really good job of making us think outside our body instead of inside our body,” Gonzalez says. “And we’ve been taught to be performative. We’ve been taught to think, ‘Do I look cute in this [sexual] position? Do I look cute in this outfit?’ and not necessarily [think about] what feels good” and pleasurable. 

Body mapping is a technique Gonzalez uses to get clients out of their heads and back into their bodies. She may ask clients to explore their bodies without sexual intent to really learn themselves better. For example, the next time a client takes a shower, they could be mindful and notice how it feels when the water hits different parts of their body and where they enjoy the sensation more. This could progress to the counselor recommending that they masturbate at home with the same sense of exploration — and without the goal of having an orgasm. The touch doesn’t even have to involve a sexual organ; it could be the simple act of sensually touching their thigh, Gonzalez adds. 

Sometimes counselors must first help clients consider their own emotions, traumas and triggers around sexual pleasure. The body is capable of not only providing pleasure but also holding on to trauma, Gonzalez notes, which can cause certain parts of the body to trigger an emotional response. These bodily responses operate as the body’s “brakes and accelerators of sex,” a phrase Gonzalez credits to Emily Nagoski’s Come as You Are: The Surprising New Science That Will Transform Your Sex Life. Environmental factors such as location, music and aromas can also affect how someone responds to sex, she adds. 

“Body mapping can help the person understand where their bodily accelerators … and brakes are,” Gonzalez explains. “We want to avoid the brakes so that they don’t get in the way … and pay more attention to the accelerators, but you can’t do that without knowing your body.”  

Walker says mindfulness and meditation techniques are also great tools to help clients be fully engaged in the present moment rather than focused on life stressors or their own anxieties and insecurities around sexual performance. 

If a woman, for example, is anxious about sexual penetration because of a past sexual trauma or a religious belief that sex is “bad,” then her body may tighten and tense whenever she engages in sexual acts. This action restricts blood flow to the area, Walker says, which will cause further stress and displeasure. A counselor could use mindfulness techniques such as engaging the five senses (what she sees, hears, smells, etc.) to help the client learn to ground herself in the present moment and relax her pelvic area. 

Pathologizing sexuality

Many clients feel particularly vulnerable discussing sexuality, which means it can be easy to hurt or offend them if the counselor’s biases or opinions enter the session. Several clients have told Gonzalez about negative experiences they had when disclosing their sexual practices to other therapists, including one client who was devastated when a clinician stated “You must hate yourself” after learning they were into bondage, discipline, dominance and submission (BDSM). Gonzalez says part of her clinical work involves first healing the trauma caused by such negative or biased comments. 

If a client mentions a sexual practice such as BDSM, then Gonzalez may ask, “What does BDSM mean for you? How does that fit into your life? How do you receive pleasure from it? Is this experience consensual, and do you have a contract that defines the power exchange?” But she never assumes that this sexual experience has anything to do with the client’s reason for coming to counseling.

We have to differentiate between what the client sees as their problem and what we think the problem is,” Gonzalez stresses. 

Unfortunately, value impositions are common when discussing sexuality, Ratcliff says. After all, sex is a topic that often evokes strong reactions — positive or negative — from people. If someone enjoys something that makes the counselor uncomfortable or is outside of their accepted sexual norms, then it may become easier for the counselor to insert their own opinions and thoughts onto the situation, he notes. For example, Ratcliff says, if a clinician is bothered by the thought of a client who says they enjoy being tied up with rope, the clinician may be more likely to infer that the client’s preferred sexual activities underlie why they struggle with assertiveness or why they are depressed. 

Sex positivity requires clinicians to maintain an open mind and be inclusive of all types of sexual expression — even those that shock them. “It’s OK for counselors to have things that ‘ick’ us out,” Ratcliff says. “Our challenge as professionals is to be able to work with people who enjoy those things and regulate ourselves.”

Biases about sex are sometimes written into the theories, approaches and assessments that counselors use. Ratcliff finds that he often needs to tweak or translate his approaches and interventions to fit the needs of his clients. He sometimes uses online relationship psychological assessments such as the Gottman Relationship Checkup, but these are often based on cisgender, heterosexual couples, so they use terms such as “affair” — a word that doesn’t fit or work for clients in a consensual nonmonogamous relationship. In fact, putting forward the concept of having an affair or cheating runs the risk of pathologizing this type of relationship, he says, so he asks clients to replace the word “affair” with “relationship betrayal,” which is a more appropriate and inclusive description. 

Walker advises clinicians to look over their clinical forms, exercises and handouts with a discerning eye to ensure they contain gender-expansive and sex-positive language. This may involve making simple changes such as including examples with the pronoun “they” or using the word “partner(s)” instead of “couple,” she says. 

Readjusting one’s language can also help counselors and clients to shift their mindset and reconsider potential stigmas associated with certain terms. Schubert often chooses to say “sexually explicit material,” for instance, instead of “pornography” because she finds this phrasing helps to remove negative connotations around it and allows clients to discuss — without shame — what materials they are using and how that might be influencing their sexual wellness. 

Boundaries and transference

Establishing clear, healthy boundaries is important in any therapeutic relationship, but it becomes crucial when addressing a topic that many people consider sensitive or taboo. Gonzalez says that clients sometimes ask questions about her sexual life and preferences, such as if she’s queer or polyamorous. She turns this back to the client and asks, “What about that is interesting to you?” This question allows her to gauge if the client is asking out of curiosity, if there is any possible issue of transference at play or if they need to know that she understands them on a deeper level.

Counselors need to be careful in self-disclosing about their own sexuality in counseling, Ratcliff says. He suggests discussing sexuality in a broader, more general sense. For example, the clinician could tell the client, “Some people enjoy this sexual activity” rather than saying, “I enjoy this sexual activity.”   

Ratcliff cautions that counselors should also be mindful of potential power impositions and harm that self-disclosure can cause. For example, a therapist disclosing that they are interested in a particular type of kink to a client who is also into kink can create an implicit power dynamic, he notes. 

Walker acknowledges that it is relatively common for transference to occur when discussing intimate topics but not necessarily for the reason people might assume. It isn’t because sex therapy is filled with salacious talk, she says, but because the counselor is a nonjudgmental person who is affirming all of the client’s strengths and qualities, which may not be acknowledged by others in the client’s life. 

Schubert once had a client admit that they were struggling because they thought that they might be developing romantic feelings for her. Schubert didn’t shy away from the discussion; instead, she asked the client to explain what they were feeling. The client told her that she was the only woman they were able to talk with about such intimate things, and they weren’t sure why they couldn’t say the same things to their partner. Schubert said, “It seems to me that this is the first time — that you’re aware of — where you’ve been able to be fully yourself and be heard. That’s powerful because it shows how courageous you are in your ability to be vulnerable with another person, and specifically another woman.” 

This response helped shift the conversation away from any possible transference or attraction, Schubert says, and placed it back into the therapeutic realm. Then, together they explored what it was like for this client to be heard and whether it was time for him and his partner to go to couples counseling so they could figure out why he was having trouble discussing intimate topics.

By embracing a sex-positive attitude, counselors can help begin to break the silence, shame and stigma surrounding sexuality. Clinicians are “taught so well to meet people where they are in their journey,” Gonzalez says, and sexuality “is just another part of the client’s journey, another part of who they are.

Song_about_summer/Shutterstock.com

 

Sex counseling versus sex therapy

Although the terms sex counseling and sex therapy are often used interchangeably, some mental health professionals note a distinction between the two. “A sex therapist can do more in-depth psychotherapeutic work with a client,” explains Lily Gonzalez, a licensed professional counselor and sex therapist in Chicago, “whereas a sex counselor is more high-level counseling and psychoeducation, but not the deeper psychotherapy, and their work is usually limited in time.”

The Association of Counseling Sexology & Sexual Wellness (ACSSW), an organizational affiliate of ACA that promotes sexuality as a central aspect of being human, defines sexuality counseling as a professional relationship that aims to do the following: 

  • Help people increase their comfort and awareness of sexuality and sexual experiences
  • Validate sexuality as a core aspect of the human experience
  • Provide evidence-based education regarding sexual health concerns 
  • Support clients as they navigate various influences on their sexuality 
  • Empower clients to express their sexuality while also respecting their own and other’s sexual rights 
  • Promote sexual wellness 

(See ACSSW’s website counselingsexology.com for more on sexuality counseling and sexual wellness.)

The American Association of Sexuality Educators, Counselors and Therapists (AASECT) distinguishes between AASECT-certified sexuality counselors and therapists. AASECT notes that sexuality counselors come from a variety of professions, including counselors, nurses and clergy, and they help clients resolve sexual-related concerns through problem-solving techniques and psychoeducation. Sexuality counseling is typically short-term care and focuses on the immediate concern or problem. 

AASECT-certified sexuality therapists, on the other hand, are licensed mental health professionals who provide in-depth psychotherapy and have specialized training in treating clients with sexual issues and concerns. They are capable of both treating simple sexual concerns and offering more comprehensive, intensive psychotherapy if needed. 

(For more on the differences between AASECT’s certifications, see aasect.org/certification-types-distinguishing-sexuality-educators-counselors-and-therapists.)

 

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Resources on sexual health and wellness 

 

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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.

Counseling after brain injury: Do’s and don’ts

By Bethany Bray May 20, 2022

Traumatic brain injury (TBI) is complicated.

Counseling practitioners may work with brain injury survivors who struggle with impulsivity, anger, despair, personality changes, memory loss, language or cognitive difficulties and a range of other symptoms. Not only do post-injury symptoms and recovery differ from person to person but the way these challenges dovetail with their mental health, relationships and overall wellness also varies.

Here are 12 important do’s and don’ts for mental health practitioners to keep in mind when counseling clients who have experienced a brain injury:

 

1) Do devote a lot of time to listening. One of the most important and beneficial things a counselor can offer a brain injury survivor is empathic and nonjudgmental listening. Having a space to talk about what they’re going through and struggling with and what they need without feeling like a burden can make a world of difference for these clients, says Herman Lukow, a licensed professional counselor (LPC) and licensed marriage and family therapist who spent three years as a postdoctoral fellow researching TBI at Virginia Commonwealth University’s Traumatic Brain Injury Model System program.

 

2) Don’t equate struggle with resistance. What might seem to be resistant behavior in this client population is often not intentional. They may miss sessions or be hard to contact, but it’s more likely to be caused by the memory and cognitive challenges they live with (e.g., confusing what day it is) rather than resistance, Lukow says.

 

3) Do be comfortable with silence in counseling sessions. Brain injury survivors may struggle with speaking or finding the right words to express themselves. Practitioners need to resist the urge to fill periods of silence, and they may also need to get creative to find other nonverbal methods or adaptive tools to communicate with these clients, notes Hillel Goldstein, an LPC with a private counseling practice embedded within the Brain Injury Foundation of St. Louis.

 

4) Don’t go it alone. Counselors can best treat these clients by collaborating, co-treating and consulting with professionals from a range of other disciplines who have expertise in helping brain injury survivors, including speech and language pathologists, occupational therapists, rehabilitation specialists and others, says Goldstein.

 

5) Do adjust your pace and expectations of progress. The therapeutic expectations, outcomes and what can be counted as a “success” will vary with clients who are TBI survivors, notes Michelle Bradham-Cousar, a licensed mental health counselor and certified rehabilitation counselor who recently completed a doctoral dissertation on counseling clients with TBI. The benchmarks or signs that counselors may associate with improvement or growth in clients may not be apparent — or appropriate — with clients who have experienced brain injury.

 

6) Don’t be a cheerleader. Life after a brain injury is hard, and survivors may feel that conversations in counseling only emphasize what they’ve lost, says Lukow. A constant stream of positivity or messages such as “you’ll get through this” from a counselor may turn these clients off; instead, they need honesty from a practitioner and validation that what they’re going through is rough.

 

7) Do ask clients if they’ve ever had a brain injury or related issues such as falls, sports injuries or loss of consciousness. Clients may not disclose past brain injury or realize that it can be connected to their mental health or presenting concern, so it’s important to ask at intake. It’s equally important for counselors to realize that a past brain injury — even if a client doesn’t think it was serious — can lead to or exacerbate mental health symptoms, Lukow adds.

 

8) Don’t forget these clients’ loved ones and caretakers. The mental and emotional burden that comes with caring for a brain injury survivor is heavy, yet caretakers often put themselves last, Goldstein notes. The loved ones of TBI survivors can also benefit from therapy, particularly the supporting environment that group counseling can provide.

 

9) Do dig deep into your counseling toolbox. The crux of what brain injury survivors need in counseling is help dealing with loss and change, says Lukow. And counselors already have an arsenal of tools and methods to help in this realm, from cognitive behavior therapy to the therapeutic relationship itself.

 

10) Don’t think of life after brain injury only in terms of loss. Post-injury recovery is also an opportunity to gain new skills and find new ways of doing things. A client may not be able to work in a job or field they used to, for example, but a counselor can help them reframe this loss as a chance to look for a new occupation that fits with the skills they do have, notes Bradham-Cousar.

 

11) Do consider this as a specialty. There are not many professional counselors who specialize in psychotherapy for brain injury, but it’s an important and much-needed expertise, says Goldstein. It could be a good fit for counselors who are interested in this client population or who thrive working in multidisciplinary teams.

 

12) Don’t assume that recovery ceases within a few years of a brain injury. Survivors can still make gains with emotional, social and psychological challenges long after — even decades after — brain injury, says Lukow, especially when supported by helping professionals who provide patient, empathic care.

 

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Read more on counseling clients who have experienced a brain injury in an in-depth feature article in Counseling Today’s upcoming June magazine.

arloo/Shutterstock.com

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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.

Mental gymnastics: Navigating challenging relationships

By Grace Hipona May 13, 2022

“I am not sure how they are feeling and what they are thinking. I am confused. I feel like I am going crazy. I question everything, and I don’t know if I can trust what I am feeling and thinking.”

Relationship issues are one of the more difficult problems to help clients manage. When clients make any of the statements above, especially in relation to someone else, I talk with them about what I have coined as “mental gymnastics.” Mental gymnastics can start with unsettling statements and questions but also can lead to impacting other areas of a person’s life. In this article, I discuss how clients can be affected and strategies professional counselors can use to help them navigate these challenges.

Direct communication

When a client is experiencing mental gymnastics, they may commonly ask, “Why is this so hard? Why can’t I make this work? Why is this so exhausting?”

Direct communication, including asking questions, is the best strategy for clients to navigate mental gymnastics. However, if direct questions are asked and the other party does not respond with an honest or genuine answer, then it becomes more complicated. Sometimes, there is a discrepancy between what a person says and how they act. Sometimes, they may not even have this awareness, especially if they are confused themselves.

Unfortunately, it may feel purposeful or malicious when others do not communicate directly, lie through omission or engage in other forms of dishonesty. A classic example is when a person asks, “How are you?” and the other person responds with “I am fine.” However, their body language and tone of voice indicate that they are not actually “fine” but are instead upset or angry. Another common exchange is one person asking, “Do you need anything?” and the other person responding with “no,” even though they need help.

When discrepancies between what clients say and how they act arise, it is natural for clients to question their own inclinations. “Can I trust how I feel or what I think?”

Adding to the internal conflict, the other person can potentially invalidate how the client feels or completely deny their reality. Therefore, as professional counselors, it is important to specifically ask clients their feelings about the relationship in question. This clarity can increase clients’ self-awareness. Clients will find it easier to navigate relationships when they are aware of their reality and have confidence in it.

Good vs. bad anxiety and needs vs. wants

One common example of mental gymnastics that I’ve encountered is when a client has begun getting to know someone (whether a budding friendship or a romantic relationship) and they experience anxiety that is more constant and intense than typically associated with relationship building. This is when clients may begin having unsettling questions and statements: “Why can’t I tell if they like me? I can’t seem to get a straightforward answer. I don’t know what they want.”

When this occurs, I help clients differentiate “good” versus “bad” anxiety. In other words, I provide a space for them to process how they perceive the adrenaline associated with their experiences. A person should experience levels of anxiety when meeting someone new and getting to know them. This could be perceived as “good” anxiety or excitement. Clients may feel butterflies in their stomach, brighter in their affect, and hopeful. With good anxiety, clients may have thoughts and questions such as, “Do they like me?”; “Did I make a good impression?”; and “I can’t wait to see them again.”

If clients experience “bad” anxiety, such as excessive worry, irritability, dread and the triggering of the “fight, flight or freeze” response, this may be a red flag. They may have thoughts such as, “I don’t know what to do”; “I can’t seem to say anything right”; and “What can I say or do so that they will like me more?”

In helping clients assess whether they are experiencing “good” versus “bad” anxiety, I ask them if in general they feel more positive emotions than negative ones. For example, “Do you feel happier more than 50 percent of the time?”

I also help clients determine their needs and wants. I describe needs as things that are non-negotiable to them, such as respect, trust, honesty, marriage, children, and religious or spiritual beliefs. Hard boundaries need to be set around these needs.

Wants are negotiable or flexible. Examples include physical appearance, financial status, educational background and geographic origin. When it comes to positive and healthy relationships, clients should have their needs met, and the relationship should feel like it is a “want” or a choice.

LinaDes/Shutterstock.com

Minimizing and denying

The answers to the assessment questions in the previous section can be interrelated and could lead to more confusion. For example, clients could determine that they feel happy most of the time with their relationship but that most of their needs are not being met. This discrepancy can cause clients to question their feelings, and this could lead to an increase in anxiety.

Another potential cause of internal conflict is receiving information from the other person that minimizes or denies the client’s experience. For example, the client may be questioning their own reality because the other person is directly challenging it: “Oh, you shouldn’t feel that way. Are you sure?”

The other person could be completely denying the client’s reality: “That didn’t happen. I know what you’re feeling. You’re not really mad.”

Some may even define this as “gaslighting” (questioning their internal reality or “sanity” based on external pressure and manipulation).

Another example that can cause internal conflict is when the client brings a concern or stressor to the other person, and that person minimizes the client’s experience. The other person might respond with, “You’re making a big deal out of nothing, and you shouldn’t feel that way.” The other person may shift the focus to themselves while minimizing the client’s experience, “You think you’re upset? I’ve felt so much worse. You don’t know what suffering is really like.”

In any of these scenarios, the attention has turned toward the other person, and the client’s thoughts and feelings have been dismissed. In other words, the client is then reactively directing their energy toward the other person, and the client has lost sight of their inner experience. The client could be more likely to “lose themselves” in the relationship and, therefore, not get their needs and wants met.

Like the sport, mental gymnastics requires a person to use energy and effort. However, unlike the sport, mental gymnastics unnecessarily uses a person’s energy. One indicator that clients are engaging in mental gymnastics is that they feel tired and their mood is generally lower than usual. Clients may describe feeling “drained” even though they are not actively and purposefully using their energy. They may feel the need to use certain strategies or efforts to engage with a particular person. Clients may feel the need to “perform” a certain way; otherwise, they may feel judged, criticized and denied any love, support, care or validation from the other person. Clients may feel dueling inclinations of needing to spend time with the other person but also wanting to avoid that person.

Another reason clients may unnecessarily use energy to engage with another person is that even when trying to support this person, clients feel like they “can’t win.” In other words, the intention and effort may be there, but the other person still feels “it is not good enough.” Even if conditions are met, the other person may find something wrong with what has happened. That person may say, “That was a nice try, but I would have liked this instead.”

Aside from helping my clients gain clarity over their needs versus their wants and insight into their internal experience in general, I believe it is important to help clients reality test. Writing a “pro/con” list or something similar can be useful, especially for clients who tend to be visual in nature. Asking the following questions can support development of this list:

  • How do you benefit from this relationship?
  • How does this person meet your needs and wants?
  • How do you feel about them?
  • How do you feel about the relationship?
  • How is your life impacted by this person?
  • How do they challenge you to be the best version of yourself?
  • What do you like about this person?
  • What do you dislike about this person?
  • What do your friends and family think about this person. 

Active and reactive decision-making

After time, effort and space have been given to the questions mentioned in the previous sections and clients continue to move forward in a relationship where mental gymnastics is present, I encourage clients to think about the consequences of this choice. At this point, clients can take ownership and feel empowered by their decision-making.

When I work with clients, I focus on strategies to help them make ACTIVE decisions rather than reactive ones. Once there is a level of insight into decision-making, they can make informed decisions. This awareness can lead to active decisions where the clients feel they have a choice. Without any awareness, clients may not feel like they have a choice. They may feel compelled to do something but not know why.

An example of a reactive decision is when a client chooses not to end a relationship even though there is evidence that the relationship is unhealthy. A client may say, “I don’t want to break up with him because I love him.”

As the client’s counselor, I would ask, “Why do you love him?”

The client may respond with, “I just do” or “I am not sure, but this is how I feel.”

If clients continue making reactive or passive decisions, this can perpetuate or exacerbate negative anxiety. Counselors can assist in exploring the client’s decision-making process so the client can answer the question “why?”

I believe when clients experience anxiety, it is not just their fear of the unknown and the byproduct of internal conflict, but also a result of them not feeling empowered in their own lives. For clients to feel empowered, they need to be an active participant in their own decision-making process. Counselors can help clients manage this anxiety by helping them focus on their locus of control.

Clients can examine what they say and how they act toward the other person. They can focus on their self-care and on other important aspects of their identity. Clients can also concentrate on purposefully coping with their anxiety in healthy ways. These strategies can lead to feeling confident in navigating potential mental gymnastics.

 

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Grace Hipona is a licensed professional counselor for NeuroPsych Wellness Center PC and holds a doctorate in counselor Education and supervision. Her dissertation focus was on disaster mental health, specifically sheltering-in-place. She is also a certified substance abuse counselor and approved clinical supervisor. Her experiences over the past 15 years include working in private practice, managing behavioral health programs, teaching graduate students, and providing supervision for master’s-level counseling students and counselors-in-residence. Contact her at ghipona@hotmail.com.

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