Monthly Archives: November 2022

Pushing back against fatphobia

By Bethany Bray November 30, 2022

“I feel fat today.”

This is a phrase that Justine Trumbetas, a licensed professional counselor (LPC) in Pennsylvania, says she often hears from clients who live in bodies of all kinds of shapes and sizes. And this seemingly simple statement contains a lot for counselors to unpack with clients.

More often than not, this thought stems from weight stigma or bias that the client has internalized from external sources. This can include anything from an offhand comment a friend makes about needing to work out to “earn” her slice of birthday cake to a medical doctor who advises weight loss for a presenting concern that is unrelated to the patient’s body size.

Trumbetas, who specializes in helping female clients with anxiety and body image-related issues, says that when clients use language such as “I feel fat” or “I feel gross,” she uses it as an opening to help them begin to recognize their emotions and negative thought patterns as well as how these thoughts affect their value and self-worth. The first step is to replace the word “fat” with a more factual, accurate word, she notes.

“I tell them that fat is not an emotion, so we can’t feel it. And we work to replace that, find the word they need … and tap in to what they’re feeling, [such as] defeated, let down, sad. And then we dig into why they feel that way,” says Trumbetas, an American Counseling Association member who has a counseling practice providing online sessions to clients in Pennsylvania and Florida. “There’s much more than feeling fat. There is a lot more underneath it. Are they comparing themselves to other people [or reacting to] something that they saw or heard from others? Typically, when we dig in, I find that their worth is tied to their body and how others view it.”

Pervasive weight stigma

Thin bodies have been idealized and prioritized in U.S. culture and society for centuries. This shows up in everything from themes in advertisements and television to the overuse — and misuse — of the body mass index (BMI) as a benchmark for health by medical professionals and others.

Weight stigma carries the message that “there’s something wrong with your body simply because of the size of it,” says Jennifer DiGennaro, an LPC with a private practice in Grand Rapids, Michigan. And it’s traumatic for an individual to be bombarded by a lifetime of messaging that implies that their worth is tied to their body size or ability to lose weight, she adds.

“We live in an eating disorder culture and a body-shaming culture,” says DiGennaro, who specializes in helping clients heal from trauma, body shame and eating disorders. “We carry this myth that everyone can control their weight,” she continues, but “there are many, many, many reasons that someone is living in a larger body, and it may have nothing to do with what they eat or how much they’re moving.”

When talking with clients and colleagues, DiGennaro finds that using different words to name this phenomenon can help others understand the stigmas surrounding weight, depending on the context and their familiarity with the issue. Weight stigma can also be described as fatphobia, fatmisia, sizeism, weight bias, weight-based discrimination, fatism or size bigotry. No matter what it’s called, fatphobia is “thinking you know things about a person simply by the size of their body, and we don’t,” DiGennaro says. “And arguing on that point is reinforcing weight stigma.”

When unpacking and dismantling weight stigma, it’s important — both for counselors and clients — to consider the full context of the messaging they receive about weight loss, nutrition, body size and related issues, says Kaitlyn Forristal, an ACA member and licensed professional clinical counselor who studied fatphobia’s influence on diagnosis decisions made by counseling graduate students in her 2018 doctoral dissertation. This includes the fact that many companies stand to benefit from keeping this stigma alive and prevalent, she adds, noting that the weight loss industry in the United States was worth $72 billion in 2018.

Trumbetas says that nearly all her clients use language in sessions that indicates they have been negatively affected by weight stigma. This ranges from describing feelings of worthlessness to noting that they had a “bad” weekend because they indulged and ate a slice of pizza, she says.

Her clients have often internalized microaggressions and messaging they’ve received from a number of sources, but she finds that the most influential are social media, their family of origin and the medical profession. Many clients talk about being raised in an atmosphere where the adults were always on a diet roller coaster, Trumbetas says, so it was common for them to make comments such as “You shouldn’t be eating that.”

She has also worked with clients who have stopped going to medical appointments because they don’t want to be judged and have assumptions made about them based on their weight. Because weight bias is deeply embedded in the medical profession, some doctors’ initial and go-to recommendation for larger-sized patients is to lose weight without finding out the context surrounding what’s bothering them, she explains.

Reconnecting to self

The counselors interviewed for this article agree that clients who have been negatively affected by weight stigma often need a combination of counseling work that focuses on quelling negative thought patterns, tolerating discomfort and reconnecting to a body that external forces have caused them to disconnect with and hate.

An important first step is educating clients on what weight stigma is and how prevalent it is in our society as well as offering the message that “your worth, your identity and your value is not in your appearance,” says Stephanie Dutson, an LPC who specializes in helping adult clients with trauma, anxiety and body image-related issues.

Dutson says she often emphasizes to clients that a body is for living in, not for looking at.

She finds that weight stigma often causes clients to feel guilt or shame about what they are or are not doing to maintain their appearance. And that guilt or shame “affects a person’s health so much more than an extra 20 pounds does,” says Dutson, who lives in Birmingham, Alabama, and has a counseling practice providing online sessions to clients located in Utah, Wisconsin and Alabama. “The research shows time and time again that social life, stress management and moving your body in a joyful way — not weight or size — are what promote health. Diet culture really squashed that intuition for most people, and [unlearning weight stigma] comes back to trusting themselves and finding connection to intuitive knowing.”

Many of Dutson’s clients have strong feelings of shame or disgust associated with their bodies, especially with parts that are often sexualized or idealized in popular culture and media (such as the abdomen, chest and arms), she notes. Dutson focuses on helping clients who feel this way regain comfort and feelings of safety with their body, including “tuning in” to parts of their body that they’ve “tuned out” or disconnected with because of weight stigma, she says.

For example, she may ask a client to gently touch or look at parts of their body that they have tuned out (e.g., a soft belly post-pregnancy) in a mirror at home. Then Dutson processes the experience and emotions the client felt at their next session. She also encourages them to spend more time doing this exercise as they become increasingly comfortable with their body. The aim, Dutson says, is to help clients gradually reconnect to their body.

Many clients have such negative feelings associated with their body that they aren’t able to look at their entire body in the mirror at first. She encourages them to start small with a handheld mirror to view one part of their body, such as an arm or leg, and eventually add additional areas.

“I tell clients to expect some feelings of discomfort, but to try and find an area of the body or [amount of] time that is moderately uncomfortable while still tolerable so they don’t become flooded or overwhelmed,” she explains.

A powerful aspect of these exercises, Dutson notes, is helping clients recognize and begin to fully feel emotions — including discomfort — in their body. “I don’t know a client with body image issues that is entirely comfortable with their emotions because emotions are so often experienced within the body,” she adds.

Trumbetas also finds mirror work helpful, and often suggests that clients focus on learning to thank their bodies for its strength. She prompts clients to think of things that their body has done for them, such as allowing them to smell their favorite scent or heal from sickness or surgery.

This is quite a perspective flip for individuals who have harbored animosity toward their body for a long time, she notes.

If a client makes a comment such as “I hate my thighs,” Trumbetas says she would prompt the client to spend time looking in the mirror and thanking those thighs for getting them where they want to go and being able to do things like climb stairs or walk their dog.

“Being kind to yourself in this way can be a foreign concept,” she acknowledges. “I tell my clients consistently that to get comfortable, you have to become uncomfortable.”

As clients practice looking at their body in the mirror, she suggests they take an empowering stance she calls the “Wonder Woman pose.” To do so, the client meets their own gaze while standing with their hands on their hips, holding their head high, chest out and shoulders down. Trumbetas will model the pose for clients during sessions and encourages clients to try it with her. Standing in this way can decrease anxiety and boost confidence, she says.

Trumbetas says she receives a lot of positive feedback from clients about the Wonder Woman pose, and many report that it’s helpful to do whenever they’re feeling anxious or need to feel better about themselves and reconnect to their own power.

Identifying triggers

Reconnecting to oneself in counseling allows clients not only to better understand their own emotions but also to pinpoint how it feels when they are affected by negative messaging about body size and appearance, notes Dutson, an ACA member.

“Understanding the core emotion of what a trigger brings up for you gives you a better road map of how to deal with that emotion,” she explains. “Most of the emotions that come up around body image are disgust, shame, anxiety or guilt. And when clients have that [emotional] self-awareness, they can ask, ‘What is the core emotion that I’m feeling?”

She then guides them to find ways to care for themselves when shame and other painful feelings arise, such as focusing on empathy and self-compassion.

For example, a client may be visiting an aunt who makes a comment that the client has gained weight since she last saw her or talks incessantly about her own weight loss behaviors or successes. Dutson will process this interaction with the client and prompt them to identify the emotions they felt and how they would like to handle a similar situation in the future.

She finds it helpful to prompt clients to track the moments that produce a visceral or intense emotional reaction regarding body size. Depending on the client’s situation and preference, she has them recount triggering situations to her verbally or write down details in a notebook or journal. She then guides clients to think about who was there, what was said, what emotions rose to the surface, what they were doing and feeling leading up to the interaction, and other aspects surrounding this triggering experience. Clients who reflect in this way eventually notice common threads of people or topics that activate them, she notes.

It can also be helpful, Dutson says, to suggest that clients write out a script or statements they’d like to use the next time they are in a triggering situation. Depending on where they are in their healing, this can include asking the other person not to talk about weight or body size in that way.

Trumbetas also helps clients identify and manage triggers, and one of the first things she does with clients who have been affected by weight stigma is to suggest they do an “audit” of their social media accounts to unfollow people and pages that spread body-negative messaging.

DiGennaro adds that helping clients talk about messaging related to weight stigma also requires counselor practitioners to suppress the urge to reassure or comfort clients who make statements such as “I feel like people are judging me.” A counselor’s role, DiGennaro emphasizes, is to be honest because people may very well be judging the client. Instead of offering reassurance, counselors can help the client unpack how they feel about such thoughts, recognize their origins and become intentional about the relationship they have with these thoughts and the way they affect their mental health, she says. Then they can help clients find and set boundaries to keep from internalizing harmful messaging going forward.

DiGennaro often helps clients plan for social interactions or family gatherings by guiding them to explore their values and identify what they are and are not willing to disclose or talk about.

“It’s a huge piece of healing work to first know what you need and want, then be able to put it into words and ultimately decide to share it with the appropriate people,” she says.

DiGennaro sometimes invites clients to constructively use the anger they may feel about issues related to body weight and size. “There is a lot to be angry about with the way our bodies and feelings about food have been manipulated by diet culture,” she says. “One pattern I often see is when a client takes the unconscious anger evoked by weight stigma and turns it against themselves with punishing or chaotic food behaviors. So once the anger becomes conscious [through counseling,] I tell clients to channel that appropriately outward. Feeling and acknowledging rightful anger allows for the setting of essential boundaries to protect from further harm from weight stigma.”

Rethinking restriction

Helping clients identify and work toward goals is often an important part of counseling. But what if a client is focused on a goal to diet or lose weight?

The first thing to remember is that it is outside of a professional counselor’s scope of practice to advise clients on nutrition, exercise, weight loss or other topics related to physical health. (For more, see Section C of the 2014 ACA Code of Ethics at counseling.org/ethics.)

Weight loss is not a behavioral or mental health issue, DiGennaro stresses. Whenever a client mentions a goal of weight loss in a counseling session, she uses that opportunity to dig into why they want to set that goal — and what outside influences might have contributed. She uses motivational interviewing and asks questions such as “What would it mean to you if you lose weight?” to explore the client’s underlying reasons.

Knowing the reasons behind their weight loss goal will also help counselors determine the best approach for the client. Maybe the client says they want to lose weight because of negative comments they’ve heard from family members. “If you dig into it, they might be actually fine with their body, but they’re sick of hearing comments at family gatherings,” DiGennaro says. “In that case, we need to work on boundaries.”

Another client, however, may realize that their core reason for wanting a smaller body size is a desire to feel more confident. In that case, DiGennaro says she would focus on counseling techniques that boost the client’s self-confidence without attaching it to their weight or body image.

“Food and body issues are often the tip of the iceberg,” DiGennaro says. “I have never worked with a person who discovers their heart’s desire is to be thin. It’s always more along the lines of finding peace, receiving love and finding meaning in life.”

Similarly, Trumbetas says that when a client mentions in session that they’ve lost a certain number of pounds, she avoids praising or encouraging them, which would reinforce weight stigma. Instead, she responds with a question such as “How does that make you feel?” to explore the context of the client’s statement.

Trumbetas uses these conversations to emphasize that weight and health do not mean the same thing, and that “fixating on one aspect of health leads to unhealthy thinking,” she says.

Clients sometimes tell her, “If I can only lose this amount of weight, I’ll be happier.” But she reminds clients that being thin will not magically make them into someone they will love. Instead, she focuses on helping them learn to avoid comparing themselves to others and strengthen their self-love (both love of their body and their whole self).

DiGennaro is a certified intuitive eating counselor, so she also offers clients who talk about dieting psychoeducation on intuitive eating and explains that research indicates that most people who diet eventually gain the weight back, plus extra.

“Trying to control your body [via dieting] often comes from a place of punishment and restriction. I see it as ultimately a disconnection from self,” she says. “Instead, I help clients get curious about what it might be like to reconnect to themselves from a place of nourishment, self-care and truly listening to their body. And this is complex work because often … there were protective reasons they had to disconnect from their bodies and reconnection must be done in a trauma-informed way.”

DiGennaro acknowledges that this perspective shift does not come easily for clients, and it often takes many sessions before they begin to replace the unhealthy thought and behavior patterns they’ve adopted to cope with a lifetime of weight stigma.

Dutson also focuses on helping clients shift their perspective away from a restrictive view of taking things away (including food) to one that allows them to consider adding supportive elements to their life. To do this, she often prompts clients who are healing from the effects of weight stigma to identify and add things to their life that bring them joy, nourishment and comfort. This can be anything from dancing to their favorite song to connecting with a supportive friend.

There is so much more to wellness than body size, and the importance of social support is often one of the biggest contributing factors that clients overlook, especially those who have negative feelings about their bodies, Dutson adds.

“Asking ‘how can we add meaning, nourishment and joy to the body?’ is a more realistic and hopeful approach [to wellness] than restriction and taking things away,” she says.

Unlearning bias as a practitioner

Hilary Kinavey and Carmen Cool, co-authors of the 2019 Women & Therapy journal article “The broken lens: How anti-fat bias in psychotherapy is harming our clients and what to do about it,” note that researchers and mental health clinicians alike have reported on the “prevalence and negative implications of weight stigma in psychotherapy” since the 1980s.

“It is our lens, our gaze and the assumptions behind it that are the problem,” wrote Kinavey and Cool, who are both LPCs. “Diagnosis by sight is inaccurate and essentially biased. We simply cannot know who engages in overeating and who engages in restrictive eating based on the size and shape of the body in front of us. As professionals, it is our ethical duty to unpack and address this prejudice and to shift our focus and commitment to the human being who inhabits the body.”

The counselors interviewed for this article also recommend that counselors consider their own internalized weight bias to ensure they don’t inadvertently reinforce those biases in their interactions with clients.

“No one deserves to be treated badly because of their body shape, size or ability,” Trumbetas says. “If a counselor has their own negative views, they need to look inward and work on themselves — with another therapist if needed.”

Weight bias creeps into counseling, Dutson says, when a practitioner makes assumptions about a client based on their body size, such as how active clients are, how they feel about their body or what they might need to address in therapy. In turn, this can influence the questions clinicians ask (or don’t ask) and the issues they cover with the client.

staras/Shutterstock.com

“We have to recognize as counselors that we live in a society that values certain bodies over others, which can be ableist and elitist,” Dutson says. “We need to understand how marginalizing it can be to leave those beliefs unchecked. It’s not a stretch to say that our culture believes that certain genes, illnesses and conditions [that affect body size] are somehow inferior.”

Forristal, an assistant professor of clinical mental health counseling at New England College in Henniker, New Hampshire, agrees counselors need to do their own work to recognize and unlearn harmful beliefs about weight and body size. “Unless we intentionally and actively unlearn fatphobia the way we do with unlearning racism and other stereotypes, we are at risk for perpetuating this harm to our clients and communities,” she stresses.

A good first step counselors can take to combat this, Dutson says, is to decouple morality from food and body issues — both in the language counselors use in session with clients and in the way they think about things personally. This includes the questions a practitioner asks during the intake process with new clients, she adds.

Food is not good or bad, and it can be a comfort without inducing guilt. Counselors should refrain from talking about their own body or weight loss in sessions or asking leading questions of a client that reinforce weight stigma, Dutson says.

Instead, she advises counselors to borrow from mindfulness techniques and approach food and body issues from a nonjudgmental, observational lens. “We’d all benefit more from that,” Dutson acknowledges, “and modeling that for your clients is very powerful.”

Forristal says that refraining from making assumptions — either positive or negative — about a client based on their body size or shape is a good start toward ridding professional counseling of weight bias. Weight stigma is a barrier to care and help seeking, so counselors who want to combat this should mention on their website and other promotional materials that eradicating fatphobia is a goal of their clinical practice, she adds.

In their article, Kinavey and Cool suggested that counselors ensure that their office space is accessible and welcoming to larger clients, which includes having chairs that accommodate a larger person comfortably and a waiting room that does not include decor or reading materials that reinforce fatphobia, such as fashion magazines.

Forristal also encourages practitioners to address any power imbalance that can affect the therapeutic relationship such as the counselor having a larger body than the client or vice versa. A client with a thin body, for example, may not feel comfortable reporting the extent of their issues with a counselor who is larger out of fear of offending them.

Counselors should not hesitate to check in with clients and ask how they feel about discussing body image issues with a practitioner who is a different size from them to ensure that they are comfortable, Forristal adds.

“We can never address these issues if we’re too uncomfortable or unwilling to broach them in the room with clients,” she says. “If a fat client expresses body image concerns to a thin counselor, the counselor can name that they hold privilege as a thin person and check in with the client about their reactions around that. Much like it doesn’t help to take a ‘colorblind’ approach when working with BIPOC [Black, Indigenous and people of color] clients, it isn’t helpful to ignore the differences in body size and power in the room.”

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Resources for counselors who want to learn more:

The National Eating Disorders Association’s page on weight stigma: nationaleatingdisorders.org/weight-stigma
The Association for Size Diversity and Health: asdah.org
The National Association to Advance Fat Acceptance: naafa.org (Visit the “learn” menu to download a brochure with suggestions and guidelines specifically for therapists.)
Hillary Kinavey and Carmen Cool’s 2019 Women & Therapy journal article, “The Broken Lens: How Anti-Fat Bias in Psychotherapy is Harming Our Clients and What To Do About It”: org/10.1080/02703149.2018.1524070

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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.

Fatphobia: How can counselors do better?

Compiled by Bethany Bray November 23, 2022

Stop and think for a moment: Have you ever seen a plus-size Barbie doll or rooted for a romantic hero who wasn’t thin?

Kaitlyn Forristal, a licensed professional clinical counselor, poses this question to illustrate the way fatphobia and weight stigma saturate our culture and society.

“We are programmed from a very young age to associate fatness with bad things … [and] counselors are not immune from socialized viewpoints and messages,” says Forristal, an assistant professor of clinical mental health counseling at New England College in Henniker, New Hampshire.

It’s up to counselors, therefore, to examine their own feelings and assumptions about weight and body size to keep from passing them on to clients in therapy, she stresses.

Forristal studied fatphobia’s influence on diagnosis decisions made by counseling graduate students in her 2018 doctoral dissertation; fatmisia is an area of research and specialty for her. Counseling Today sent her some questions via email to learn more about how weight stigma can show up in the therapy room and what counselors can do to dismantle it — both in themselves and in their clients.

How might fatphobia and weight stigma show up in counseling? Misdiagnosis is one area, but what else?

Yes, misdiagnosis is a concern due to a societal belief that “obesity” is a medical disease. Aside from diagnosis and treatment, counselors are also at risk for projecting their own (potentially negative) beliefs about their bodies and health status onto their fat clients. Despite what a clinician may assume, many fat clients are comfortable in their bodies and have no intention of changing them.

It could also be dangerous for counselors to assume that a fat person’s presenting issues, such as body image struggles, anxiety, depression or other mental health concerns, will be alleviated if the client loses weight. It is likely that fat people have internalized fatphobia — a set of negative beliefs about themselves because they are fat — and believe that losing weight will help them to solve their problems. While this may be true to some extent, losing weight cannot repair relational issues or make up for [brain] chemical imbalances.

If a person is struggling with the stigmas associated with being fat, or expresses hatred of themselves for being fat, attempting to change their body is not the solution. We eradicate prejudice by addressing the socialization of fatphobia and working to make our society safer and more inclusive for everyone.

What would you want counselors to know about approaching the assessment and intake process in a nonstigmatizing way? How can counselors ask about weight or weight loss, eating habits, etc., without a client feeling they are being shamed or judged?

Using the same intake measures and assessments with both fat and thin clients is the best way to approach this; don’t assume that a fat person overeats or that a thin person exercises regularly.

Consider why you may want to ask about weight loss or eating habits: Is it to confirm your suspicion that a fat client doesn’t get enough cardio or because you [assume] that their weight loss/gain is a symptom of depression?

If a fat client reports on an intake form or during an interview that they struggle with self-esteem due to their body size, want to lose weight or have poor body image, counselors should address that the same way they would with a thin client. If a new client doesn’t mention struggling with these things but happens to be fat, they are probably there for other reasons and you don’t need to ask about weight loss or eating habits.

Counselors don’t need to be afraid to discuss body size, fatphobia and marginalization with fat clients, but they also don’t need to broach this with a client just because they think someone may have an issue solely because of their body size.

How might counselors be making assumptions that someone who doesn’t fit society’s norms for shape and size is unhealthy and/or somehow to be blamed for their challenges? How might this bias creep in without counselors realizing?

It is an unfortunate societal belief that we can tell someone’s health status by looking at them. We see this all the time with news coverage of the “obesity epidemic” (spoiler alert: fat people have always existed!) and dehumanizing b-roll [news footage] of [faceless] fat people walking around and living their lives.

Something that is really strange about society if you think about it is the notion that others’ bodies are for us to comment on or have an opinion about. How often do you see someone who has changed size (lost or gained weight) and made an assumption about them, whether they have “let themselves go” or are now healthier due to a smaller body? When you run into someone you haven’t seen in a while and they are smaller, do you automatically congratulate them or tell them how great they look? Each time you do this, you are making an assumption that they lost weight intentionally and that it is worth celebrating that there is now less of them.

There are many medical conditions that are often attributed to fat people (diabetes, heart disease, sleep apnea) that medical research doesn’t support. The average size person in the United States is “overweight,” so it is likely that many findings that fatness is a cause of these medical conditions are misinterpreted when fatness is correlated to these conditions. It is important to be good consumers of research and pay attention to who is putting out studies that demonize fatness (I’m looking at you, Weight Watchers!) and who the intended audience is.

Researching the history of the body mass index (BMI) can help as well. Considering that the BMI is still used in western medicine for pathology and treatment of patients is baffling and is not rooted in accuracy or health outcomes. The BMI is unnecessarily vague (e.g., “overweight” — over what weight?) and doesn’t account for muscle mass or many other confounding factors. Some of the most elite athletes in the world are “morbidly obese” according to the BMI.

It was never created to be used the way that it is now, and aside from the harmful labels it puts onto people’s bodies, it creates real issues for mental health care treatment. For example, due to the BMI categories, many fat people have difficulty receiving treatment for eating disorders, which is detrimental to client and community health and to the profession of counseling.

What do counselors need to do to check themselves and unlearn old patterns and assumptions about weight and body size? How can counselors do better?

Unlearning negative beliefs about fat people is a similar process to unlearning socialized beliefs about other marginalized identities (LGBTQIQA+ community, BIPOC [Black, Indigenous and people of color], disabled people). There is nuance to this in the United States as we are an individualistic society who believe that for the most part, people get what they deserve or work for.

Therefore, fatphobia falls into a category with other social issues like poverty where we feel more comfortable attributing blame to individuals that we believe can change their status if they only tried and worked hard enough for it. Poor people can just work harder or get better jobs to “pull themselves up from their bootstraps,” or fat people could lose weight if they only had more self-control. Obviously, neither of these things are true for the vast majority of people facing this discrimination, but the societal belief that we can change our circumstances continues to harm those in our communities.

Counselors can do better by speaking out about these things and advocating for the rights and dignity of fat people. It should come as no surprise that bias against fat people is rooted in racism and xenophobia.

Fatmisia is also rooted in capitalism; the weight loss industry was worth $72 billion in 2018. Selling weight loss programs, weight loss surgeries and weight loss-focused fitness programs is a business that is only viable because people buy into the notion that fatness should be avoided at all costs (literally).

Having this information is helpful for counselors to (a) reconceptualize the way they feel about their own bodies, (b) provide validation and psychoeducation for clients struggling with body image or other weight-related issues and (c) advocate for changes in the way that others in society view and relate to fat people.

How can counselors support a client who names weight loss as a goal in counseling? What should a counselor’s role be in this situation?

A counselor’s role is always to support their client in treatment, and there are many valid reasons for clients to want to lose weight: to be safer in society by living in a smaller body, because a family member has expressed concern for their weight, a medical provider suggests it for overall health, or as a requirement for a certain procedure, etc. However, counselors are not medical providers, physical therapists, dietitians, etc., and should refrain from providing any medical advice as this is outside of our scope of practice and unethical.

It can be easy to automatically support a client who wants to lose weight because we believe that a fat body is always an unhealthy one, but this is not the case and could cause harm. Most research on dieting shows that intentional weight loss does not work and that only 5% of dieters maintain their weight loss for an extended period of time; most dieters gain back the weight they lost and more due to the metabolic disruption of putting one’s body into starvation mode.

Counselors can, of course, ask about the reasons the client is bringing this up in session: Are they having body image concerns, experiencing disordered eating or relational problems? These are issues that counselors are trained and qualified to help with. Exploring these issues may reveal the deeper issue that a client has an eating disorder or is being verbally/emotionally abused by a partner. A counselor’s role in either of these cases would be to explore options for the client and set goals in treatment. If a counselor has training/knowledge in this area, this is a good opportunity to self-disclose their own body image concerns and ask the client if they would like [the counselor] to share with them some information about weight loss, the diet industrial complex, etc., that may help them reframe these issues.

What should counselors avoid doing or saying in sessions with clients to keep from harming them with weight stigma?

The easiest way counselors can know how to speak about clients’ bodies is by asking them! Some people prefer to describe themselves as fat because it is merely a descriptive word like tall, dark-skinned, etc. For others, there is such a negative connotation with the word fat (and a lot of harm associated with it) that they prefer other ways to describe themselves.

Counselors should avoid making assumptions about fat clients that they wouldn’t make about their thin clients, such as [whether] they overeat or binge eat, do not exercise enough, hate their body, etc. Practicing weight neutrality, or making no assumptions (good or bad) about a client’s weight or body size, is a great start.

It is also imperative that counselors resist the notion that fat people can or should lose weight to avoid stigma and marginalization due to their body size. We would not expect a little person to just grow taller to access the world with more ease, and we should not project this onto fat people either. Humans have always come in all shapes and sizes and being fat is just one way of having a body — it is that simple.

Michael Poley/canweallgo.com

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See more on this topic in a feature article, “Pushing back against fatphobia” in Counseling Today’s upcoming December magazine.

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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.

Treating depression by focusing on solutions and acceptance

Compiled by Lisa R. Rhodes November 21, 2022

Tanongsak Panwan/Shutterstock.com

Depression is a common mental health disorder and affects people from every walk of life, regardless of their age, race, ethnicity or socioeconomic background. According to the National Alliance on Mental Illness, approximately “21 million adults in the United States — 8.4% of the population — had at least one major depressive episode in 2020.”

Common treatments for depression often include cognitive behavioral therapy (CBT) and psychotherapies that focus primarily on a client’s past. However, they are not the only approaches counselors can use. Solution-focused brief therapy (SFBT) and acceptance and commitment therapy (ACT) are evidence-based counseling approaches that have also been found to be effective in treating depression. Counseling Today asked six counselors to discuss the effectiveness of these two clinical approaches for treating clients with depressive symptoms.

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Fostering hope through SFBT

By Foley L. Nash

For me, one factor in the effectiveness of SFBT is the set of themes that runs through its basic tenets. The main themes are building exceptions to the presenting problem and making rapid transitions to identify and develop solutions intrinsic to the client or problem. These themes resonate well with clients, particularly those experiencing depression, as well as with a subset of depressed clients who experience comorbid anxiety, which can occur in as much as 70% of depression cases.

In treating depression, the emphasis of a solution-focused approach is to counter hopelessness, which is an important and common factor related to the frequently present risk of suicide. SFBT benefits depressed clients by engendering hope for the possibility of finding solutions in ways that are tied to the following basic tenets:

A focus on competence, not pathology (emphasizing the client’s power and hope)
The goal of finding a unique solution for the individual client (not a cookie-cutter approach)
The use of exceptions to the problem to foster optimism (hope)
The use of past successes to support/increase client confidence (hope)
The view of the client as the expert (acknowledging the client’s power)
The use of goal setting in charting a path to change (scaling questions are important in goal setting)
A shared responsibility for change between client and therapist (supportive partnership)

In SFBT, the emphasis shifts from problems to solutions, which empowers clients by allowing them to access their own internal resources, strengths and prior successes.

The following are the aspects of SFBT that appeal to me:

It’s an evidence-based practice (EBP) and its proven effectiveness has been documented. As a managed care clinical director, I see increased emphasis on EBP providers by large payers. In my private work, employee assistance programs also like the use of EBPs for the greater likelihood of faster change in their shorter treatment episodes.
It’s largely focused on the skillful use of language for therapeutic purposes. As the Greek philosopher Epictetus said, “People are disturbed not by things, but by the views they take of them.” Helping clients to see things differently is one of the useful functions of SFBT, which allows clinicians to ask questions such as, “How did you make that improvement happen during that time?” or “What would your best friend say you did differently when things were better?”
As a former language teacher/linguist who now conducts therapy in English and Spanish, I ascribe to the outlook that language is the tool of thought. SFBT can be immediately helpful in guiding clients to think differently about potential solutions. Instead of accepting that clients are as helpless as they may feel, counselors can try asking about how they have managed to achieve and sustain some of the times when the problem was absent or less severe. It’s helpful for the therapist to have some affinity for fluency in language and in the SFBT tools. As counselors study some of the SFBT principles, strategies and techniques, they will encounter many examples of questions that use language in helpful ways to change a client’s perspective, and they can become more skilled, thoughtful and proactive about how to use language to bring about a shift in a client’s perspective.
I’ve found over time that SFBT and its tools are also very helpful in helping clients become “unstuck” and breaking an impasse.

SFBT focuses on helping the client to reframe the situation, develop second-order change that supports solutions, and see the situation as something they can manage and change by using their own strengths and abilities. While first-order change is behavioral, as in doing things differently (sometimes described as matter over mind), second-order change is conceptual (often described as mind over matter) and involves helping a client to see things differently. This type of change can help a client with depressive symptoms to be more readily able to make the desired behavioral change to move toward a modified or new solution.

I have also found that SFBT is effective in treating depression along with comorbid anxiety. In my practice, clients frequently present with both depression and anxiety. It’s useful to focus initially on whichever condition is creating the most significant impairment in functioning for the client. This can provide a quick initial improvement and encourages the client to continue to address the less problematic condition, which, in my experience, is usually the anxiety.

Comorbid anxiety and its occasional panic attacks often engender fear in clients, especially the fear of the next panic attack after an initial one, as well as the corresponding sense of fear about the loss of control. By providing hope to clients, SFBT has treatment application for both depression and anxiety.

— Foley L. Nash is a licensed professional counselor supervisor with a private practice in Baton Rouge, Louisiana. He works mostly with adults and often provides short-term employee assistance program services. Contact him at foley1@foleynash.com.

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Working toward a solution-focused goal

By Marc Coulter

Jeremy (a hypothetical client) was hopeful and enthusiastic early in life, but after a cross-country move and a long-term relationship ended just before the pandemic, he had difficulty coping.

Some days, Jeremy couldn’t get out of bed to work. Other days, he showed up, but he felt dark and hopeless and didn’t care whether he lived. Jeremy’s depression continued through the pandemic and medication didn’t help.

When working with severely depressed clients such as Jeremy, SFBT practitioners maintain a stance of optimism and hope, knowing that a client’s past experiences and feelings of depression do not determine future outcomes.

A solution-focused perspective directs the course of therapy toward solutions, rather than focusing on problems, and guides the questions we ask. With empathy, compassion, respect, curiosity and hopefulness, we acknowledge and honor whatever agonizing feelings, or perhaps the lack of feelings, clients such as Jeremy experience while co-creating a preferred future.

Hope

SFBT counselors often explore what gives depressed clients hope. In Jeremy’s case, what gave him hope was knowing that change was possible. Sometimes clients live their lives and show up to counseling sessions despite not feeling hopeful. SFBT counselors explore how clients show up and participate in their lives despite the lack of hope. In session, we reaffirm what they’ve said is meaningful in their lives and why it may be important to keep moving forward despite the lack of hope.

Solution building

In the book Tales of Solutions: A Collection of Hope-Inspiring Stories, Insoo Kim Berg, who along with Steve de Shazer co-founded SFBT, and Yvonne Dolan wrote that SFBT counselors begin therapy with a detailed description of a client’s desires. Clinicians can then explore possible times when these desired outcomes may have been present, even in small ways, to find solutions to their problems. The solution-building process for Jeremy might include questions such as “How might you want to cope given your circumstances? How have you been able to manage up until now? What helps even a little? What helps you make it through the day?”

If Jeremy couldn’t imagine even one small movement toward feeling better, the counselor might ask, “What helps prevent it from getting worse?”

Focusing on Jeremy’s best hopes for therapy, the counselor might also say, “Suppose you’re walking away from our last session together and you’re thinking to yourself, ‘That was a really good use of my time, energy and money.’ What would you be walking away with that would make a difference?” Jeremy might respond, “Maybe I would feel less depressed.” The counselor could then ask, “Yes, of course, and if you felt less depressed, what might you feel instead?” Jeremy might say, “I guess lighter, more hopeful.”

The miracle question

When working with a client who is overwhelmed, depressed and suicidal, solution-focused counselors often ask the “miracle question,” a concept co-developed by Berg and de Shazer. The miracle question includes components of what the client has determined is a meaningful and important solution to their problem. In Jeremy’s case, that was “feeling lighter, more hopeful.”

Using this technique, the counselor could ask Jeremy if it would be a miracle to feel this way, and Jeremy would agree. The counselor could ask him to imagine that while he was asleep the night before, a miracle happened. He would feel lighter and more hopeful, but because he was sleeping, he would have no idea the miracle happened.

The counselor could then ask Jeremy, “What might be the first thing you notice upon waking that would let you know that something was different?” After a pause, he might reply, “I would get up and not stay in bed.” The counselor and Jeremy could then explore how this would make a difference to him and the important people (and even pets) in his life. They could continue to slowly explore Jeremy’s miracle morning and the differences he and others had noticed.

Scaling questions

The counselor could also use scaling questions, an SFBT tool, which can help to ground the miracle day for Jeremy in the reality of his life. For example, a scaling question might be, “On a scale of 1 to 10, with 10 being that miracle day and 1 being life prior to beginning counseling, where are you right now?” Jeremy may reply and say a 2. The counselor could then ask why he was that high (why he didn’t choose 1 or even -12) and explore what he was doing in his life that put him at that level rather than a lower one. Jeremy might name things like engaging with colleagues and taking care of his dog. Next, the counselor could ask him to imagine what he could do that would put him just a little higher on that scale, maybe even a half a point, and what difference that might make?

— Marc Coulter is a licensed professional counselor in Lakewood, Colorado. He is a member of the American Counseling Association and past president of the Colorado Counseling Association. Contact him at marcjcoulter@liveyoursolution.com.

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The benefits and limitations of SFBT and CBT

By Nicole Poynter

SFBT and CBT are both effective in treating depression, but in different ways. Here are some of the benefits and limitations of both.

If a client’s purpose for coming to therapy is to find a solution to a problem, then SFBT may be the right therapeutic approach. SFBT usually lasts for six to 10 weeks and focuses on a client’s strengths and capabilities. SFBT pays attention to the client’s problems in the present. In counseling, we believe that individuals have the inner resources, strengths and skills that are needed to help them to achieve their goals and overcome difficult life situations. The purpose of SFBT is for therapists to focus on a clients’ capabilities. This therapeutic technique focuses on problem-solving, generating solutions and moving toward a goal.

The benefits of using SFBT for treating depression include the fact that it is short term and that is more cost effective than long-term therapy. Another benefit is that the counselor uses compliments in therapy, such as “That is amazing to hear,” when a client talks about a goal that has been met or a strength that was used, which can help to motivate clients to work toward their therapeutic goals. SFBT is also future-oriented, so clients do not get stuck in the past. The therapist focuses on what the client thinks their life will be like once the concern is resolved.

However, there are some limitations for choosing SFBT as a therapeutic model of choice. Some clients take more time to open up in therapy, so having only a few weeks for treatment does not make it easy to solve problems. This modality also focuses on the present, and it does not investigate the past and past traumas, which often contribute to unhealthy behaviors in the present. In addition, the counselor must trust the client and accept what the client desires for treatment, even if their goals are not beneficial. SFBT relies heavily on the therapist and client working together and works on the assumption that the client is willing to do the work to achieve their goal.

CBT helps clients look at problems differently and encourages them to think in healthier ways. This approach focuses on thoughts, feelings and behaviors and how they are all connected. If a client has a negative thought, it can lead to a negative emotion, which can lead to unhealthy behaviors. In a CBT session, the counselor focuses on the client’s negative thinking, or cognitive distortions. Counselors help clients look for evidence to support a thought and evidence to support their thought distortions. After clients determine that they have more evidence against a negative thought, then they can work with the counselor to turn it into a more positive thought.

There are some also some disadvantages to using CBT to treat depression. This approach is not intensive, so it is better for people with mild depressive symptoms. CBT has a high client dropout rate, which can be due to the hard work that is required in therapy or because it is not a quick fix. Although CBT is the strongest evidence-based treatment for depression, it takes a commitment to make it work. Clients must continue to use the skills they have learned to help prevent relapses.

Neither one of these modalities is easy for clients. Homework is vital for both approaches, so clients can practice what they have learned in session. Change is gradual and takes time to manifest. There is no one-size-fits-all treatment for improving mental and emotional well-being.

Both therapeutic treatments are effective in treating depression, so how does one know which one to use in practice? Talk to clients to understand their goals and preferences. Clarifying goals for therapy with a client will help determine what treatment modality is most appropriate. Being a therapist who is empathetic, client-centered and supportive is what is most important, regardless whether they use SFBT or CBT.

— Nicole Poynter is a licensed professional clinical counselor at Avenues of Counseling and Mediation LLC in Medina, Ohio. She works with children, adolescents, adults, and families and specializes in anxiety, depression, LGTBQIA+ issues, attention-deficit/hyperactivity disorder, parenting concerns, relationship distress, anger management and adjustment issues. Contact her at npoynter@avenuesofcounseling.org.

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Rekindling connection to self and others through ACT

By Lottena Wolters and Caitrin McKee

Since I (Lottena) began my D.C.-based private practice in 2016, new clients have increasingly presented with a profound loss of faith, but not in the religious sense.

Theirs is a loss of faith in personal safety, which is included in the second level of Maslow’s hierarchy of needs, along with law and order, physical security and economic stability. Some of my clients have also lost faith in themselves and their fellow human beings and feel acutely disconnected from the communities outside their inner circles. This loss of faith is the primary and most persistent symptom of their depression.

How do we help our clients feel connected and experience joy when they are bombarded with stressors such as news of political division, the ongoing COVID-19 pandemic and the worsening impacts of climate change? It can be deeply distressing to realize we lack the power to change the turmoil in the world, especially for our clients who are experiencing depression.

But what if the goal of therapy is not to change our clients’ emotions or reduce their depressive symptoms, but instead enable them to compassionately accept their feelings while engaging less with self-bullying thoughts? ACT is an evidence-based mental health approach that helps clients learn to accept what is out of their personal control and commit to actions that improve satisfaction with their quality of life.

Some of the most meaningful outcomes of ACT for depressed clients are increased resilience, a measure of one’s overall wellness that can reduce the risk of depression, and greater self-compassion. Self-compassion allows us to experience negative events and emotions with acceptance, which leads to a reduction of suffering.

At the onset of treatment, I (Lottena) have clients complete a resiliency questionnaire, a stress inventory and the Valued Living Questionnaire (VLQ). The VLQ is an ACT self-directed tool used to help clients assess their values across 10 domains of living (family, marriage/couples/intimate relations, parenting, friendship, work, education, recreation, spirituality, citizenship and physical self-care) and evaluate how successfully they have lived in accordance with those values in the past two weeks. Clients are asked to rate the 10 domains on a scale of 1 to 10, with 1 being “not at all important” and 10 being “very important.”

I (Lottena) find that clients who are experiencing depression often rank themselves at a 2 or 3 in the domains that are most valuable to them. These clients will also score low on resiliency and high on external stressors. This was the case for one of my former clients, who I will refer to as “Mr. A.”

Soon after rapport was established in therapy, Mr. A completed the resiliency questionnaire, stress inventory and VLQ. He scored high on stress and low on resiliency. The VLQ illustrated that Mr. A felt he was unable to prioritize his life, primarily his marriage, work and family. He ranked himself between a zero and a 2 for how successful he had been at living in accordance with his values during the previous two weeks. This client could not fathom how to get above a 5, and he felt that he should be a 10 in each domain.

Mr. A’s hopelessness was so intense that he would either disconnect from his feelings to function professionally and socially or drown himself in his sadness. Mr. A woke up with feelings of dread and felt hopelessly unmotivated about work, often arriving at least an hour late for his job. He socialized only when he was intoxicated, and he avoided conversations with his family. Mr. A reported that his wife complained he was only present in body but not in spirit. His depression impacted all areas of his life.

After using ACT therapeutic interventions (such as the willingness and action plan and exercises that incorporate mindfulness practices) in session, this client began to rank his success in these domains at a minimum of a 6, and usually higher, for most two-week periods. His faith in himself and his loved ones was seldom below a 5, even when he experienced an episode of depression. And he could connect to his feelings of optimism, pride and joy.

Mr. A’s depression now has significant periods of remission, and when he experiences depressive symptoms, they rarely cause major problems for him at work, home or socially. The acceptance of both his depressed symptoms and new positive emotions allows him to treasure and protect his joyful experiences. He has undergone a profound transformation through his dedication to the ACT process.

Thus, counselors should be open to trying ACT, which is sometimes overlooked as a therapeutic approach. I (Lottena) have utilized ACT for over 14 years as a clinician, and I often recommend it during supervision sessions with newly licensed therapists and graduate students. I find that ACT is flexible enough for both younger clinicians and more experienced clinicians who treat clients reporting increased feelings of hopelessness and persistent depression. And I can say that both the research and my own personal experience demonstrate its effectiveness with depressed clients.

— Lottena Wolters is a licensed professional counselor and founder of the F.L. Wolters Group in Washington, D.C. She works with young adults and adults struggling with anxiety, mood disorders and attention-deficit/hyperactivity disorder. Contact her at lottena@flwoltersgroup.com.

— Caitrin McKee is a registered yoga teacher and the patient care coordinator at the F.L. Wolters Group in Washington, D.C.

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Helping clients become unstuck with ACT

By Jared Torbet

In the initial assessment, Camie (pseudonym) presented as depressed, unmotivated and indecisive, and she ruminated on her insecurities, which are all common symptoms of depression. She also used humor and a noticeable dismissal or minimizing of her feelings. Once I noticed these avoidant strategies, I felt ACT would be a good fit for this client.

At our next session, I helped Camie notice and name her internal experiences, including her thoughts, feelings and sensations; this is a basic mindfulness skill that Steven Hayes, the psychologist who founded ACT, believes is the most important mindfulness skill one can master. Camie’s internal world came into view as she began to notice and name that world in the present moment with ease.

We progressed to working with those internal experiences in a more helpful and workable way than she was accustomed to. Before I go further, let me share a warning label that comes with ACT. As therapists, we must do ACT, not explain ACT. It was vital that I guide Camie through an experiential journey, not a psychology lesson. Camie had a hard time differentiating herself from her depression, insecurities and fears. She was stuck.

I asked her to hold her depression, insecurities and the reality of being stuck in her hands and imagine it as an object. She described it to me as a big, heavy, lava-red, smokey, hot, smooth, oval-shaped sphere that was about 2 feet wide and 1 foot tall. “Where do you feel this object?” I asked. She replied, “Right here on my chest.”

Together, we playfully engaged with the object. We handed it back and forth. I had her set it on the coffee table between us and walk to the other side of the room. I said, “If this stuff is sitting here on this table, and you’re standing over there, what does that tell us?” She replied, “I’m not that stuff.”

She noticed a feeling of freedom and motivation from this exercise. This led us to discuss the range of her values, including relationships and career goals, as well as her fears and doubts. I guided her through an expansion exercise. We both breathed deeply while widening our arms and imagining making room for values, goals, fears and doubts. I asked how much of her energy is spent on these important things. She said, “Pretty much none.”

“You spend so much time and energy trying to figure out, or get rid of, this heavy, red sphere,” I told her. “What would happen if you spent that time and energy on the things that matter the most to you?” She replied, “I would probably be a lot further in my life.” I asked, “Where would you be?” Without hesitation, she told me, “I would be teaching English as a second language (ESL) overseas.”

I said, “Wow, that sounds amazing! What is stopping you from going?” She smiled and replied “this” while she simulated holding the heavy, red sphere. So I asked, “What if you packed it in your suitcase, and just took it with you?”

I could see the wheels turning. This was our segue into her accepting and allowing fear and doubt to be there. I taught her that her fear, which shows up as anxiety, is just trying to protect her. When she imagined her fear/anxiety, it took the form of her child-self.

I used the analogy of her being the captain of her own ship, with her thoughts, feelings and sensations being her deck mates. It felt right to offer the choice of inviting her child-self on board as co-captain. This helped her to organically embrace self-compassion and self-love. I told her that she cannot control all her deck mates, but she can guide the ship and build tolerance for those on board. And as long as she’s traveling in the direction of her values, her deck mates won’t cause as much ruckus, and some will even help her, especially her co-captain.

Camie, through her dedication to therapy and her hard work in session, was able to notice her thoughts, feelings and sensations. She was able to see the difference between her internal experiences and herself. She was able to defuse, or unhook, from unproductive thoughts, while bravely accepting her emotions and sensations. She learned to align her choices and actions with what mattered most to her, such as teaching ESL overseas, which she eventually did.

ACT is not for everyone. In my experience, ACT requires a client to be able to practice mindfulness and engage in mental imagery. Clients with aphantasia (the inability to voluntarily create mental images in one’s mind), for example, would most likely benefit from a different modality. Also, in cases where the client is at risk of suicide, homicide, child/elder abuse, domestic abuse, trafficking and other high-risk behaviors, including self-harm, more immediate and tangible interventions should be considered with safety as top priority. These are situations that should not be accepted but avoided and reported.

— Jared Torbet is a licensed professional counselor and owner of Anxiety & Depression Clinic of Columbia in Missouri. He specializes in adults and teens who struggle with anxiety, depression or attention-deficit/hyperactivity disorder. Contact him at hello@comoclinic.com.

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ACT: The mindful approach

By Katy Rothfelder

ACT is an empirically supported and evidence-based treatment for individuals experiencing depression, yet it is an approach many clinicians are not trained or fully comfortable exploring. For clients experiencing depression and the clinicians who use ACT to treat them, we must first come in contact with the totality of human suffering. From this place, we can bear witness to the suffering within our clients in the here and now. It is from this willingness to let suffering come close, to see it as one of the many thousands of threads forming one cloth of the client, that we as clinicians can form a workable framework for the way in which internal and external experiences are woven to diminish valued living, as noted by Kelly Wilson and Troy DuFrene in their book Mindfulness for Two: An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy.

ACT moves beyond the language composed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This approach, which includes self as context as one of its core processes, defies labels such as “depressed client,” and instead appreciates the unique, narrow and broad experiences of the client. It takes the language and behaviors the client exhibits, such as “there’s no point,” and looks to transform those overt and covert behaviors into valued, flexible ways of being.

Mindfulness practice is a critical part of ACT. It can be argued that mindfulness, as it is understood in contemplative practices, is the totality of many of ACT’s six core processes — acceptance, defusion, self as context, values, committed action and contact with the present moment. And ACT’s core process of contact with the present moment is what we might contextualize as modern-day mindfulness. According to Jon Kabat-Zinn in his book Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life, mindfulness is “paying attention in a particular way: on purpose, in the present moment, nonjudgmentally.”

Unique to ACT is the way in which the six core processes interact, merge and flow with one another. They are not mechanistic in form, but rather are existent within a particular context and in service of creating psychological flexibility.

Lindsay Fletcher and Steven Hayes, in their 2005 article “Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness” published in the Journal of Rational-Emotive and Cognitive-Behavior Therapy, defined psychological flexibility as “contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values,” which can also be considered a workable definition of mindfulness.

Psychological flexibility is a practice and the outcome we continuously return to in ACT. Rather than seeking to get rid of unwanted, unpleasant thoughts or experiences, ACT aims to support individuals in living full, rich and meaningful lives without defense, while also engaging in the moment with what is most important to them. With many clients experiencing depression, as well as other experiences such as anxiety or trauma, contacting the present moment in a particular way can be helpful in reconnecting with valued living.

Contacting the present moment involves commitment and deliberate action, drawn from one’s values, with an awareness of the self as containing thoughts, emotions, roles, bodily states and memories. In essence, ACT supports individuals in experiencing their “wholeness,” with flexibility and persistence in valued living.

ACT is not done to a client, but rather is experienced with and between the client and clinician, moment to moment, in a flexible, processed-based practice.

— Katy Rothfelder is a licensed professional counselor associate who is supervised by John Hart at the Anxiety Treatment Center of Austin in Texas. She specializes in obsessive-compulsive disorder and related disorders, anxiety, depression, trauma and neurodiversity. Contact her at katy@anxietyaustin.com.

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Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@counseling.org.

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

Voice of Experience: Self-assessment and professional growth

By Gregory K. Moffatt November 17, 2022

A soon-to-be fully licensed clinician sat across from me for one of our last supervision sessions. I told him the same thing I say to everyone when they get to this point. After today, you will have your license in your hand, and depending on the nature of your practice, you never have to talk to another mental health professional again for the rest of your career.

Although it is improbable that any clinician will literally never speak to another person in the field, it is not at all improbable that they may not have any “supervision” for the rest of their career. That should make us all shudder. I regularly present trainings — often on supervision, ethics or both — at conferences. I can tell who is there to learn and who is there just to get a piece of paper that says they sat in a room for five hours. I wouldn’t want my counselor to be in the latter group.

I want the newly trained clinicians I supervise to see the ethical responsibility they have for their own self- assessment, competence and professional growth. Those who isolate themselves in their own practices and see clients day in and day out, are at risk of being the same counselor a year from now that they are today. They won’t have someone sitting across from them each month asking them “What are your strengths and what are your weaknesses?” like I do with my supervisees.

Using a 10-point scale, I evaluate my supervisees using nine areas of competence: ethics, theory, diagnostics, case presentation, clinical skills, documentation, diversity, self-care and remediation. I ask my supervisees to rank where they are in these nine areas during the final weeks of supervision, and they almost always rate themselves higher that I rate them.

I know why. They are very good at the things they know and the issues they face regularly. But what they lack sometimes is a recognition of what they don’t know — questions they don’t even stop to ask.

For example, when I asked one clinician, “On a scale of one to ten, where are you in your understanding of the Diagnostic and Statistical Manual of Mental Disorders (DSM)?” she gave herself a nine. But when I probed a bit, she admitted she hadn’t even looked at the latest edition, DSM-5-TR, and didn’t know what changes had been made. She is a competent clinician who knows what she needs to know with the clients she sees every day. But she didn’t know what she didn’t know. That is why supervision, consultation and training are critical.

Some clinicians are just lazy and unethical. They won’t grow because they don’t want to. I can’t do much about them.

But others fail to pursue professional growth because they don’t know any better. Evidence of weak professional growth might look like the following: You see your continuing education requirements as “hours you have to get” as opposed to opportunities for growth. If this is the case, I have concerns about your professionalism.

Some clinicians wait until the month their license renewal is due and then scramble to get any continuing education credits that meet their state requirements. Hmmm, that doesn’t scream “professional” to me.

If a counselor doesn’t see the need to regularly meet with other professionals in the field, discuss cases or ask for someone to look over and evaluate their work, then it sounds like someone who thinks they have “arrived” and have nothing else to learn.

When it comes professional growth, I practice what I preach. A few years ago, a married couple came to me in an attempt to repair their seriously broken relationship. It was an incredibly complex and challenging case for me. Even though I’ve been in practice for decades and started my general practice in the 80s as a family therapist, I’m not a licensed marriage and family therapist (LMFT), so I wasn’t fully confident I was seeing everything I needed to see with this couple.

I sought supervision from a LMFT I trusted. He was humbled at my request because he was my former student and former supervisee. But he had far more experience in the marriage and family arena than I did. I consulted with him for months about this case, and happily the marriage survived.

In addition to seeking supervision when needed, I also evaluate myself using the nine areas of competence that I use to evaluate my supervisees (i.e., ethics, theory, diagnostics, case presentation, clinical skills, documentation, diversity, self-care and remediation).

My challenge to you is to rate yourself on these nine areas and, even more important, have a colleague rate you as well. If you don’t have a colleague who knows you well enough to evaluate you, then that tells you that you have some work to do.

Colored Lights/Shutterstock.com

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

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

The emotional effects of cancer

By Donna Degrasse November 15, 2022

Mental health becomes the center stage for clients and their families dealing with cancer. The person with cancer feels their whole life has been turned upside down; they experience many emotions, including inevitability, loss, shock, anxiety and depression. Their family members, on the other hand, feel desperate to help and “fix” them, and they feel anxious because they do not understand what is happening other than the fact that their world has suddenly changed and not for the better.

The medical treatments for cancer often feel worse than the cure. The physiological effects can be intense because treatments can have side effects such as itching, burning, sores in the mouth, skin scarring, hair loss and blood clots, and these changes may lead to feelings of anxiety. Other conditions include diarrhea and constipation from the multiple medications the person takes, including opioids, blood thinners, steroids such as Dexamethasone, and benzodiazepines such as Xanax, antidepressants medications, antipsychotics medications such as Olanzapine, or other drugs. Some treatments cause people to lose the hair on their head or all over their body. Because people sometimes consider their hair to a part of their identity, losing their hair may feel like their entire identity has been taken away. They will experience this reminder every time they look in the mirror because it takes up to a year to discover what kind of “chemo hair” will grow back.

Loss and uncertainty

People going through cancer treatments feel uncertain about their future, and every slight ache or pain makes them fear the cancer is returning, which causes some form of anxiety. They also feel a sense of loss because they feel they cannot accomplish the things they had hoped or they envision not seeing their loved ones anymore.

Clients can also experience a loss of control because they feel everything in their world has suddenly been taken away from them. Cancer leaves the person feeling stripped of their choices, including how they will wear their hair and what foods they choose for their nightly meal. Clients with cancer, for example, tend to eat the same thing every day because if they find one food that agrees with them, they will stick with it.

I once worked with a 62-year-old white woman who had been diagnosed with bilateral lung cancer that she later discovered had also spread to her liver, brain and spine. Understandably, this client was depressed, anxious and angry at the world. She wondered why this had happened to her, and she felt helpless because she didn’t have any control over what was happening to her body.

Using psychotherapy with this client allowed her to see that her life has meaning and that she still has control over some choices. She could decide whether to continue with radiation on her brain or chemotherapy treatments for her body. She could also decide how she chooses to look at her diagnosis. Does she see her diagnosis as the end or as something she has to contend with? Does she want to let the cancer diagnosis control her life or does she want to live like she wants? Counseling can help this client process these different thoughts and outlooks on life. With a counselor’s guidance, she can begin to realize that she has choices and learn to enjoy the little things in life rather than focus on the things she does not have power over.

Humanistic psychology and cognitive behavior therapy (CBT) are helpful clinical approaches for clients with cancer who feel a sense of loss. Humanistic psychology can help clients see that they are holistic individuals capable of determining their behaviors and goals, and CBT helps them challenge their irrational “ought,” “should” and “would” statements that clients often tell themselves.

Evidence also suggests that mindfulness-based treatments yield benefits for clients who are dealing with cancer treatment. In addition to being cost-effective when compared to other more conventional and contemporary management methods, mindfulness approaches help clients manage the adverse effects of treatment and symptoms from the cancer progression such as a sense of loss. Several of my clients dealing with cancer have remarked on how they have lost control over their lives and actions, and in Western cultures and health systems, mindfulness is a way to stay aware and in control. A mindful approach, when used effectively, can also reduce stress, improve physical health and help clients reach a state of heightened consciousness and awareness.

Anxiety

I worked with a 69-year-old white man who had non-small cell lung cancer. He underwent a left upper lobectomy (surgeons removed the upper lobe in the left lung) and three months of chemotherapy to treat the cancer. After being in remission for nine years, he developed a chronic cough and discovered he had another tumor — this time on the right lung. The doctors told him that they thought this was a second, new form of cancer and not a metastasized form. He then underwent 68 rounds of radiation therapy and three months of chemotherapy.

Despite being officially in remission again, this client is not overly optimistic because he has been down this road before. In addition to the two lung cancers, he has had melanoma on his nose and was exposed to Agent Orange, a chemical herbicide, during the Vietnam War. This client is always waiting for the other shoe to drop.

Counselors can help clients find positive aspects to their life rather than waiting for something bad to happen. Clinicians can provide clients with tools and interventions to help them cope with their illness and alleviate their anxiety, depression and feelings of hopelessness by teaching them to practice positive affirmations and mindfulness techniques. Supportive-expressive therapy is one evidence-based treatment that allows clients to express their emotions and helps increase their social support; this therapy can also improve the client’s capacity to cope with their cancer.

Resentment and anger

A female client who was going through cancer treatments told me she had feelings of resentment because despite being a healthy person, she was the one who had been diagnosed with stage 4 lung cancer, while her sister who was not as healthy had not. The client was very conscientious about eating only nutritious foods (those high in antioxidants) and maintaining good physical health. She didn’t understand why she was diagnosed with stage 4 lung cancer and had tumors in both lungs, one on the aorta and one close to the esophagus. Her sister, on the other hand, smoked cigarettes, drank alcohol, and for most of her adult life struggled with an addiction to cocaine, but she was in perfect health.

Anger is another emotion clients with cancer may experience. For example, I knew a 19-year-old white man who had been diagnosed with lung cancer that had spread to his liver and intestines. He needed a colostomy bag for his intestines, so he was angry at the world. He was mad that his cancer diagnosis determined how he ran his life, who and how he dated, and what he did in general. His chemotherapy and pharmacological intervention schedule were once a week for three hours, and the treatment left him tired and worn out. A client such as this would benefit from counseling because a clinician could help them see that their life does have positive aspects, they do have choice in life and that not everything is wrong and hopeless.

Admitting feelings of resentfulness and anger can be challenging for clients. Clients rarely share their true feelings with those close to them for fear of worrying or upsetting a family member or friend. Instead, they often bottle up their feelings of depression, anxiety, resentment and anger, which causes the client even more stress, worry and anxiety.

Many clients who are dealing with cancer diagnoses need to talk or vent to someone who is not their family or close friend. Thus, one of the most important and beneficial things a counselor can offer these clients is empathetic and nonjudgmental listening, caring and genuineness. Having space to talk about what they are going through and struggling with and what they need without feeling like a burden to family and friends can make a world of difference for clients with cancer. Counselors can be a reliable source of comfort and a valuable resource for clients. They can use different theories, including mindfulness, humanistic, person-centered, feminist and CBT, to normalize and ground the client’s worries, fears and anxieties. Counselors can also use Carl Rogers’s tenets of unconditional positive regard, empathetic listening and congruence to connect with clients genuinely.

Self-care

Because dealing with cancer can cause clients to feel uncertain, anxious or angry, it’s also important to teach and model effective self-care strategies and techniques. Self-care can be anything the client chooses to do that makes them feel less stressed, anxious or depressed and more in control of their situation. Strategies can include going for walks, taking a bubble bath, or scheduling downtime to relax. Self-care can also consist of spending more time with family, getting a pedicure, hunting, fishing, bird-watching, sleeping in on Saturday mornings or enjoying a cup of coffee. Undergoing cancer treatment can make clients feel all their choice and control has been taken away, and self-care can give them some semblance of control in their lives.

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Donna Degrasse

Donna Degrasse is a licensed mental health counselor in Florida, a trained trauma professional, a marriage and family therapist, and cognitive behavioral therapist who specializes in working with clients and families dealing with a cancer diagnosis. She has been counseling clients since 2016, and she has been working with clients and families dealing with a cancer diagnosis for over a year. She brings compassion, empathy and caring to each family member and client she sees. She is also a doctoral candidate in the counselor education and supervision program at Capella University. Contact her at donnadegrasse0102@outlook.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.