Monthly Archives: June 2022

Why the body matters

By Katie Bascuas June 27, 2022

Somatic therapy, or therapy that incorporates the body into the therapeutic process, continues to grow in popularity. This is likely due to the evolving nature of our understanding of trauma and the need for various approaches to treat the impact of traumatic experiences, which often have a significant physiological impact on the body, especially the nervous system. But as a relatively new therapeutic approach, which lacks the equivalent evidence-based research to support its efficacy compared to other modalities, somatic therapy is not without skeptics. Many clinicians who use it, however, advocate for its ability to help clients, especially those who may have tried other modalities with mixed results and those who are processing traumatic experiences. 

Incorporating somatic techniques into psychotherapy work came almost second nature to Kimberly Hanson, a licensed professional counselor (LPC) in Charleston, South Carolina, and a trained dancer. 

“I understand a lot about the body, and how our emotions can be reflected through our body and vice versa,” says Hanson, who uses movement exercises and breathwork as part of her work with both adults and children. 

“I’ve done exercises where [clients] stand up, and they’ll stretch their arms up to the ceiling and then drop down and swing them on the floor and bring them back up, all while focusing on their breath,” Hanson says. She also incorporates modern dance techniques such as expanding and contracting the body into her clinical work. For example, she once worked with a client to process a fear of taking up space and using his voice by asking him to stand up, spread his arms and move in a circle to establish his own personal zone. “We did some expansion work with that and coupled it with some breathwork, and I’d ask him what he noticed when he took up territory and established his own personal boundaries,” Hanson recalls. “That was very impactful for him.”

Hanson has found that pairing body-based techniques with other more talk-based therapies to be incredibly effective when working with clients. “It can give [counselors] a lot of information,” she explains. “We are a three-part being. We are body, mind and spirit, and all of those things integrate together, so why don’t we incorporate that into our therapeutic process? 

Using a somatic approach may look different depending on the counselor’s training and preferences. Some clinicians may be fully certified somatic experiencing practitioners (SEPs) trained in the somatic experiencing (SE) program based on the work of Peter Levine, whereas others, such as Hanson, may be trained in other modalities but incorporate somatic-based techniques such as mindfulness, movement and breathwork into their therapeutic work. Even the pathways to incorporating somatic techniques can look different to most counselors. However, one thing that many of these clinicians have in common is their belief that the results of body-based techniques often speak for themselves.

Brain-body connection

Mike Wendt, an LPC at Sherman Counseling in Appleton, Wisconsin, has been doing SE work since 2019 and says that it has transformed his therapeutic orientation. “It’s gotten to the point where this is my main modality,” he notes. “It’s really that powerful. It just floors me with what I’ve seen in practice.” 

Wendt, who has a background in neuroscience and is certified by the Biofeedback Certification International Alliance in the use of electroencephalographic (EEG) biofeedback, says that neurofeedback was his gateway into therapy. “I was very interested in the mechanics of how the brain works and the neurological patterns associated with things like anxiety, depression and trauma,” he says. While fine-tuning his neurofeedback skills, however, he kept encountering clients with a lot of trauma markers in the brain. For example, alpha brain waves, which can be detected with an EEG, show up differently in traumatized and nontraumatized clients, he explains. When a client who has not experienced trauma closes their eyes, the EEG shows a healthy increase of alpha waves in different parts of the brain, he says, but for a traumatized client, the rise in these waves may be blunted or absent. And for some severely traumatized clients, it may even decrease, he adds. 

After noticing these neurological markers among several clients presenting with trauma, Wendt says that he began looking for other modalities to help treat traumatic experiences. “There haven’t, historically, been a lot of effective ways to work with trauma, so I thought if I’m just going to keep encountering these neurological markers, I better come up with an effective way to work with it outside of neurofeedback,” he recalls.

Wendt later stumbled on some writing about SE while researching neurofeedback and decided to attend a training session in 2019. “It was incredibly eye-opening how everything with SE just tied together with neuroscience and changes in brain pathways — so using the body to train the brain and not the other way around, which is where I was coming from with the neurofeedback,” he says. “This tied things all together for me when we brought the body on board.”

When he first began incorporating SE into his practice, Wendt would start a session with neurofeedback until he noticed a client’s physical reactions, and then he would shift into more somatic work. “There’s always a somatic reaction when trauma is brought to the surface,” Wendt explains. “Later on, I would just skip the neurofeedback entirely and just go into what is a person’s body language saying to me.”

He once worked with a 16-year-old female client who was experiencing chronic physical pain and was referred to Wendt for his expertise in neurofeedback. In working with the client, Wendt also incorporated SE and was able to help the client to reduce the pain to a level where she could focus on other issues, such as an eating disorder. 

Wendt says that he brought in body work to help treat the eating disorder by reflecting the client’s posture and how it changed when she discussed her journey dealing with disordered eating. He would notice how her hands would fold over stomach, for example, as she discussed different parts of her experience, especially the time she was hospitalized and when discussing her body image compared to her friends, whom she thought had a more “normal” body weight and physical condition. After reflecting what he noticed, Wendt says that he then asked the client to try moving her hands out away from her stomach as she talked. “What I had her do is experience what it was like in her body when she would put her hands out a little further, so she would be more open physically and less threatened emotionally, and then she would bring them back again and feel her anxiety rise and fall,” Wendt explains. “And she’d also feel the comfort of having her hands folded around her stomach as security.” 

He also helped this client work on developing positive coping strategies using SE, and over time as the client continued to experience and process the anxiety, she was able to move her hands away from her stomach completely without fear or hesitation. When this happened, Wendt recalls that the client looked at him and said, “Did you trick me?” He asked her what she meant, and she explained that “the feelings of how she looks and how others see her weren’t there anymore.” And eventually, the client felt comfortable enough to engage in activities she might have previously passed up such as wearing a bathing suit at the beach. 

Improving self-regulation 

For Nancy Skocy, an LPC and SEP in Tucson, Arizona, SE became part of her clinical work after she experienced its effects via her own personal therapy. 

“I worked with other kinds of therapy and personally have been in therapy myself, and what I had discovered in my own work is that I could understand a concept — for example, the concept of setting a boundary — yet when it came to doing it, I would have the words [to verbalize the boundary], but it seemed that something was missing in that I didn’t know how to be effective around setting [or enforcing] the boundary.”

Skocy also has a background in equine therapy, and she says that working with horses, combined with her personal experience with somatic therapy, helped her to see the possibility for helping clients work on emotional regulation.

“If you are emotionally dysregulated when you’re trying to work with a horse, the horse reads that emotional dysregulation in your body,” she explains. “Taking those types of nuances into the SE world is when I started realizing that many times when I was communicating with family members or loved ones and I was upset emotionally, I would communicate in a dysregulated way and it would not be effective.”

She says that she noticed a similar theme among some of her clients who struggled with emotional dysregulation, which affected their communication styles as well as their relationships. “What I noticed was that a lot of my clients had a hard time shifting to taking responsibility for self-regulation,” Skocy recalls. There’s often a belief that other people will regulate us, she adds, especially in clients who have experienced trauma. 

She finds that having clients track their bodily sensations, in addition to their emotions, helps them improve their ability to self-regulate. “Tracking emotions isn’t the same thing” as noticing physiological responses, she says, “because if I’m tracking my emotions — I’m angry, I’m hurt, etc. — I will then justify my reasons for attacking someone else.” Taking this extra step of noticing bodily sensations and then regulating the nervous system response allows clients to come from a more empowered and controlled place when responding to emotionally triggering people or situations, she adds. 

One way Skocy shows clients how to regulate their emotions is by helping them shift negative bodily sensations into more positive ones. For example, if a client reports feeling tense or constricted, Skocy may prompt them to remember a time when they were happy or to think about a loved one and to notice how their body feels. She may also ask clients to explain how they know they feel happy, which may be because their cheeks feel warm or they notice that they’re smiling. 

“Finding the positive is where you restore the balance,” she says. “When I think about someone that loves me or a happy time that I had, I can learn how to shift things myself, and I can settle into a more regulated state and think about how I want to approach communicating with someone.”

In that sense, clients then have more autonomy around how they show up in the world, including the boundaries they set. “A boundary is no longer telling somebody, ‘When you do this, I’m going to confront you,’” Skocy says. “It now becomes, ‘It’s important for me to take care of myself and to protect myself in my relationships as well as to consider the other.’” 

Filling a gap 

Whitney Norris, an LPC and SEP in Little Rock, Arkansas, and co-owner of Little Rock Counseling & Wellness, was also drawn to SE work after experiencing the benefits firsthand through her own personal therapy. She later completed the three-year SEP training, which had an effect not only on her therapy worldview but also on how she presented herself as a clinician.

“The first thing that I noticed with SE training was the way that I showed up in the room, noticing my own reactions to what was going on in the room and noticing and differentiating what was going on with the client even if I didn’t speak any of it,” Norris says. “I felt like I was more present.” She adds that SE training and learning more about her own nervous system helped her to expand her capacity to sit with different things that may come up in a session or that might happen in her own life. 

Norris, who specializes in trauma work, says SE also helped her fill a therapeutic gap that she felt was missing in her work. She had some clients from whom talking about their experience was not that helpful and others who found eye movement desensitization and reprocessing (EMDR) to be too intense. She says using SE is especially helpful for these clients — ones she admits “might have otherwise been falling through the cracks treatment-wise” — because it incorporates the client’s bodily response in a way the other therapies do not.

Although she occasionally runs into a client who is initially hesitant to try somatic techniques — largely due to the fact that they may differ from anything the client has tried before — she finds that most clients are willing to engage in SE and are typically surprised at the results. In fact, clients often tell her, “I have no idea how that worked, but I feel like it did” or “I don’t understand what we just did, but that felt helpful.”

Skepticism

That sense of mystery behind somatic therapy and how it works, coupled with a lack of research compared to other modalities, can contribute to a feeling of skepticism. Some critics argue that there is not enough research to prove the effectiveness of somatic-based techniques. 

In a 2021 literature review of the effectiveness of SE published in the European Journal of Psychotraumatology, for example, Marie Kuhfuß and colleagues found preliminary evidence suggesting positive effects of SE for the treatment of symptoms related to posttraumatic stress disorder (PTSD) as well as affective and somatic symptoms, yet they also noted that the quality of research surveyed was mixed due to risk of bias. The authors recommended further research through randomized controlled trials. 

Meanwhile, a 2017 randomized controlled study of SE — billed as the first of its kind — found evidence to suggest that it is an effective treatment modality for PTSD. The study, published in the Journal of Traumatic Stress by Danny Brom and colleagues, randomly assigned 63 participants living in Israel, all of whom had reported traumatic experiences within the previous four years, to two groups: one that underwent 15 sessions of SE and another that was assigned to a waitlist. In the post-session analysis, researchers found significant effects of SE on posttraumatic and depression symptom severity among participants assigned to the treatment group.

Danny Brom and colleagues also noted, however, that the small sample size as well as the difficulty in measuring the effectiveness of a treatment that does not adhere to a strict protocol were both limitations to the research. 

Unlike a modality such as EMDR, which is protocol-driven and more black-and-white in its approach, Norris says, SE is less linear and looks different to various practitioners who may incorporate a variety of techniques based on their own preferences or the needs of a client, making it harder to research. But “it doesn’t necessarily mean that it’s ineffective because there isn’t that type of research out there,” she says. “It may mean that it doesn’t lend itself to be able to be researched in that way.” 

Challenges

Skepticism and the need for more research aren’t the only challenges counselors may face with somatic-based work. “I frequently run into people not wanting to have a relationship with their body,” Skocy says. In fact, she points out that some clients may have a dislike or even hatred of their own bodies and feel shut down physically. 

Hanson agrees and notes that she sometimes encounters clients who are resistant to trying a somatic technique or who don’t experience any immediate benefit. When this happens, she says that she often tries to use the resistance or the lack of effect as a catalyst for further exploration. “As a trauma professional, I’m trained to understand those blocks, so we’ll do something else to try and access why they’re not getting anything or why they feel numb,” she explains.

Eugene Titov/Shutterstock.com

Both Norris and Wendt agree that the learning curve associated with somatic therapy provides another challenge. “There’s a reason the [SE] training is spread out over three years — you need to have time to integrate each piece,” Norris says. Because she didn’t learn about the nervous system or the body in her graduate program, she had to catch up on those pieces, all while learning the specific SE techniques.

Not only is there sometimes a knowledge gap, but the work also takes practice. “It is very much an art form,” Wendt says. “If you push someone too quickly, they might shut down and go into that freeze or collapse state, and you’re most likely not going to get them back in that session.”

The possibility of triggering someone while doing SE emphasizes the importance of creating safety for clients. Wendt says that he uses mindfulness skills such as body scans to help clients safely connect to their bodies, and he encourages clients to think of a pleasant experience or a safe person that they can focus on when they want to feel safe and relaxed during a session. 

“That way we have something that they’re able to tether to because the goal of SE is not to approach trauma to the point of being overwhelmed, but to approach the outer orbits where can we feel the first whiff of that signal in our body that tells us that something isn’t right,” Wendt says. “Oftentimes we don’t need to go any further than that, but we want to have a tether because if we go too far, the person can shut down very quickly and then you have to start over again.”

Try it for yourself

Some clinicians are hesitant to try somatic approaches because they fear retraumatizing or triggering a client. Yet many who support the work have been able to move through that fear, and they say that the results they see among clients are worth it. 

The counselors interviewed for this article all recommend that clinicians who are interested in delving into somatic therapy should try it for themselves as part of their own personal therapy. They suggest that practitioners read, research, and take training and continuing education courses about the practice of somatic approaches and body-based interventions to gain a deeper understanding of this approach and how it can be helpful to clients. Counselors can also find a therapist who specializes in somatic work and try a session or a series of sessions. 

“That really tipped me over the edge of being convinced,” Norris says. “I had done a lot of therapy up to that point, and it was all helpful, but once I started doing my own SE therapy, it was just beneficial in ways that other stuff I was doing wasn’t.”

She and Hanson also make the point that without doing the work yourself, it can be hard to fully comprehend how the techniques work and why they can be effective. 

“You can’t do these techniques without understanding it from a personal level,” Hanson says. “There’s just no way. You can try, and it will either feel forced or feel too rigid, and the client will pick up on that and know that this isn’t what you do.” 

She adds that the essence of this type of work is experiencing — being present with the feelings and sensations of the body as they arise — and that needs to feel genuine. “Part of the goal of these processes is that they’re organic and that it feels natural, so the therapist must be very comfortable with these types of interventions in order for the client to feel comfortable with it,” Hanson says. And “you have to do it yourself to get that understanding.”

 

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Contact the counselors interviewed in this article:

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Katie Bascuas is a licensed graduate professional counselor and a writer in Washington, D.C. She has written for news outlets, universities and associations.

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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.

It’s time for a financial change in counseling

By Derek J. Lee June 23, 2022

There is a broad awareness that we are in the throes of a mental health crisis in this country. Open discussions of increases in depression, anxiety and suicide attempts are common among news outlets and social circles, while the real impact is being felt in the homes of those suffering every day. When discussing the mental health crisis, the typical focus is the increasing incidence of mood disorders and suicidality. What has been consistently and systemically overlooked is our lack of providers. This article is going to delve into the financial reality that contributes to our mental health crisis.

When someone needs a counselor, the counselor is “worth their weight in gold.” Why is it then that counselors may be the most underpaid, advanced-degree medical professionals in this country? Recently, I was talking to a couple of peers who are also professional counselors, and one stated that a new professional they know was just offered a job starting at $29,000. The other shook their head, looked down and then back up in frustration, and stated, “Last week when I was driving through Michigan, a fast-food place was offering $1,000 sign-on bonuses and $18 an hour.” We will get into the whys later, but this is the disparity that is also a reality in our field.

By the numbers

Let’s start by looking at how much counselors actually make. According to the CareerExplorer website, the average salary of a mental health counselor in the United States is around $35,642 per year. The bottom 20% are placed at $29,800, whereas the top 20% are placed at $57,100. CareerExplorer also offers breakdowns of the average mental health counselor salary by state, with Tennessee coming in at a low of $31,000 per year and Alaska being at the top of the chart with an average salary of $63,900. My current home state of Ohio shows an average salary of $44,100 for mental health counselors, with the bottom 20% at $31,800 and the top 20% at $65,100.

CareerExplorer appears to offer the most accurate of the pay ranges I found in my search because it focuses on master’s-level mental health counselors providing direct care services in a variety of settings. Several other resources show salary ranges of $33,000-$75,000, with some going as high as $100,000, but most of these blur the lines by including Ph.D.-level psychologists, testing, and a number of services that significantly skew the average salary.

As professional counselors, we know what it takes to enter this field, but the general public does not. Educational and experiential requirements can vary somewhat state to state, but for many of us, it starts with a 60-credit-hour master’s degree, which also typically includes an unpaid 100-hour practicum and a 600-hour internship. State boards, the National Counselor Examination, background checks and ongoing supervision get you in the door. Then you must continue with supervised hours, continuing education, training in models and additional hurdles. These are not bad things; they build our body of knowledge, increase standards for the field and lend us credibility. They also come at a cost of both time and money, which are valuable commodities in our field.

With an understanding of the rigor and length of the educational requirements of clinical counselors, and the additional information of what the typical salary range is, how does this compare to national averages? According to the U.S. Bureau of Labor and Statistics (2021), the average salary for someone in the U.S. with a master’s degree is $77,844. The average salary for someone with a bachelor’s degree is $64,896. These are not starting salaries, but average salaries, just as the average salary for a master’s-level counselor in Ohio is $44,100 and nationally is $35,642. If you reference Northeastern University’s Education Pays Chart, you are able to see where counselors fall.

Implications

Now that we have established that counselors are significantly underpaid, it is important to explore likely implications.

The first implication is burnout, which affects the field twofold in that it shortens careers significantly and impairs providers who continue to actively work. The average counselor has a productive life span of 10 years before burnout is almost inevitable.This does not account for increased stress in our society due to the COVID-19 pandemic, politics or a volatile social environment.

Why does average salary impact burnout? Because the lower the income, the more stress is created. According to Matthew Killingsworth (2021), drawing on 1,725,994 experience-sampling reports from 33,391 employed U.S. adults, the results demonstrate that both experienced and evaluative well-being increased with income. Factors include being able to pay student loans, afford housing and not worry about how a master’s-level medical professional will pay for a child’s sporting or extracurricular activities. It also extends professionally, in that increased reimbursement allows for lower caseloads, increased preparation time, and more funding for training and professional development.

This creates a natural transition to the second implication — the link between better care for the professionals and improved patient care. If we are supporting our professionals through decreasing caseloads to more manageable levels, increasing purposeful training and promoting more professional development, we are going to see improvements in patient care. Research demonstrates that when using researched-based interventions, we see significant increases in client care, but also accountability in the profession. Effective care means improved outcomes and reduced durations of service, which not only means happier people, but also healthier and more productive people.

A third implication is the impact on recruiting and retaining quality professionals in our field. Unfortunately, in the past decade we have witnessed a tremendous number of counselors shifting to other professions and fields. Some have moved to aligned fields, such as school counseling or education, and many have moved to much different venues, including real estate, IT and software development.

As mentioned previously, we are often experiencing a productive span of 10 years after an education that required seven years to achieve. This is, by any standard, a very poor return on investment. These moves are frequently the result of burnout and the desire to improve their financial situation.

In a similar vein, it can be difficult to attract individuals to the field when it is widely known how stressful and underpaid the profession is. This is even more complicated, as in the past two years we have seen an unprecedented spike in need, with such limited resources and an extended training period.

If the field is to continue to recruit the best and brightest, it also has to offer them competitive wages. If the goal is to increase our recruitment, that point is even more important. It goes beyond simple difficulty and pushes into societal values and ethics when highly educated counselors are starting at significantly lower salaries than individuals with entry-level positions in business.

As we consider education, recruitment and wages, it is also important to examine this topic in terms of social justice. Counseling is a field that has disproportionately high numbers of women and marginalized populations, while also demonstrating disproportionately low wages. Nothing has been found in the literature to demonstrate a causal relationship, but the correlation is difficult to deny. With a workforce that, according to the U.S. Bureau of Labor and Statistics (2021), is 73.3% female (compared to the U.S. average of 46.8%) and nearly 40% nonwhite (compared to U.S. averages of 22%), this is a field composed largely of minoritized workforce populations.

The fact that counselors are, by nature, helpers and are often willing to give freely of their time does not mean that they should be treated unfairly as a labor force. This lends to revisiting the education required and a comparison with other professions.

The fact that a counselor has completed a 60-credit-hour master’s program is significant, as most master’s programs require 30 credit hours, with “more complex and in-depth programs” increasing this to as much as 40 credits. According to U.S. News & World Report (2021), the average master’s program requires 32 to 36 credit hours. It is also important to note that most programs do not have an intensive internship requirement like that of counselor education.

If we look at similar practitioners, such as nurse practitioners, a master’s in nursing is a minimum of 36 credits, and a doctorate in nursing is an additional 36. Another line of work that could be considered similar would be a physician assistant. To become a physician assistant, a master’s degree is required, which is a standard three-year program, as well as 2,000 clinical hours. As these three have the most similarities regarding education and clinical setting and resulting in jobs that include diagnosing and treating medical disorders, these are my base of comparison.

As we have already established, the average counselor in the United States makes $35,642 per year, while the average annual salary for nurse practitioner is $114,510 and the average annual salary for physician assistant is $115,390. It seems quite reasonable for the counseling field to be funded in a manner that allows for paid internships, starting wages in the $75,000 range, and average earnings to be in the range of a nurse practitioner or a physician assistant.

The solution is simple: to align the reimbursement rate for counselors to a rate commensurate with that of similarly educated professionals in the field of medicine, which would also realign income to that of similarly educated professionals in all fields. Well-run mental health offices carry much of the same overhead as other medical and professional offices, including clean and inviting environments, support staff to assist with clients and administrative needs, commercial-grade furniture to handle heavy use, and solid construction that also provides sound deadening for the space. Offices need technology, which continues to expand with electronic health records and testing, and the electronic health record systems themselves, along with constant upgrades and IT support.

The idea of moving the average counselor salary from $35,642 to the wages discussed above would seem to require reimbursement to triple, but it would not. If we were to share the burden, both by focusing on increased efficiency and increasing reimbursement, these changes could be implemented with a reimbursement increase of approximately 80% as opposed to an expected 300%. This would provide the opportunity for clinicians to decrease caseloads slightly, provide better care and make a wage commensurate with their work, education and ongoing educational requirements.

Ask yourself this question: When you are seeking help from a counselor for your child or significant other who is suicidal, do you want someone who is on the top of their game, or someone who is struggling to make ends meet and may be nearly as stressed out as those they are serving?

ashadhodhomei/Shutterstock.com

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Derek J. Lee is the founder and CEO of Perrysburg Counseling Services and The Hope Institute. In addition to clinical work and administrative roles, Derek is finishing his Ph.D. in counselor education at Ohio State University and teaches in the Department of Clinical Counseling and Mental Health for Texas Tech University Health Science Campus.

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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.

Building trust with reluctant clients

By Bethany Bray June 22, 2022

The Washington Post’s “Dear Carolyn” advice column recently fielded a question from a person who was unsure if they were ready to seek counseling to cope with a strained relationship with a parent. Although the person was aware that counseling could be helpful in this particular situation, they were still reluctant to seek services. “I can’t bear the thought of sharing any sort of emotions or history with a complete stranger, especially when I hear people have to reshare as they try two or several counselors to find the right one,” they wrote.

In her response to this letter, advice columnist Carolyn Hax advocated for the person to try counseling and addressed their hesitancy by saying, “The ‘total stranger’ is actually the point. … That extra, disinterested, trained, and informed set of eyes can help any of us see things we’re too close to see.”

The author of this letter is hardly alone in their hesitance. Data from the National Alliance on Mental Illness indicates that roughly one in five American adults experienced mental illness in 2020, yet less than half received treatment.

And part of this reluctance may stem from the fact that counseling does involves being vulnerable to a stranger — albeit a professional stranger — and working through emotions, trauma and issues that can be painful, sad or fear-provoking. When combined with feelings of shame, stigma or bad memories of a past therapy experience, it’s no wonder that clients are often nervous, fearful or hesitant to start counseling.

Counselors understand the importance of the therapeutic relationship. But when a client is hesitant or reluctant, practitioners need to make trust and relationship building the central focus of counseling work, along with a little extra patience and unconditional positive regard.

An extra dose of validation

Bri-Ann Richter-Abitol, a licensed mental health counselor (LMHC) in New York and a licensed clinical mental health counselor and supervisor in North Carolina, has worked with clients who were so apprehensive about trying counseling that they were visibly shaking in their first few sessions.

Richter-Abitol owns a private practice in Wake Forest, North Carolina, that specializes in counseling for anxiety disorders. She and her staff offer individual and group counseling with a focus on creating a welcoming, nonintimidating environment.

When a client’s body language indicates that they’re nervous or hesitant as they begin counseling, Richter-Abitol uses it as an opportunity to acknowledge their concern and validate that what they’re doing is hard. Her focus becomes normalizing the therapy process, rather than jumping into any kind of assessment or intake regimen.

“This [hesitancy] is extremely common, even for clients who have been in counseling before. … If I notice that a client is really anxious, I use immediacy and point out that it is scary to be here, and I applaud them for coming in,” says Richter-Abitol, an American Counseling Association member.

Clients who are hesitant to try counseling need transparency, patience and an extra dose of validation from their counselor, agrees Megan Craig, an LMHC who counsels clients at a community mental health agency in the Boston area. She often emphasizes to clients that they’re not doing something “wrong” if they are having trouble opening up or aren’t immediately comfortable in therapy. Applauding a client’s bravery to walk through the door also creates an opportunity to ask them what motivated them to make that first appointment — and, in turn, helps the counselor learn more about the client, Craig adds.

Validation played a key part in fostering connection with a female client Craig once worked with who kept being referred to different clinicians within Craig’s agency because of staff turnover.

By the time she was put on Craig’s caseload, the client was “exhausted” and fearful of losing yet another practitioner. So, she had spotty attendance and would often cancel appointments.

“She felt like she hardly wanted to be there [in counseling sessions]. She had told her story so many times, only for her clinician to leave. She kept having to start over from scratch and be vulnerable with a new person,” Craig recalls.

Craig was honest with the client and broached the subject directly, validating that her exhaustion was understandable and warranted.

Craig also realized she needed to slow the pace of therapy with this client. Their early counseling sessions focused on lighter topics, such as work stress. It was one year into counseling before the client was comfortable enough to begin talking about heavier topics, including her trauma history.

The client’s attendance eventually improved but not until Craig spent months building a relationship with her.

“At first, I second-guessed myself and wondered if this [early work] was ‘therapeutic enough.’ But that’s what she needed. That was what was therapeutic for her,” Craig says. “She needed to establish the trust that I wasn’t going to leave and would stay with her. Just me showing up [to counseling sessions] is exactly what this client needed.” 

Fear of judgment

Counselors are no strangers to the importance of the therapeutic relationship, and decades of research show how central and essential it is to client engagement and growth, says Michael Tursi, an LMHC in New York. Counselors, however, must make relationship building an utmost priority for clients who are hesitant. They have an opportunity to display nonjudgment every time they respond and interact with a client, he notes.

“It’s one thing to say, ‘the therapeutic relationship is essential,’ but there are some clients who really might not be willing to engage at all until they see certain things, especially nonjudgment, in their counselor,” he says. “When counselors meet with clients, right from the beginning, they have an opportunity to display nonjudgment.” 

Tursi, an assistant professor in the mental health counseling program at Pace University’s Pleasantville, New York campus, has done research on client experiential avoidance (i.e., when a person is resistant to experiencing strong or adverse sensations, emotions or thoughts) and engagement in counseling. For his doctoral dissertation, Tursi interviewed a cohort of clients in counseling who self-identified as experiencing this phenomenon, and he, along with two other colleagues, published the findings in a 2021 Journal of Counseling & Development article.

Tursi measured his study participants’ level of avoidance by having them complete the Multidimensional Experiential Avoidance Questionnaire developed by psychologist Wakiza Gámez and colleagues.

According to Tursi, one data point in his research quickly became very clear: Each and every one of the participants talked about fear of judgment from their counselor. The study participants acknowledged that they became more engaged in counseling once they established that their counselor was trustworthy and nonjudgmental.

In fact, the participants viewed counseling as a potentially harmful or threatening relationship until their counselor had fostered a trusting relationship with them and eased their hesitancy, Tursi adds.

Some participants talked about “testing” their counselor by intentionally saying something to elicit a response to gauge how trustworthy the counselor was. Even if a client does not do something like this intentionally, Tursi notes, they are very aware of how a counselor is responding to them.

“Nonjudgment is central to working with any client. But these clients might need a counselor who is quite in tune with [the fact that the] client is concerned about judgment and be patient with that,” says Tursi, an ACA member.

A key aspect of creating an atmosphere of nonjudgment is for counselors to be aware of a client’s comfort level, he says. This includes keeping an eye out for indicators that a client is anxious, such as body language, and checking in regularly with the client to talk about how they feel things are going.

A client should never feel pestered or pushed into talking about issues; they should come to the decision to disclose on their own, Tursi emphasizes. Counselors need to temper the expectations of what they think or expect a client will need or be willing to do. 

“Attending to where your clients are is important. We shouldn’t go into therapy and assume clients are going to disclose right away rather than do the therapeutic work that we think they need to do,” he explains. “Counselors should make sure they’re focusing on providing conditions for these clients to engage. … The client is never going to get there [make progress], in any kind of meaningful way, unless they’re engaging in sessions.”

Tursi hopes his research spreads awareness among counselors that experiential avoidance is very common and that some clients may come into counseling believing — for a variety of reasons — that it could be a relationship that is potentially harmful. Tursi draws on the work of Barry Farber, a professor of psychology and education at Teachers College, Columbia University, when he emphasizes that it’s easy to have unconditional positive regard for clients who come in ready to trust and work with their counselor. But it’s equally important to provide that regard for clients who are hesitant, although it may be more difficult. Patience should be a counselor’s watchword, Tursi adds.

“As counselors, we have to be aware of situations in which we have difficulty providing positive regard and continue professional development to improve our abilities to provide nonjudgmental acceptance at times that it is difficult,” Tursi says.

Check yourself 

As a practitioner who specializes in counseling clients with anxiety, Richter-Abitol finds that rapport building with clients who are hesitant must involve self-awareness on the part of the clinician. This includes keeping her own wants, expectations and assumptions about work with clients in check, she says, and asking for client input on the pace and direction of their treatment.

Richter-Abitol is transparent with her clients: She lets them know that they are “in control” of what they want to talk about in sessions and emphasizes that she won’t “make” them talk about anything they’re not ready to.

“You have to meet the client where they’re at and let them set the agenda. I have had clients who have taken months to build rapport, and if you [the counselor] are not patient, you may never get to that point,” Richter-Abitol says. “You have to constantly check yourself outside of sessions and tell yourself that even small successes contribute toward long-term goals. Small things add up.”

polkadot_photo/Shutterstock.com

Richter-Abitol, like Tursi, argues that the therapeutic relationship must take priority with these clients, rather than diving into a treatment plan based on their diagnosis or what the practitioner thinks they need. Counselors should get creative to find ways to bond with the client prior to moving into heavier work, she suggests. For young clients, this might be therapeutic games or activities; for adults, it might be a discussion of lighter topics that help paint a picture of who they are, including things that they like, dislike and what motivates them.

“Those conversations can lead to deeper ones,” she says. “It’s not helpful to be too rigid. You can have things that you’d like the client to work on, but ultimately it has to be up to them. Flexibility is important.”

Richter-Abitol has found that clients feel more empowered when she lets them take the reins in this way. And many begin to open up naturally when they don’t feel pressured to do so.

This approach requires counselors not only to be in touch with and sensitive to their client’s needs and level of readiness in counseling but also to check their own inclination to take charge when a client is slow to make progress. It’s all too easy to assume that a client who isn’t making progress — or not progressing in a way the counselor might want or expect — isn’t benefiting from counseling, Richter-Abitol notes.

Instead, she advises practitioners to take a step back and consider the client’s full context, including the barriers and challenges that are making it difficult for them to engage with a counselor.

“Their fear or discomfort can come off as resistance or presenting a vibe that ‘I don’t want to be here.’ … They just don’t know how to feel about this space yet, and you need to give them time to figure that out,” Richter-Abitol says. “Don’t make the assumption that someone who is uncomfortable isn’t gaining anything from the experience. It might not be that they don’t want to be there but they just don’t know how to be there yet.”

Have honest conversations 

If patience is the first thing that clients who are hesitant or slow to engage in counseling need from a practitioner, transparency is the second. For Craig, this comes in the form of direct questions to the client to gauge their comfort level and an honest invitation to let her know when things aren’t working.

If a client appears uncomfortable or is hesitant to engage in counseling, Craig will address it directly, saying, “Here is what I’m picking up on. Tell me if I’m right or wrong.” She emphasizes to clients that she cares for their well-being and genuinely wants to hear how they’re feeling — and that they have a choice and a say in the counseling process.

Sometimes what counselors view as resistant behavior in clients can be caused by the use of methods or techniques that aren’t a good fit for that individual, Craig says, or it can be that the practitioner themselves is not the right fit. Because clients may not bring up problems to a counselor on their own, she makes a point to broach the topic with honesty, explaining that no therapist is going to be the best match for everyone who walks through their door.

“If someone is taking the huge step to start counseling, I want them to benefit from it as much as possible. I’m honest and tell them that they’ll never make progress if we are not a good fit,” says Craig. “People are not ready for different reasons, and that’s why I like to have such open conversations. … I might not be able to give them everything they need, but I certainly want to talk about it and I want to try.”

She not only checks in regularly with clients throughout therapy but also makes time for a deeper conversation about what is and isn’t going well once a year (on their anniversary as her client). 

During these check-ins, she prompts clients with questions such as:

  • How do you feel about our work together?
  • Do you respond well to me taking the lead in counseling, or do you prefer to take the lead?
  • What has been helpful during our work together?
  • What do you need more of? And less of?
  • What did you expect from therapy and how has this not met your expectations?
  • What’s working and what’s not?

Not only do these conversations provide Craig with valuable feedback, but they also help set an example for the client to advocate for their own needs outside of counseling, she notes. Learning to be able to communicate their needs and expectations is a big — and important — milestone for many clients.

Craig recommends clinicians ask clients directly about how things are going in counseling rather than fall into an easy pattern of making assumptions about individuals who are avoidant or hesitant to engage. Honest feedback from a client is a good thing, Craig stresses, and not something that a counselor should take personally.

Overcoming cultural barriers

Counselors also need to take a proactive approach when clients are hesitant because of challenges and barriers related to their cultural background, says Camila Pulgar, a licensed clinical mental health counselor associate who is a research faculty member at Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.

Building trust and forging connection with clients who are from marginalized cultures require a counselor not only to be comfortable broaching the subject of culture (and cultural differences) in client sessions in an ethical and compassionate way, Pulgar says, but also to be fully aware of and sensitive to the many barriers that keep them from accessing counseling or being fully comfortable in the setting. 

A native of Chile, Pulgar specializes in the mental health needs of Latinx clients, including suicide prevention. She does clinical work once a week in her faculty position at the medical center, and she is the only bilingual (Spanish/English) provider on her team. Being the only bilingual counselor is not unusual for Pulgar; in fact, this has been the case for most of her professional career, she says. The mental health care system in this country is simply not built to support the needs of clients whose first language is not English.

Language is only one of many barriers that can deter clients from minority cultures from seeking or becoming fully engaged in counseling, Pulgar points out. Individuals may face logistical challenges such as trouble accessing transportation to appointments, finding child care or affording the cost of sessions. They may also be fearful or have adverse feelings about counseling because of stigma, past harm or skepticism about therapy within their culture or family group.

“If people make it to my office, they’re usually hesitant to share their mental health journey with their family members because of stigma. I often hear ‘I don’t want anyone else to know I’m here’,” says Pulgar, who also sees a small caseload of clients at her private practice in Winston-Salem, North Carolina. “When we talk about their supports and who they can reach out to in times of crisis, they often don’t list anyone [in their family] because they don’t want their family to know they’re struggling.”

Shivonne Odom, a certified perinatal mental health provider whose private practice is the only practice in the Washington, D.C., area that specializes in perinatal mental health care and is owned by an African American therapist, says this is also common among her clients, the majority of whom are African American.

She’s had clients whose families reacted very negatively when they found out the client was attending therapy, and other clients have chosen not to disclose the fact that they were seeking counseling to their families and, in some cases, even their spouse.

Hesitancy is very common among Odom’s clients; she recently had a client tell her that she needed to take an hour-long walk to calm her nerves before logging in for her first counseling session.

There is an extra layer of stigma for minority clients who are seeking perinatal mental health care because pregnancy and childbirth are often assumed to be a joyful and happy time — not one of despair. All of these challenges add up and severely affect clients’ help-seeking behaviors, says Odom, a licensed professional counselor in Washington, D.C., and a licensed clinical professional counselor in Maryland.

Pulgar notes that conversations around challenges in minority mental health care often place the blame on the stigma that many cultures have regarding counseling. In reality, minority populations face many barriers when seeking treatment, and that should be an equally, if not more, important part of the discussion.

This issue is compounded by the fact that most of the evidence-based treatment methods that students are taught in graduate counseling programs were created by and tested within members of the majority population. So, it makes sense that many of counselor’s go-to methods may not be a good fit for some minority clients, says Pulgar, an ACA member.

Clients can also become discouraged if they are referred to counseling by a medical provider and none of the counselors on the referral list look like the client, Odom adds. Because of this, she goes out of her way to accept many different types of insurances and often consults and works with multidisciplinary professionals in related fields, such as lactation consultants, to advocate for her clients and ensure that other providers know of her services.

Counselors should also be aware that these clients are often unfamiliar with the process of counseling. A first step toward forging a therapeutic connection can be to explain what therapy is (and isn’t) and why it’s helpful, along with the concepts of privileged information and confidentiality, Odom says.

Pulgar and Odom emphasize that one way to reduce these clients’ stress and barriers to treatment is for counselors to become knowledgeable of culturally connected resources in their area, such as nonprofit organizations and support groups and services.

Free support groups can be very helpful to validate a client’s feelings and experience in a way that individual counseling can’t, Odom says. And if there isn’t a group that matches your clients’ culture and identity (e.g., single mothers by choice), she suggests that counselors consider seeking training to start and lead one.

It’s equally as important for counselors to forge a connection with the marginalized community in their area as it is to build a strong therapeutic relationship with individual clients, Pulgar says. She suggests that practitioners start by becoming involved with organizations that serve the local marginalized community and participate in events such as health fairs.

“Get out of the four walls of the office,” Pulgar stresses. “Marginalized communities are so collective, and community is an important part of life.”

Small changes, big impact 

Counselors have an opportunity to build trust with a client with every interaction. And sometimes, seemingly “small” things that are outside of the core work of counseling can make a big difference to a client. Here are just a few small steps clinicians can take that will make a big impact on clients. 

Explain the process of counseling and why it’s helpful. Don’t assume that clients know what therapy is or what it entails, Tursi advises. “If they’ve never been to counseling previously, the idea of connecting with feelings might be very foreign to them,” he says. “They might start counseling thinking that the counselor can just make these [difficult] feelings go away. When instead, counseling [works to] change their relationship with their feelings — and a practitioner may need to explain that.”

Remember that a breakthrough does not mean clients are completely comfortable in counseling. A counselor whose client makes a significant gain toward trusting their practitioner in one session may feel that they’ve built their relationship enough to move on and address other issues. However, the only way to truly build trust is to have patience and show a client, over time, that you are trustworthy, Craig says. This is especially true for clients whose trust has been broken by others in their life, including health care providers. “Remember that even if they open up about their fears, it doesn’t mean they’ll be less fearful at the next session,” she adds. “It’s about patience and giving them that chance to warm up.”

Welcome clients before they even sit down. Forging trust with hesitant clients takes “more than what you are doing in the [counseling] room, it’s the whole experience,” Richter-Abitol says. “And we want to make people feel as welcomed as possible. … I know what it takes to walk through that door, and how hard it can be.”

She has taken client comfort into consideration in every aspect of her practice, from choosing cozy décor for the waiting room to a casual staff dress code. She built her website to be particularly user-friendly and extend a welcoming vibe before clients even set foot in the door. For example, she provides a detailed biography of all members of the clinical team, including photos of the practitioners, adjectives that describe them (e.g., bubbly, enthusiastic, loyal, creative, motivated) and a description of what a client can expect when working with them. 

“We try and dial down the clinical and dial up the parts of our personality” on the website to make potential clients feel comfortable, Richter-Abitol explains. “With the anxiety population, fear of the unknown is a big issue, so seeing the office and the pictures [online] helps fills in that space [and] helps people form connections before even coming in.”

Pronounce their name correctly. And if counselors are not sure how to pronounce the client’s name, they should ask and remember it, Pulgar says. This is a seemingly small thing that can be overlooked by practitioners, she notes, but it lets the client know that a counselor values their identity.

Don’t assume they’re resistant. Clients who are opposed to treatment and those who are hesitant or slow to engage in counseling can exhibit some of the same behaviors, such as canceling appointments frequently, answering a counselor’s questions with one-word answers or avoiding talking about heavier topics. However, counselors have an opportunity to build trust and explore the reasons why a client appears reluctant, rather than labeling them as resistant.

“We have been taught [in counselor trainings and graduate programs] that it’s a normal way to view clients. It’s really discouraging to know that [the word ‘resistant’] is even part of the dialogue,” Craig says. “Just because your perception as a clinician is that a person is not trying doesn’t mean that they’re not trying. They might not be doing the homework you assign, but they’re showing up every week. And that may be all that they can do right now. That is trying for them. Be sensitive to what they need to make progress.”

Do no harm and seek training. An important aspect of building trust with hesitant clients is ensuring that a practitioner is providing ethical, appropriate and competent care to keep from exacerbating their hesitancy or repeating any bad experiences they might have had previously in therapy. This includes seeking training, consultation or supervision when a counselor has a client who comes from a culture or is dealing with a challenge that the counselor is not familiar with.

In the case of perinatal clients, clinicians who are not trained in the needs and nuances of work with this population risk providing inaccurate — or even harmful — care, Odom says. Some of the symptoms that can be common in perinatal clients, such as intrusive thoughts about harming their baby, can easily be misinterpreted, she explains.

“We [counselors] have an ethical duty to only practice in areas in which we are trained, and if we’re not, we have an ethical obligation to reach out to providers who are and consult with them,” Odom says. “Don’t be afraid to take a training on perinatal [mental health]. I have seen way too many clinicians treating these clients [inappropriately] and it leads to clients having to unjustly interface with systems that will do harm.”

Leave the door open for them to return. Clients who are hesitant about counseling are more likely to drop off a practitioner’s caseload. Counselors should take measures to focus on retention with this client population, but they should also understand that when the client stops counseling, it doesn’t mean that it wasn’t beneficial. Sometimes people simply have so much going on that life “gets in the way” and they can’t come to regular sessions, Pulgar points out.

Practitioners should emphasize to these clients that they’re always welcome to return to counseling whenever they’re ready. Instead of placing blame and asking the client not to return after missing multiple sessions, a counselor can instead say, “I understand this may not be the best time to start counseling in your life, but please do reach out when it is. I am here for you, please keep my number,” Pulgar says.

“The truth is, not everyone is ready for counseling when it comes time for the appointment, even if they made the phone call [to schedule]. They may not be ready to engage yet in the process of what counseling demands,” Pulgar says. “Stay calm and don’t overthink ‘What am I doing wrong?’ or ‘What more can I do?’ Take a couple of deep breaths and think about ways that the door stays open. … If clients get a good sense of counseling just with that interaction with you, maybe in a year or five years, they will come back. That interaction, although brief, can give them a positive feeling about counseling.”

 

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Reasons why 

Many different factors and barriers deter people from seeking counseling or feeling comfortable in sessions. This is by no means an exhaustive list, but some common client fears and concerns include:

  • The client (or someone they know) has had a bad, hurtful or unhelpful experience previously with a mental health or medical practitioner.
  • They come from a culture where counseling is not widely accepted or a culture that has been historically maligned or harmed by mental health professions.
  • They are struggling with an issue that involves feelings of shame. 
  • They are afraid to confront the issue they are struggling with; this can include hesitancy to relive trauma as they process it or fear of showing vulnerability or imperfection.
  • They fear being given a diagnosis and/or being misdiagnosed.
  • They worry the counselors will judge them.
  • They fear meeting and opening up to a person they don’t know. 
  • They experience overwhelming negative or catastrophizing thoughts (e.g., “Counseling is not going to work”).
  • They face logistical challenges (lack of insurance or inability to pay, trouble finding child care or transportation, etc.).
  • They worry that others (family, peers, etc.) will find out they are attending counseling.
  • They do not have a choice in attending counseling (e.g., a person who is mandated to complete therapy, often as the outcome of a court case).
  • They are hesitant or unable to connect with a practitioner who doesn’t come from the same background or experience as them (e.g., a Latinx or LGBTQ counselor, one who has served in the military, one who understands miscarriage and infertility).

This information came from interviews with the following counselors: Megan Craig, Shivonne Odom, Camila Pulgar, Bri-Ann Richter-Abitol and Michael Tursi.

 

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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.

The effects of gender socialization on boys and men

By Suzy Wise, Matthew Bonner, Michael P. Chaney and Naomi Wheeler June 15, 2022

This piece is the final of a three-part series for CT Online. It is the result of the work of ACA President S. Kent Butler’s Gender Equity Task Force. The first article, “Breaking the binary: Transgender and gender expansive equality,” was published on April 4, and the second article, “Counseling girls and women in the current cultural climate,” was published on May 5.

Tim Marshall/Unsplash.com

In this article, we shine a spotlight on how boys and men are impacted by gender equity and how counselors may apply this knowledge in pragmatic, clinical ways. Because gender equity is often conceptualized through a privileged, Western lens, we weave in an intersectional perspective to underscore boys’ and men’s diverse experiences and identities.

As we learned in the second article in the series, girls and women continue to be marginalized by gender-based oppression, so it is not surprising that gender equity issues have historically been associated with them. However, what is often not discussed is how boys’ and men’s well-being may also be negatively affected by the patriarchal system that benefits them.

Readers may wonder what these issues have to do with professional counselors and the counseling profession, given that gender-based terms and conversations often have political connotations associated with them. Counselors whose clients do not present with overt conflicts around gender and gender socialization may avoid direct inquiry on this part of the client’s identity and could miss one or more ways that male clients adapt to the world around them, and thus, how gender has shaped them as people.

Consider that in 2020, an estimated 11.3% of men in the United States sought counseling, despite a greater need for it. Socialization practices for men include such things as stoicism, rugged individuality and solitary problem-solving. These can be very positive characteristics and behaviors, but they can also create isolation, sublimation of emotions and self-blame. It is imperative that we explore the influence of gender equity in the lives of boys and men and reduce the societal stigma impeding their help-seeking processes.

Broadening our perspective on masculinity

Research shows that, compared to girls and women, boys and men face disproportionate rates of harsh discipline in schools, academic difficulties, insufficient education, higher rates of completed suicides and higher rates of substance use and dependence. The counseling profession often overlooks boys and men as a specialized group, in part because of their inherited positions of male privilege and power, as if that privilege automatically erases the presence of potentially debilitating problems.

Professional counselors may be more effective in working with boys and men if they hold a flexible conceptualization of masculinity as diverse, multiple, and intersectional, to form a more inclusive view of how boys and men exist in the world.

One helpful way to understand this is to see boys and men representative of multiple and complex expressions and identities of unique personhood, rather than as a monolith or archetype — one version of masculinity. This is referred to as multiple masculinities. As we additionally layer in the cultural experiences and backgrounds our clients represent, we can take an intersectional perspective. As an illustration, we explore three of many types of masculinity and manhood: traditional masculinity, “toxic” masculinity and precarious manhood.

Traditional masculinity can be thought of as the possession and expression of prized Western characteristics, such as being white, heterosexual, and cisgender, as well as being the person who provides for and protects a family or group. This type of masculinity is commonly seen as holding a lot of power and privilege in society, and it typically rejects or excludes men who embody stereotypically “feminine” characteristics like empathy, caring and softness. Throughout the ’80s and ’90s, the men’s movement sought to connect men with their intrinsically masculine nature through retreats in the woods, rituals of manhood and initiation ceremonies. The movement appealed mostly to white, heterosexual, upper-class men to the exclusion of other cultures, classes and sexual/affectional orientations.

“Toxic” masculinity is a colloquial term that includes those traits of masculinity that are oppressive, such as interpersonal violence, shaming, bullying, gang involvement and self-entitlement. This view of masculinity is controversial because some see it as an attack on masculinity and because of the belief that there is inherent toxicity in being a man. Research indicates that toxic masculinity is the result of boys and men feeling insecure and then acting from that insecurity against those seen as weaker than them.

Related to the concept of toxic masculinity is precarious manhood, defined by psychologists Vandello and Boson as a felt sense of manhood that is “hard won and easily lost.” It is elusive, requires achieved status, and is confirmed by others through one’s demonstrations of manliness. It is so tenuous, however, that just one unmanly action or behavior can call one’s manhood into question, regardless of the attempts to prove it. Attempting (and failing) to prove oneself according to stringent societal and systemic norms creates an unstable sense of one’s manhood, which may in turn incite toxic behaviors to restore balance.

While these are just three examples within a multiple masculinities framework of many types, we recommend above all that counselors take an intersectional approach that will give space for our clients to bring all of themselves to the therapy room. This necessitates an awareness of cultural and subcultural influences of how unique relationships to manhood are formed.

Understanding the gender role characteristics of machismo as well as the influences of acculturation and socioeconomic status can be beneficial in counseling Latinx boys and men. When counseling African American boys and men, understanding the “cool pose” as resistance to indignities and inequality is helpful from a contextual perspective. Counseling Indigenous men will encourage self-examination and connection to community and needs to include decolonization practices toward healing and authenticity. Transgender, gender expansive and nonbinary people express masculinities that usually do not conform to the narrow, rigid and heteronormative nature of traditional masculinity, and they have often been damaged by the behaviors of toxic masculinity.

Diverse and multiple masculinities have persisted and evolved despite traditional masculinity’s pervasiveness in society, and it is important for counselors to recognize and affirm and help their clients to know that there is more than one way to be a man.

Masculine identity socialization

Very early in life, young boys learn patriarchal language and what it means to work and provide for the family, as well as how to operate in the world as a man. They also learn the consequences of not evidencing these lessons. Through overt and covert behaviors, implicit and explicit messages, and a system of rewards and punishments, early caregiving environments reinforce ideas about how men and boys should embody and express masculinity to avoid reproach by others.

Appearing or performing in less masculine ways than expected may trigger early and continued rejection experiences, especially when boys demonstrate what are regarded as feminine traits like sensitivity, compassion and kindness toward others. These boys may be shunned by other boys and looked down on by men they may look up to, or idealize, for the very characteristics they are expected to possess. These experiences can trouble a boy’s internal sense of self and the way he interacts with the external world, which often includes a desire for peer acceptance and connection.

Some of these learned characteristics include being logical, engaging in visible conflict and adventure, attaining wealth and status at work, being self-confident, being a quick and resolute decision-maker, striving actively for power, exacting concrete results and tangible rewards, and being invulnerable, competitive and strong. All of these and more create an image of the “ideal man” — one that is not real but ideal, an image to which boys and men should aspire but which they will never realistically attain. Because of how gender socialization is structured, this model and these characteristics are taught and reinforced by both men and women in the home, school, church, work, social and other environments. Boys and men who cannot easily develop, maintain and expand on these qualities may frequently feel an impending sense of failure to live up to their expectations.

Paradoxically, power is one of the privileges that men are automatically afforded by the patriarchal system in Western society, yet they rarely feel that they realistically have this power. They instead feel a lack of power, which is further threatened when historically marginalized groups seek power of their own. This may contribute to a sense of insecurity, insufficiency and a concomitant need to enact power-related behaviors on those around them, as reinforcement of their inherited position.

Joseph Pleck, a prominent researcher on gender role socialization for men, described three consequences for men’s seeming inability to live up to the roles prescribed for them:

1) A man’s long-term failure to perform expected behaviors and traits may lead to low self-esteem and other potential mental health consequences.

2) A man may be successful at performing and attaining desired masculinity, but only through a traumatic socialization process (e.g., hazing, bullying, sublimation, rejection, isolation), which may create negative side effects such as poorer mental health outcomes.

3) A man may be successful at performing and attaining desired masculinity, but this comes with negative side effects because of the rigid characteristics themselves (e.g., low family involvement, reinforcement of traditional gender roles at home, negative health consequences typical for men).

The pressure to perform traditional masculine behaviors can lend itself to a restricted range of adaptive or healthy coping strategies, which has clear implications for the overall health of men and their help-seeking behaviors. When men come to counseling, they rarely offer presenting concerns related to explicit problems with their level of gender role adherence, but instead they seek help for substance use issues, anger management, work conflicts or interpersonal distress, and usually at the insistence of a spouse or partner rather than of their own volition.

Gender equity and boys’ and men’s health

Gender equity has a significant influence on boys’ and men’s health and well-being. Studies show that men who recognize and affirm gender equity have better mental health, more satisfying relationships, reduced mortality, and engagement in other prosocial behaviors that bolster healthy living, such as increased physical activity and decreased substance use.

However, in general, there continue to be significant gender disparities whereby boys and men experience greater health-related repercussions. One such example is life expectancy. In 2020, the life expectancy for men was 75.1 years compared with 80.5 years for women. The disparities become more salient when intersecting factors such as race are considered. Black men have the lowest life expectancy of any group and on average live six years less than white men. These patterns are also seen in suicide rates of boys and men. A 2021 report by the Centers for Disease Control and Prevention (CDC) revealed that although suicide rates among white men and women dropped by 5%, suicide rates increased among 10- to 24-year-old Black (23%) and Latinx (20%) boys and men.

The COVID-19 pandemic further highlights a significant health issue influenced by gender equity. According to the CDC, men are 1.6 times more likely than women to die from COVID despite a similar number of confirmed cases in both sexes. Death rates from COVID for Black and Latinx men are six times higher than those for white men. These disparities are partially explained by the fact that the immune responses of men tend to be lower. This, in combination with gendered practices and behaviors typically associated with masculinity, such as smoking, drinking, not following preventative public health recommendations (i.e., mask-wearing, handwashing), avoidance of receiving health care, and higher rates of co-occurring health issues (e.g., heart disease, diabetes, hypertension), contributes to the high COVID death rates among men.

One explanation for why many boys and men experience gender-based health discrepancies is due to restrictive and prescriptive socially constructed masculine gender norms. One such masculine norm is their supercilious attitudes about their health and well-being, which often lead to unhealthy behaviors.

Boys and men are socialized to be independent and autonomous, leading many of them to think they can rely solely on themselves to solve their own problems and health issues. Given that researchers have found a negative correlation between self-reliance and help-seeking behaviors, it makes sense that boys and men may often not speak up, seek therapeutic assistance or get medical care until it is too late. Because traditional masculinity rewards boys and men who disguise their health-related needs, ailments and sufferings behind an armor of self-reliance, aggression and physical toughness, their health can be negatively impacted.

Barriers toward help-seeking behaviors

Young boys are often socialized in ways that promote risk-taking and rugged independence, restrict emotional expression and prioritize demonstrations of physical prowess, reinforced by the generational attitude that “boys will be boys.” These factors may contribute to greater stigma for boys’ and men’s mental health help-seeking, and the lower rates of mental health treatment, because counseling support is seen as a weakness and not a strength.

Counselors may consider intentional efforts to engage boys and men in counseling services and to assess appropriate levels of care more effectively. Counselors often adapt their practices to meet their clients’ particular needs, so to with boys and men — activity-based work in sessions, behavior-influenced theories and adventure therapy may encourage men to participate more fully. Counselors should also consider developing strategic community partnerships to support mental health education efforts for boys and men.

Programs such as Brother, You’re on My Mind, a National Institute on Minority Health and Health Disparities initiative aimed at engaging African American men in discussions about mental health, often include counselors who can demystify the counseling process and contribute to shifts in common misperceptions about the mental health of boys and men. Similarly, there are school and community-based programs tailored for boys and men that develop positive definitions for masculinity and support healthy sexuality and relationships. Whether through community partnership or direct discussion in session, counselors can explore the role of masculinity in boys’ and men’s presenting concerns, their coping, and resources for social support.

The importance of relationships and a trauma-informed approach

Socialization of masculinity also influences how boys and men engage in relationships. People’s relationships with others, from birth through adulthood, influence how they construct ideas and behave regarding gender expression, sexuality/affectionality and healthy relationships. Research shows that rigid ideas about masculinity can influence heterosexism (homophobia) and cissexism (transphobia), unsafe sexual practices and even aggressive forms of initiating romantic and sexual encounters.

As previously described regarding precarious manhood, boys and men may feel pressured to demonstrate their manhood in unhelpful or unhealthy ways as an indicator of their masculinity or to maintain their social position. This felt pressure also relates to shame and lower rates of reporting/disclosing when a boy or man experiences abuse, trauma or relationship violence.

For instance, although gender-inclusive campaigns for relationship violence are rare, one in 10 men will experience relationship violence in their lifetime, and one out of every 10 rape victims is male. Intimate partner issues (e.g., divorce or separation, loss of child custody) and relationship violence also increase the risk of suicide, especially among men ages 35 to 64.

Therefore, counselors need to be aware of the risk as well as the protective factors associated with mental health challenges for men and the tendency for many men to underreport symptoms.

Research shows that men uniquely benefit from positive relationships with others, such as from being married or partnered and engaging in reciprocal social activities and endeavors.

Meaningful attachments in men’s relationships and friendships significantly reduce the negative influence of childhood adversity and traumatic life events and enhance their mental and physical health.

A wide body of research also supports the effects of father involvement on healthy child development. Fathers often play, communicate and parent in different ways than mothers. As a result, father involvement has significant influences on child well-being, including school readiness and behavior, cognitive development, self-confidence, secure attachment and development of empathy. Finally, men may play critical roles in family discussions about how to treat girls and women and challenge stereotypes associated with masculinity and femininity.

Intersectional counseling practice

The Multicultural and Social Justice Counseling Competencies describe an essential first step for professional counselors to engage more deeply in their self-understanding of their knowledge, beliefs, skills/abilities and responsibilities for advocacy with clients. This process centers the client-counselor relationship and encourages an authentic exploration of the client’s place in society, how systems of oppression and privilege have affected them, and how the work of counseling connects to client advocacy.

Given the strong and systemic gender socialization in society and the way boys and men are often caught in the traditional masculinity trap, counselors should take time to assess the many diverse psychological, affectional, cultural, ethnic, religious and economic contexts in which their male clients exist.

If counselors have not first engaged in their own self-awareness and reflexivity work, they may continue to view the world from their own vantage point rather than the client’s. For instance, if a male client comes to counseling presenting with anger/aggression and repetitive violent behaviors, the counselor could potentially disempower or harm the client by assuming the client “is just an angry person” or that the client embodies a toxic form of masculinity. Both assumptions may foreclose on the possibility of deeper issues, such as past traumas, repeated discrimination and oppression, or maltreatment, and could forestall the client’s potential for growth and development.

Instead, the counselor may recognize that the client’s emotions and behaviors may be justified because of the contextual circumstances and the tools and resources he possessed at the time. The client might have felt he had no choice in how he behaved because of the constraints placed on him by society. The counselor could explore the client’s relatedness to strict gender socialization patterns as well as the emotional effects this brings. The counselor could affirm the client’s characteristics of being strong, powerful and courageous, and help the client develop alternative forms of expression and problem resolution to avoid negative outcomes. And if the client should choose to, he can learn to channel these characteristics toward gender equity and advocacy for disempowered groups.

Inquiring about men’s early patterns of gender socialization and uncovering what was expected of them when they were boys, as well as discovering what the consequences were for not meeting these expectations, will give counselors important insight for the counseling process.

Counselors should listen for how tightly male clients tie their self-worth to their masculinity, as any disruption in their understanding of themselves and their manhood can cause deep internal conflict and potentially negative external behaviors, such as through sexist, homophobic or transphobic actions. Counselors can help male clients envision a broader sense of themselves and a more complex view of manhood — one that embraces self-acceptance and affirmation, interdependence and relationality, and which values positive expression of emotion.

Counselors can also contribute to reexamination of gender stereotypes, social pressures and sexual misconceptions in session through the use of gender-specific group psychoeducation programs such as Time Out! For Men (applied in tandem with substance use treatment to explore gender role stereotypes and how they influence relationship factors such as communication skills and sexuality) or the Men’s Trauma Recovery Empowerment model (applied to help with trauma healing and posttraumatic growth). Research seems to suggest that the treatment effects are comparable in terms of client outcomes regardless of whether a gender-specific approach is utilized. However, for some boys and men, representation in gender-specific mental health services may help reduce internal barriers to help-seeking.

In addition to building a strong foundation of therapeutic rapport, which will also contribute to men’s mental health outcomes, counselors should inquire about male clients’ sources of social support and how their personal ideas of masculinity influence their well-being and relationships. This may provide male clients a safe space to work through both the challenges and positive contributions of what it means to be a boy or man in society.

Conclusion

Professional counselors are in a unique position to support boys and men to achieve gender equity as it relates to their health and well-being.

First, counselors can empower boys and men to advocate for their own health and well-being by educating them on the relationship between self-reliant attitudes and poorer health outcomes.

Second, counselors acknowledge the diverse intersecting identities of boys and men and how these identities may predispose certain groups of boys and men to adverse health experiences.

Third, counselors can help young boys and adolescents examine existing gender norms and roles and how the adoption of these norms may impede healthy living. This focused conversation may allow important space for child and teen clients to identify their authentic beliefs, values and forms of gender expression as they continue their growth and development.

Fourth, counselors should recognize that boys and men are not a homogeneous group and that there are many subgroups of men with diverse and varied ways of expressing masculinities that are validated and affirmed in the counseling space. Counselors should strive to be creative and flexible in their counseling approaches with boys and men to best meet their treatment goals and objectives.

Finally, counselors are encouraged to work with boys and men to explore and debunk the negative gender stereotypes that contribute to maladaptive thoughts and behaviors that thwart their health and well-being.

 

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Find out more about ACA’s Gender Equity Task Force at acagenderequity.weebly.com.

 

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Suzy Wise is a licensed professional counselor in Illinois, a national certified counselor and an assistant professor and core faculty in the clinical mental health counseling program at Valparaiso University. Suzy’s participation on the ACA Gender Equity Task Force included chairing the Boys and Men subgroup and being a contributing member of the Transgender and Gender Expansive subgroup. Contact Suzy at Suzy.Wise@valpo.edu.

Matthew Bonner is a licensed clinical professional counselor and an assistant professor of counseling at Johns Hopkins University. He is a member of the ACA Gender Equity Task Force. His research interests include multicultural issues, assessment in counseling, and human services models of treatment. Contact him at mbonner6@jhu.edu.

Michael P. Chaney is a licensed professional counselor in Georgia and Michigan and an associate professor in the Department of Counseling at Oakland University. He is co-chair of the ACA Gender Equity Task Force, a member of the ACA Ethics Committee and editor of the Journal of LGBTQ Issues in Counseling. Contact him at chaney@oakland.edu.

Naomi J. Wheeler is a licensed professional counselor in Virginia, a licensed mental health counselor in Florida, a national certified counselor and an assistant professor in the Department of Counseling and Special Education at Virginia Commonwealth University and coordinator for the Couples and Family Counseling concentration. Contact Naomi at njwheeler@vcu.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.

Past, present or future: Where do you usually live?

By Madhuri Govindu June 10, 2022

Your monkey mind wants to live in either the painful past or the anxious future. It doesn’t like to stay in or savor the present moment.

This mental habit of ruminating over what has happened or what will happen can make life a miserable journey. Many people are unable to control their mental chatter and continue to suffer. But there’s hope if you can learn to tame your mind to stay in the present moment.

Life happens here and now

Life exists in this present moment. Not in the past or future as most of us are accustomed to. As a mental health counseling student, living in the present moment has been my anchor in a life filled with unexpected ups and downs. Undoubtedly, living in the “now” has served as a saving grace for me as we all continue to battle the darkest days of our current realities.

When I was younger, I couldn’t understand why “the past” would be a crucial part of someone’s life. I constantly pondered why adults ruminated about things that happened decades ago. This quest to understand people’s mindsets led me to quit my corporate job as a training and development manager with Accenture, a multinational company in India. Thereafter, I pursued my passion for counseling psychology, which brought me to the United States in 2018. Currently, I am a graduate student at Penn West University (Edinboro University of Pennsylvania) and will graduate with a mental health counseling degree in 2023.

Early on, I wanted to build a platform that would help those struggling with issues such as depression, anger, fear, past trauma, bullying and an inability to find a solid direction in life. Soulful Conversations, an in-person platform, allowed people to have heart-to-heart discussions and helped thousands of individuals cope with past traumas and future anxieties. This journey taught me that living in or thinking too much about the past is nothing but a disease — one that afflicts millions of people today.

Ruminating over what happened, why it happened and “how could it happen to me?” has become an irresistible habit for many individuals. Through the Soulful Conversations community, I started to understand better the workings of the human mind. For the first time, I questioned my audience: “Ask your mind, what is its next thought?” Interestingly, the moment you ask your mind this question, it goes blank, as if it has been put under a spotlight and its auto-running mode has been caught.

After trying this technique, my audience found a sense of relief to experience a much-needed pause in their uninterrupted mental activities. As people created even a 10-second gap between their reckless past and future thoughts, they found immense respite in their inner stillness. They discovered deep peace within that emanated from shutting the endless chatter of their untamed monkey minds.

Are you in the present moment?

As a counselor, it is vital to be aware that living in the present moment can help us reduce stress, stay more focused and better understand the repetitive patterns in our lives caused by our compulsive habits. When you are in the present moment, you are not waiting for the next moment to be fulfilling or happy. This is because you are not unhappy in the “now,” subject to unpleasant clingy thoughts from the past, empathy fatigue or any other distraction.

You are now more present with your family and friends. You are livelier, content and stress-free because you refuse to entertain past experiences or future anxieties related to health, money, family, work, etc. It may be helpful to have a phone wallpaper featuring the NOW clock or a gemstone that reminds you that everything you are experiencing exists only in the present. Don’t forget: Memories are just thoughts in your mind, quite similar to your thoughts about the future.

Gratitude changes everything

Many times, we carry stressful work situations or unsatisfactory client encounters with us in our minds. We repeatedly replay them in our minds to analyze and dissect how that meeting could have been better. Often, this stress spills into our personal space as well. We carry these feelings of resentment while we are spending time with family members and friends.

We forget that we have the right to “choose and appreciate” whatever the present moment brings to us. So instead of ruminating about past and future worries, we can choose to drop all fears and swim in the magic of the present moment. With practice, the ability to stay in the present moment can be mastered.

The present moment brings an opportunity to offer gratitude, which makes life more livable and joyful. Gratia, the Latin word for gratitude, means grace or gratefulness, and even a small act of thanking the present moment — appreciating what you see, feel, hear and sense around you — deepens that awareness. This helps you leave the perennial stream of unconscious mental chatter, which is eventually the root cause of myriad problems.

Tame the monkey mind 

The monkey mind can hop in and hop off from one branch to another within seconds. It can scuba dive into the ocean of sorrow and bring you back into the sky of happiness in a matter of

Stephen Tafra/Unsplash.com

seconds. As counselors, we must try to bring ourselves to the present moment and erode the old conditioning by doing simple things consciously.

These activities can retrain our monkey minds to see the beauty in the present moment. The racing mind is like a galloping horse without any direction. It feels as if the mind is unstoppable, and you are helpless because you simply have no idea how to tame the unruly mind. In such situations, the easiest way to bring your mind to the present moment is to bring your attention back to your breath. Ask yourself, “Am I breathing consciously?” This question helps you to step outside the compulsiveness of identifying yourself with your thoughts.

So how do we build awareness? How do we become aware of our mindless mental chatter? Some of the simple ways such as chewing food slowly, washing hands consciously, taking occasional deep breaths, and setting alarms for present-moment reminders can be very helpful. Furthermore, the regular practice of meditation can help counselors in de-weeding the garden of their minds.

Even 20 minutes of meditation can help us observe everything the mind holds on to and help us see the workings of the mind more clearly. We can then navigate through the mind’s workings and ensure that we do not attach to any of the weeds that slowly creep into the subconscious mind. Hence, a regular practice of de-weeding through meditation is important.

Suffering and counselors

No one is immune to suffering in this world, not even counselors. Like all humans, they have their own professional and personal challenges to deal with. Also, navigating from one client to another, counselors often help others deal with afflictions such as addictions, trauma, posttraumatic stress disorder and so much more. Counselors try their best to help their clients, but this leaves them with very little time for their own recovery and self-care.

However, the good aspect is that counselors are well equipped to understand the unnecessary problems and conflicts created by the mind. So if we can leave the client stories behind, meditate for five minutes before each session, and then step into the next one, a lot of our projections will disappear. It is important to note that the moment you realize that you are not living in the present moment, you are immediately transported back to the present moment. Isn’t that wonderful?

We must understand that the countless voices in our heads will never be silent. At times, it even annoys us, and this inner dialogue makes us miss most of life’s present moments because we are never in the NOW. So, realize that you are not the voice in your head — you are the conscious being who has the power to observe this voice and still not believe in it.

Mind full or mindfulness?

One mindful step at a time can help us embrace inner peace. I personally have trained my mind over the last two years to consciously bring it back to the present moment. As counselors, our work involves welcoming clients from diverse cultural backgrounds and helping them hold their inner peace. This doesn’t leave us with a lot of buffer time to recover, rejuvenate and refocus on the next client.

Hence, it is extremely important for counselors to focus on their mental movements and understand if there is an underlying stillness. A simple practice of five-minute meditation can help counselors embrace the present moment between sessions. The art of practicing self-observation to identify your intrinsic motivations, projections and deflections can help counselors go into tiny mindful retreats and hold their inner peace.

Judgment detox

If counselors can continue to observe their own minds in a nonjudgmental way, then they will be more effective in their profession. The present-moment awareness practice can help in increasing focus and alertness, having a relaxed state of mind, being more mindful with clients and not getting distracted easily.

Being fully aware of the counselor-client relationship can lead to building deeper connections, being more efficient as a counselor, embracing self-compassion and living a fulfilling professional life. What’s more? It will be easier for counselors to bounce back from intense sessions as they continue to deepen their present-moment practice. Random mind wandering is common, and being aware of how often your mind wanders and leaves the present moment is a great indicator of your happiness and mental well-being.

How often have you found yourself unhappy while having sex, exercising, watching your favorite show on Netflix or taking a warm shower? It is the presence of thoughts, drifting mind and past woes or future anxieties that jeopardize your present-moment happiness. A moment of pause, deep breathing in that pause, and being aware of the pause can soothe your nervous system immensely.

With consistent practice, there will be a significant reduction in your thoughts and a more focused approach at work, and an absence of worry and rumination can help you become happier. Another interesting creative approach is using mandalas, which are visual diagrams that can help one become more mindful of the present moment. These intricate patterns allow one to dive deeper into the drawing and deepen one’s relationship with the present moment.

Conclusion

I hope counselors will feel more conscious of their mental chatter and be more confident in helping themselves with some of the present-moment techniques that I have shared. It is fulfilling to know that we deserve to take mental breaks, focus on self-care and refuse to succumb to the cessation of endless mental activities.

In one of my Soulful Conversation sessions, I had mentioned, “Don’t take the time, effort, patience and mental health of counselors for granted. We sacrifice a lot to maintain a peaceful and positive demeanor while underplaying some of our inner challenges. We believe in our own ability to impact the lives of others in a positive way and create a culture of wellness by touching the lives of others mindfully, one day at a time.”

 

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Madhuri Govindu is a counseling psychology graduate student at Edinboro University of Pennsylvania. Her work was featured in The New Indian Express in 2018 when she began to invite individuals from all walks of life to embrace the present moment through her open social change platform titled Soulful Conversations. Contact her at madhurigovindu23@gmail.com.

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