Monthly Archives: January 2023

Counseling Connoisseur: Brain science, courage and chronic pain

By Cheryl Fisher January 19, 2023

A young woman with wrist pain is holding her wrist and has a painful expression on her face

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‘Courage doesn’t always roar. Sometimes courage is the little voice at the end of the day that says I’ll try again tomorrow.’ —Mary Anne Radmacher

It all began with the numbing of my hands. Too much time was spent holding my smartphone, I surmised. I went to my doctor after the tingling began to keep me up at night. Carpal tunnel. Wear a brace at night, and it should resolve. If not, a simple surgical procedure would fix the problem.

A year later, the numbing was replaced with swollen, painful joints that now included my shoulders and feet. Mornings were the worst — it took me twice as long to get anything done because of the stiffness and pain. As a self-proclaimed gym rat and former aerobics instructor, I was forced to modify my daily workouts, as I was committed to keeping a routine. Moving helped, and by midmorning, I was able to function relatively well most days. Still, something was terribly wrong, and it was impacting every aspect of my life.

The blood work continued to come back negative for an autoimmune disease, but my family history and presenting concerns all pointed to rheumatoid arthritis. I was immediately placed on a disease-modifying antirheumatic drug that carried its own side effects, including fatigue, which I was already experiencing from a lack of sleep.

There were many days that I questioned how I was going to manage a private practice and a demanding academic career, while just barely having the energy to feed the dog, get dressed and eat breakfast. But there were even more mornings that I put on a smile, cringed through the pain and focused on the possibilities of the new day ahead.

Chronic pain

According to R. Jason Yong and colleagues, in their 2022 article published in the journal Pain, 1 in 5 adults in the United States experience chronic pain. Using data from the National Health Interview Survey, the researchers found that the experience of chronic pain negatively impacted the participants’ quality of life. Previously enjoyed activities were forfeited due to restrictions in mobility.

In addition to physical discomfort, there were psychological effects to living with chronic pain and illness. These included an increase in anxiety and depressive symptoms. Let’s face it — pain can sabotage even the best of days. I knew that from my own experiences. Therefore, imagine my excitement when I found research that completely changed my understanding of pain and offered real tools to cope.

Neuroscience advancements

Over the past decade, the science regarding the etiology of pain has evolved to a biopsychosocial model. This approach examines not only physical injuries but also the role that our thoughts and beliefs about pain and injury play in our overall experience of pain. Therefore, most models are antiquated in that they dismiss the brain’s function in assessing and moderating pain. Additionally, newer pain science research examines individual histories around trauma and childhood experiences as they have been found to be associated with a decrease in pain threshold and more frequent bouts of pain. In addition to the roles of trauma, childhood experiences and cognitive appraisals, pain science has also adopted the following tenets.

Pain is not purely physical. While pain is designed to protect the body, it is not purely physical. According to Robert Edwards and colleagues, in a study published in The Journal of Pain in 2016, pain is a “multidimensional, dynamic interaction among physiological, psychological, and social factors that reciprocally influence one another.” We often think that pain is related to an injury or tissue damage, but research indicates that chronic pain is often unrelated to physical injury. There are neurological changes that occur to create the sensation of pain even when there is no physical damage to the body. Therefore, when we focus solely on the physical aspect of pain, we miss so many other elements that contribute to coping and recovery.

Pain is processed in the brain. The brain sends biochemical messages to the cells in the body, and they in turn provide the brain with a status report. While injury can certainly be read by this process, stress also accounts for changes in the body that can register as pain (e.g., nerve pain or migraines). When activated, the body’s own analgesics (e.g., endorphins) are released to attempt to address the symptoms.

Everyone’s nervous system response is unique and can be altered. Additionally, with chronic pain, individuals can become sensitive to the possibility of pain. For example, initially, I experienced tremendous pain in my hands and wrists — so much so that even after my swelling and pain had significantly subsided, I was fearful of trying to do a pushup or yoga poses such as downward dog. I would cringe just thinking about it.

Neurologically, the brain keeps track of our pain threats, and it begins to anticipate the threat to the point of significantly decreasing the pain threshold. It is like a hypersensitive alert system that may even “sound the alarm” prematurely. This should sound familiar. It is a conditioned response. My brain became conditioned to anticipate pain in my wrists and hands, and anything that might pose a threat was received with a pain rating that exceeded that actual discomfort (if any). The good news is that anything learned can be unlearned.

Neural pathways can be reprogrammed. Individuals with chronic pain are prone to hypersensitivity. They have learned to expect pain, and their neurology is now wired to react even when the injury or stimulus no longer exists. In addition to the reactive neural pathways, the brain interprets each experience with cognitive appraisals of the pain sensation and situation. For example, a person may avoid activities that previously triggered pain or discomfort with the appraisal “I can’t do this activity without feeling pain.” However, David Seminowicz and colleagues’ study, published in The Journal of Pain in 2013, found that using cognitive behavioral tools to confront and reframe thoughts and beliefs around pain changed the brain and reprogrammed neural pathways, resulting in a decrease of pain sensation.

Implications for counselors

Counselors can play an instrumental role on a pain management team. Utilizing cognitive and meaning-centered approaches, counselors can help clients recognize the thoughts and meaning they ascribe to pain and illness that maintain or even increase the pain sensation. Conversely, challenging and changing those thoughts and beliefs can alter the neuroprocessing that results in the reduction of the experience of pain. Here are a few techniques for your toolbox when working with clients with chronic pain:

  • Word swapping (reframing). Language matters. It conjures images, and the brain (in particular, the amygdala) responds to these images. Swap out words that conjure fear with words that are more comfortable. Substitute the word “pain” for “sensation” or “pressure.” Use phrases such as “not as cool” or “not as loose” when describing the experience of heat or tightening sensations. This will reduce the amygdala’s engagement and help the brain create new neural pathways.
  • Meditation. Meditation can help retrain the brain and nervous system to process pain sensations. There are numerous guided meditations that specifically address chronic pain.
  • Positive self-talk. Often, we succumb to our fear of the pain and catastrophize the scenario. This increases the amygdala and stress response. Try talking to the pain. Whether it’s with a determined voice (e.g., “OK, I’m not going to miss out on this event because you [pain] are presenting. You are just going to have to leave me alone today.”) or a softer approach (e.g., “I know we can feel better. I’m going to make tea and do a brief meditation, and we will feel much better.”), be intentional and empowered in your self-talk.
  • Journaling or expressive writing. First pick a situation and write down your feelings and thoughts about it. Don’t hold back. For example, the first time I had to ask my husband for help opening a container during a flare-up was horrific. I hold the belief that I am independent, strong and capable. This is part of my identity; I see myself as Wonder Woman! So I hated asking for help. I felt vulnerable and scared. Now write another version of the narrative. In this scenario, my rewrite would be that after many years (decades) of believing that I had to be strong, I was shown that I have support and do not need to be physically strong. It is wonderful to be cared for, and opening jars also allows my husband opportunities to feel needed.


In her 2019 Netflix special The Call to Courage, Brené Brown says, “Courage starts with showing up … and letting ourselves be seen.” As counselors, we know that it is no small feat to show up and face the uncomfortable. It can be scary to be vulnerable and shed that superhero mask. We can validate and normalize the challenges of living with chronic pain, and we can bring our Adlerian pom-poms and cheer on our clients’ bravery. We can remind clients that not only can they live satisfying lives with chronic pain, but as they engage in the work of pain management, they are doing it.


Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and associate professor for Alliant International University California School of Professional Psychology’s online master’s in clinical counseling program. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer, nature-informed therapy and geek therapy. Contact her at

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.

Unexpected lessons and connections in sex offender counseling

By Lavinia Magliocco January 16, 2023

A person with their back to the camera sits at a table with a man. They are engaged in a conversation. Two notebooks are on the table in front of them.

In my final year of graduate school, I interned at a nonprofit agency where I was fortunate to have a great supervisor and experienced colleagues. They asked me whether I would feel comfortable working with Steve (pseudonym), a client who was on parole for sex offenses and was seeking additional support beyond mandated treatment.

Several factors emboldened me to say yes. First, I would be this client’s ancillary counselor; he was already working with another clinician with expertise in this population. The fact that his issues were beyond my competence would have precluded my working with him except for this contingency.

Second, at 58 years old, I’m not easily intimidated. Still, I was conscious of my limitations as a new counselor with no experience with this population and no training specific to this type of client. But ultimately, my support among a team of solid practitioners and a great supervisor made me think, “If not now, when?” So I took the leap and said yes.

This opportunity to work with a person who had committed sex offenses confirmed my trust in the power of a strong therapeutic alliance. Although this client tested me and I struggled at times, I discovered a capacity within myself that I had not experienced before. I learned about the barriers this population faces in rehabilitation from incarceration and developed a unique approach to help him regain a sense of connection to others. In the process, I gained a deep appreciation for the client. The following is the story of my experience working with Steve, who gave me permission to share his story, and what I learned.

Meeting Steve

I started working with Steve in the middle of the pandemic. Because Steve had spent the last several decades incarcerated, he was not up to speed with computers and was unsure about how to do telehealth. I arranged to meet him at a local Starbucks so I could help him set up Google Meet or Zoom on his computer. As a clinical rehabilitation counselor, helping clients with accessibility issues is important to me. Steve’s physical health and mobility were challenges for him and critical considerations in our work together.

When I walked into Starbucks, I saw a large man seated in a corner, arms crossed over his chest and a guarded expression on his face. It was Steve. He offered me a coffee, which I declined, but I told him I needed to visit the restroom before we started. I purposely left my jacket and handbag on the table where we sat. This was not a preplanned gesture but an instinctive response to his body language. Establishing trust would be crucial to working together. And what better way to gain trust than to give it?

In those 45 minutes, we focused on practical issues and had a few laughs around computer frustrations. I later learned Steve spent most of his life in various prisons. The last stint meant he’d entered prison before personal computers were common and the social media that we know today was not invented yet. He told me later that my willingness to help him with his computer in person was a deciding factor in his ability to let me into his confidence.

Finding the right approach

Another clinician worked with Steve on his sexual impulses, and I consulted with her once a month. We developed a good working relationship, and her support and expertise allowed me to focus on other issues Steve had. Steve’s stated goal for our work together was socialization. This posed some challenges, however, because his opportunities for socializing were severely restricted by his parole. At the very least, our counseling sessions provided the much-needed human contact he craved.

I scoured libraries, the internet, and the Association for the Treatment and Prevention of Sexual Abuse for articles on working with people who commit sex offenses to glean recommended evidence-based treatments. Several articles recommended using cognitive behavior therapy (CBT), motivational interviewing, self-regulation and other skills-based interventions. I knew Steve’s other therapist was working with him on self-regulation, so I consulted a colleague who encouraged me to use motivational interviewing.

I also received support from our agency’s psychiatric nurse practitioner who identified that most of Steve’s issues stemmed from complex posttraumatic stress disorder. It took months for Steve to trust me because of traumatic experiences with mental health clinicians who, 40 years ago, had tried to “cure” him of his attraction to men and had deemed him “incurable.” Steve signed a release of information form so that his two mental health clinicians and psychiatric nurse practitioner could communicate with each other about his case.

During his counseling sessions with me, Steve vented his frustrations about his parole officer and expounded on how he had been victimized by his family, friends and the system. He was initially unwilling to take responsibility for his predicament, but he provided me with opportunities to validate his feelings: He had been victimized early in his life like many who later commit sex crimes. His experiences included traumatic attachments, early seduction and sexualization, assault, and traumatic brain injury. It took months before he could admit that he was responsible for his subsequent actions. But through the use of CBT interventions, he was able to understand that just as adults had taken advantage of him sexually without his consent, he had replicated that behavior with others because it was all he knew.

In a 2013 article, “Treatment of sex offenders: Research, best practices, and emerging models,” published in the International Journal of Behavioral Consultation and Therapy, Pamela Yates said that counselors can help maximize treatment gains with this population by “demonstrating empathy, respect, warmth, friendliness, sincerity, genuineness, directness, confidence, and interest in the client.” Yates also noted that establishing a positive treatment environment contributes to positive outcomes, meaning clients are less likely to reoffend. After reading Yates’ list of characteristics, I felt reassured that the best approach with Steve was to lean into cultivating unconditional positive regard.

I asked permission when offering interventions. For someone who has been stripped of power in repeatedly traumatizing ways and who then acted out by traumatizing others, using this motivational interviewing protocol dramatically changed the tenor of our sessions and created a more collaborative environment.

Mindfulness, on the other hand, which is a clinical approach I often use with clients, was not something Steve could tolerate yet. I learned that many people with complex and chronic trauma find somatic mindfulness, which puts them in intimate touch with their bodies, to be overwhelming. Steve had difficulty connecting with mindfulness exercises and said he preferred to talk instead.

Using art to build connection

I was aware that society’s implicit assumptions around people who commit sexual crimes were influencing me negatively even before meeting Steve, so I knew I had to be mindful of my own biases or prejudices. To avoid any personal biases, I approached our sessions with curiosity and empathy.

As I got to know Steve, it was easy to feel warmth for him. He was affable and gallant in an old-fashioned way, and he longed for connection. Some of his affability did seem manipulative at times, yet I was moved by his vulnerability. He hungered for attachment. He was a fundamentally social person who enjoyed interacting with many kinds of people, so he found his inability to interact easily with others because of his strict parole conditions to be especially difficult.

His traumatic history often led him to objectify and sexualize people he was attracted to. He regularly mentioned young men he had seen on the bus or at the store that he found sexually attractive. During one session, Steve was telling me about his attraction to a young man who was a cashier at the supermarket he frequented. I listened, at first inwardly groaning at the repetitive, seemingly reflexive nature of his attractions; he didn’t really differentiate between one object of lust and another. In an attempt to understand and distinguish this particular attraction from the others he had mentioned, I decided to try to help him become more aware of and specific about his sexualization of these men, so I asked, “What do you find attractive about this man?” Steve became poetic as he described the cashier’s physical beauty — his face, hair, hands, posture and smile. I could picture this cashier vividly, and I could feel vicariously how this young man affected Steve.

Struck by this, I blurted out, “You’re a lover of beauty!” Steve looked startled. I explained, “You’re moved by beauty. That’s a value.” As a professional ballet dancer, I am also moved by beauty and understand viscerally how someone can be aesthetically driven.

That exchange sparked an idea of a way to help him feed his longing and loneliness. If he could not find connection with the humans that were off limits to him due to stringent parole, maybe he could find it in other kinds of beauty such as art, films and photography.

I began to share movie recommendations with him. I first recommended Wim Wenders’ documentary Pina (a film about the German dance choreographer Pina Bausch) because of the way this film handles topics such as attraction, desire, power and violence. I knew Steve may be titillated by the dancers’ beautiful bodies, but I hoped it also spurred a deeper dialogue on difficult interpersonal dynamics. I also hoped he might feel nourished by the sheer splendor of the film.

After the first time he watched the film, his comments were superficial yet enthusiastic. But his observations became more nuanced with each viewing. The film inspired him and awakened in him a love of performance, especially musical theater, and he started finding musicals and other theatrical performances to watch on his own. I found myself wondering if he might have had a career in the arts if his life had worked out differently. It also amazed me that my previous career as a professional ballet dancer enabled us to share a connection, and I began to think about how to spark a desire in him for self-cultivation and expression.

We looked at photographs of muscular, kinetic statues such as Gian Lorenzo Bernini’s Apollo and Daphne because I wanted him to see that sensuality and beauty can be found and fed in ways besides sex. I justified this clinically with the idea that sublimation is an effective, mature defense mechanism where his unacceptable impulses could be transformed into socially allowable behavior.

With my supervisor’s permission, I asked Steve to watch the classic Luchino Visconti film Death in Venice and used his identification with both characters — the older Gustav von Aschenbach as well as the young boy Tadzio to whom von Aschenbach was drawn — to explore his difficult history. Steve had been objectified like the young boy Tadzio. Steve often talked about how attractive he was in his youth and how older men had preyed on him. But now he identified more with von Aschenbach, the older, dying character who becomes longingly obsessed with Tadzio. The film allowed him to externalize his narrative and see himself portrayed in these characters. The poignancy of the film, which takes place during a cholera plague in Venice, also did not escape Steve. In his strict parole during the COVID-19 pandemic, he was as isolated as von Aschenbach was by the social restrictions of the early 1900s European society during the cholera epidemic.

Identifying with the beautiful youth and the dying man awakened an existential awareness in him that I believe helped him take responsibility for his actions. Sharing my passion for art and performance helped me connect with Steve, which then helped him see that beauty, sensuality and connection can be found in the arts. In this way, I believe he felt less alone.

People who commit sexual offenses in the United States, those labeled “registered sex offenders,” become pariahs. They cannot easily find work or places to live. On parole, they are subject to random lie detector and drug tests for which they must pay. Their crimes end up defining them for the rest of their lives. Imagine the worst thing you’ve ever done. Now imagine that is all anyone ever sees you as for the rest of your life. This negative stigma that follows people who commit sexual offenses can make it more challenging for them to change or for others to notice if they do change. By engaging Steve’s aesthetic side through the arts, I offered Steve a different way to experience himself — one that contrasted with the negative stigmas he often faced.

Doing no harm

My desire to help Steve also led to one crucial mistake. After the holidays and a health crisis, Steve became deeply depressed. I became concerned for his mental and physical health. His parole officer had forbidden his attendance at 12-step meetings and prevented any possibility of him joining a support group for LGBTQ+ individuals at a local center by divulging his entire history to the director, who decided they did not want to have him anywhere near the center.

Although Steve was no longer in prison, his current living situation resembled it: He lived in a one-room apartment, which was the size of a prison cell, and he had no contact with people other than his various doctors, mental health team and pastor. This isolation was a factor in his depression, so I met with his parole officer, the other mental health counselor and the psychiatric nurse practitioner to discuss ways to address this issue. I hoped to advocate for more lenience in allowing him outlets and contact in the community. I wanted his parole officer to understand that Steve’s depression and loneliness could lead to his reoffending because prison offered a built-in community and opportunities for sex.

The result of this meeting, however, was that the parole officer felt she was being attacked and became defensive. And Steve paid the price. She cracked down on him and told him in no uncertain terms that she believed he had manipulated me. I chastised myself for being so naive as to mistake my agenda as a mental health clinician advocating on behalf of my client for the parole officer’s agenda. Her job was to safeguard citizens from someone who was perceived as a dangerous criminal. Steve’s feelings were irrelevant to her. In retrospect, I see now that this situation was a parallel process where I experienced the parole officer’s stringency alongside my client. In my zeal for and identification with Steve’s plight, I did not think to put myself in the parole officer’s shoes and see how she might feel when confronted with three mental health practitioners petitioning for leniency.

I apologized to Steve saying, “I thought I was helping but instead I made things worse for you. I am so sorry! I was naive. Let’s try to repair this situation.” Acknowledging my mistake was crucial for the repair, and from Steve’s perspective, it vindicated his own experience by having me come up against the restrictions he faced. By the end of my internship, we had recovered from my mistake and our alliance was stronger because of it. Saying goodbye was emotional for both of us. We had forged a relationship in which, I believe, Steve felt seen in a way he never had been, and I was moved that he allowed me into his confidence to the extent that he did.

It’s important to note that Steve successfully navigated another nine months of parole without reoffending. He recently wrote to me and said, “Our trust didn’t begin because you left your purse at Starbucks — it happened because I connected with you and your willingness to step out from behind a desk and meet me where I was comfortable.”

Lessons learned

At the end of my time working with Steve, I asked him what he gotten out of therapy with me, besides having someone to vent to and meet with once a week. He said he had learned to trust more because of our relationship. In particular, he mentioned our first meeting at Starbucks as being pivotal in building this trust because I took the time to meet him in person and help him with his technology. He also said he felt I cared for and understood him, and that made him feel like a human being.

This experience working with Steve taught me a few lessons as well. I learned how being curious and willing to take risks are essential components of this profession. If I had allowed Steve’s status as a “sex offender” to prejudice me, I would not have been able to engage with him with as much spontaneity and enthusiasm as I did.

I learned that motivational interviewing and asking for permission before using a clinical intervention helps empower the client. Steve appreciated every opportunity to feel that therapy was his choice rather than an imposition, and this empowerment helped disarm his defenses and enabled his trust to grow.

I learned the critical importance of consultation. I not only received essential guidance and support but also gained confidence through clinical consultation. It took a village. I would like to thank my colleagues Sarah Williams, Casey VanHoutan, Krista Fuqua, Marisa Monahan, Marie Mellberg and the other colleagues who provided advice, consultation and guidance while I worked with this client.

I learned the importance of doing no harm and how easy it is to lose my perspective in countertransference. Even the best of intentions can hurt in situations with conflicting agendas.

Finally, I learned how leaning into the therapeutic alliance is both challenging and rewarding. It enabled me to care deeply about someone whom our society judges and condemns. Ultimately, recognizing that Steve has a love of beauty was the linchpin that evoked his humanity, strengthened our connection and was profoundly moving for both of us. At our last session together, Steve wept because we would not be able to continue working together; I think he felt truly seen by me. I was also moved to tears by his willingness to come on the journey with me, a new counselor. He trusted me in spite of my inexperience and offered me the opportunity to deepen my own humanity.

Lavinia Magliocco is a clinical rehabilitation counselor and licensed professional counselor associate at Three Firs Counseling LLC. The practice specializes in working with chronic illness/disability and complex trauma. Prior to becoming a counselor, she was a professional ballet dancer in New York City, a professional writer and therapeutic Pilates teacher at her studio Equipoise — Enlightened Exercise LLC. Contact her at

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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 impact of cultural resiliency on traumatic loss

By Jessica Meléndez Tyler and Nancy Thacker Darrow January 12, 2023

A profile shot of a woman looking out a window.

Alexandra begins her scheduled counseling session with the news that her sister suddenly passed away the day before. The counselor is caught off guard and begins to provide supportive therapy. The counselor learns that while Alexandra’s sister had been sick for some months, her sudden health turn was unexpected and rapid. Alexandra was at the hospital when her sister died and was charged with taking the lead on making funeral arrangements.

Alexandra appears numb and detached in session. The counselor attributes this to the initial shock of the loss and provides warmth and comfort to Alexandra. In the following sessions, the counselor notices that although Alexandra appears to be functioning well following what she endorses as a traumatic loss, she demonstrates a flat affect in sessions, states she has accepted the loss and resumes work immediately although she reports feeling little connection to her current life.

The counselor is concerned that Alexandra is avoiding her grief experience, which may lead to the development of pathological symptoms. However, Alexandra reports that she is functioning just as she was before her sister’s death, only with a lost sense of purpose or spirit. She redirects therapy topics to present stress management and adjustment issues in a new career. After exploration from the counselor, Alexandra acknowledges that without her sister, she finds little point in continuing to pursue her goals as every plan was something she would share with her sister.

Cultural factors

As counselors, working with traumatic loss can be a difficult subject matter. Unfortunately, Eurocentric American society has generally promoted the avoidance of grief in subtle ways, which causes many people to be uncomfortable around people in pain. In addition, we often inadvertently provide the subtle message “it is time to move on” after a loss.

In Loss, Trauma, and Resilience: Therapeutic Work With Ambiguous Loss, Pauline Boss argued that traumatic grief — a grief “so great and unexpected that it cannot be defended against, coped with, or managed” — is significant, complex, and a diverse public and social health concern. The COVID-19 pandemic, along with a rise in social justice issues and a charged election in 2020, created difficult trials and mass grief that continues today. People experienced numerous losses at individual and community levels: loss of personal health, job security, identity, human rights security, mobility, physical safety and loved ones. Typical responses to traumatic loss may be fear, helplessness, illness, instability and even violence. As counselors, we help clients make sense of loss, redefine their lives and find meaning again. But understanding the multitude of factors needed to grieve traumatic loss is an advanced clinical skill, particularly with clients from minoritized backgrounds who have been systematically silenced.

As noted in Robert Neimeyer and colleagues’ Grief and Bereavement in Contemporary Society: Bridging Research and Practice and Darcy Harris and Tashel Bordere’s Handbook of Social Justice in Loss and Grief: Exploring Diversity, Equity, and Inclusion, cultural traditions often affect the way people respond to grief, whether that involves wearing a particular color or garment, crying or praying. Thus, understanding how trauma impacts mental health requires a broader view of identity, community, adaptation and resistance as forms of resilience. Cultural awareness, responsiveness and understanding are essential to increasing access and improving the standard of care for traumatized individuals. However, there are misconceptions about resilience encompassing an individual’s level of grit and fortitude when facing adversity. In reality, particular groups may risk developing traumatic grief because of repeated exposure to pain and suffering (e.g., the Black community, immigrants, members of the LGBTQ+ population). Also, these marginalized populations may not receive adequate treatment or community support for the causes of their grief and trauma because they may only be treated under the medical model, if they are treated at all. Taking a social justice approach, we as counselors can increase individuals’ feelings of meaning, connectedness and support following a traumatic loss. And by exploring the role and impact of cultural resiliency in navigating traumatic loss, we can consider how cultural strength can be utilized in treatment to decrease the vulnerability of disadvantaged communities.

When working with clients going through a traumatic loss, what are the perceptions we hold about the healing process? About resiliency? About treating historically harmed and excluded populations? When people and communities are overwhelmed and unsafe, they experience the world as dangerous. The rest of the world may not know about what our clients have been through, or they may have no appreciation for it. When this happens, traumatized people and communities may feel completely alone, forgotten or ignored. With traumatic loss, focusing on cultural sources for resiliency is paramount to supporting marginalized populations. This construct provides a focused way for counselors to engage with individual stories of suffering, locate causes, charge responsibility, validate the person’s struggle and activate more effective responses.

A cultural resilience approach

Utilizing resiliency soon after a traumatic event can prevent severe mental health concerns. As documented by the literature, resilience has been associated with several positive physical and mental health outcomes. However, as counselors, we must be mindful that most measures of resilience are still skewed toward Western, individualistic practices. Culture can buffer its members from the impact of trauma because it can create meaning systems and provide healing rituals where one can express their pain while remaining connected to a group. A cultural resilience approach to treating clients experiencing traumatic grief can offer a wide range of culturally responsive techniques to decrease client helplessness, hopelessness, self-blame, guilt, shame and worthlessness, especially for those with a poor clinical prognosis. In addition, a social justice approach to integrating cultural resiliency in therapy can be used to evaluate clients’ beliefs about loss, belonging, defeat, marginalization, honor and self-preservation.

Through cultural resiliency, our clients can have a pathway to express their pain in connection to their belonging group. We, as counselors, can increase our clients’ feelings of meaning, connectedness and support following a traumatic loss. We can consider how cultural strength can be utilized in treatment to decrease the vulnerability and oppression of disadvantaged and harmed communities. A social-ecological approach can incorporate cultural variables to activate resilience and acknowledge cultural components of the trauma and a client’s response.

When working with Alexandra, the case example mentioned previously, the counselor could conceptualize Alexandra’s loss from a multicultural and social justice lens, instead of focusing just on stress management. Alexandra is a Black, single, cisgender woman in her 20s who identifies as a Christian. She is in a professional role following her graduate program, and she says that she is close to her two parents and feels supported by them.

First, the counselor considers how Alexandra’s identified cultural and ethnic groups have historically demonstrated resilience. Next, the clinician asks, “How might I effectively integrate a cultural resiliency approach to my work with Alexandra?” The counselor then respectfully asks Alexandra, “What does the healing process look like within your culture as a Black person, a woman and a Christian?”

Alexandra sits and considers the counselor’s question for a minute. She then answers, “That is difficult to answer. As a Black woman, I recognize the expectation to be a strong Black woman. Emotions are a vulnerability that literally makes us less safe so we must push through no matter what. We prevail. As a woman, I also expect to take care of others before myself so my own healing will come with time, but the important thing is that my people are taken care of. As a Christian, healing looks like having faith in God and knowing that this is all a part of God’s master plan. However, I have been angry at God since my sister’s death, so I do not want to discuss faith and his master plan.”

Without identifying a client’s cultural or ethnic affiliation that guides navigating life’s circumstances, counselors may empathize personally with the client but miss the sociopolitical framework that influences the client’s traumatic loss experience. In a 2003 article published in Violence Against Women, Bonnie Burstow discussed how counseling requires both personal and political empathy to understand a client’s social location and how oppression has impacted their well-being. Society and systems are critical in clients’ trauma experiences, and a person’s group identity or identities and the historical trauma with which they are associated often underly their personal trauma history. Trauma occurs in layers, with each layer affecting every other layer.

The counselor considers Alexandra’s reply, and then says, “I hear multiple cultural influences shaping your understanding of healing. I wonder how these cultural components of healing inform your process of grieving the loss of your sister?” Alexandra sits for a moment in silence, with a thoughtful look on her face. “I feel conflicted,” Alexandra says. “I am prevailing, keeping on with my job, taking care of surviving family, and organizing my sister’s things. But I am confused and angry; everything feels unjust. How am I supposed to grieve something that should not have happened?”

The counselor validates Alexandra’s experience of injustice and her conflicted feelings. Alexandra’s question also opens the door for deeper conversations about how her cultural groups have responded to injustice and formed cultural resiliency strategies. But how can the counselor engage in the meaning-making process (the one taught in counseling programs and supervision) with Alexandra through a cultural lens?

Cultural healing and meaning making

For counselors working with clients navigating traumatic grief and loss, exploring historical and cultural healing can deepen the conversation around bereavement and mourning and aligns with our counselor identity of being strengths-based. Some of our clients come from ethnic and cultural groups that have overcome the most traumatic of trials. An intentional counselor can draw upon generations of resilience and attitudes of overcoming impossible odds despite injustices. When counselors focus only on an individual’s lived experiences without considering historical and cultural context, then beliefs about weakness, powerlessness, helplessness and worthlessness may abound because we think that we are entirely responsible for the quality of our life or lack thereof. However, when counselors explore a client’s identity and lived experience in relation to their identified groups, belief systems about belonging, strength and persistence in adversity come to the surface. In this latter scenario, healing can include considerations about how a client’s traumatic loss experience is part of a more significant social injustice that requires institutional and community remedy.

Healing involves a process of forming vulnerable narration about concepts that have been suppressed or silenced. In other words, it is important to narrate the concepts that have only been quietly discussed in the safety of within-group communities or within internal processing and self-talk. Such healing involves a therapeutic relationship of empathic witnessing and a commitment to deepening one’s understanding of the origins of the client’s pain and suffering that has often been pervasive through time and circumstance.

Returning to the example of Alexandra. If the counselor chooses to remain focused only on client functioning and symptom monitoring, they lose an opportunity to deepen the processing and healing of Alexandra’s pain that surrounds her traumatic loss. Prompting deeper reflection on the origins of Alexandra’s pain within her identities (i.e., a sister who was helpless to protect her sister from death, a Black woman who feels that she must make sure everyone else is OK before she allows herself space to grieve, and a religious woman who believes that her higher power wholly abandoned and betrayed her devoted family through this loss) can elicit more meaningful transformations in therapy. Instead of oversimplifying and focusing sessions on the pain of losing a sibling, the counselor can use deliberate Socratic questioning to probe into deeper associations of powerlessness and injustice. This exploration can help Alexandra gain the power to name her generational, historical and personal losses; feel equipped to protect herself through generational resilience; and combat alienation in her traumatic loss through cultural and ethnic identification and belonging.

Counselors can aid in this process by asking clients to tell their story of grief, not only for the immediate loss but throughout their life and previous generations. What has their identified group endured, and how pervasive are those histories in their lived experience? What and who contributes to our client’s grief story? How did they learn their expectations of what it means to suffer? By asking these questions, counselors can help grieving clients label their experiences and examine their beliefs about how their cultures factor into their feelings of traumatic loss.

The counselor decides to guide Alexandra to explore her anger with God gently. The counselor acknowledges that spirituality can be tricky to unpack because it may be perceived as unfaithful or sacrilegious to express doubts about one’s spiritual beliefs outwardly. Alexandra pauses and considers the counselor’s invitation to verbalize how her anger toward God feels. She is hesitant as she begins discussing an almost superstitious belief that if she and her family were faithful and devoted to their religious practices, they would be granted blessings and saved from the suffering others outside her religious faith might experience. She looks down, sheepish in her admission that she genuinely believes that good things happen to good people, and yet her good sister died regardless. Here, the counselor can help Alexandra not only examine her beliefs about being a strong woman of faith but also assess the intersectionality of her being a “good” woman and how that impacted her grief experience. Being a good woman means that Alexandra is outwardly stoic and strong and demonstrates resilience through continuing her responsibilities (e.g., checking in and cooking for her loved ones, managing her sister’s funeral arrangements) and by not becoming emotional around others or needing to be consoled by others.

Over several sessions, the counselor and Alexandra explore reclaiming her personal and community space. They acknowledge the outcomes of Alexandra’s labor to be resilient despite her suffering and implement rituals and ceremonies that express her grief and outrage in a way that is true to her identity as an angry woman, a betrayed woman and a woman who mourns for the generations of Black women who could not express their suffering openly and be met with warmth. The counselor then offers the client warmth and acknowledges the vulnerability it took for Alexandra to name these experiences in therapy and accept support as she not only reconnected with her historical strength and resilience as a Black woman but also rebuilt ties and traditions to being a religious woman who also historically overcame adversity.

The counselor also guides Alexandra to reconnect with nature in her grief processing, as nature has repeatedly demonstrated its resilience through catastrophic impacts. Through this, Alexandra can draw symbolic strengths and models of what resilience looks like. Her grief response changes over time; she no longer feels she must earn her right to be comforted or take up space in processing the traumatic loss. Instead, she resonates with the notion that, like in nature, she can just be and bend and transform as the circumstances require, while remaining rooted in the generations of strength and resiliency that shape her.

Through counseling, Alexandra realized that her grief of suddenly losing her sister would be ongoing and without end. However, she discovered parts of her cultural resiliency that would be beneficial to help her process this grief; using culturally resilient strategies to cope with the loss of her sister allowed Alexandra eventually to readily embrace the injustice and make meaning of the loss experience. Her bond with her sister will always remain, and her meaning-making journey will include how she continues to name and recognize how her sister shows up in her life and informs her cultural resiliency.

Often, to avoid superficial platitudes (e.g., “things happen for a reason”), individuals find themselves at a loss for words to support others going through traumatic loss. Exploring the role and impact of cultural resiliency to help clients grieve traumatic loss can metamorphize their process of bereavement and decrease counselor helplessness in the therapy room. When a horrific event occurs, we, as counselors, do not have words that will heal, and there is no cognitive reframe possible that can make a client’s suffering cease. Nevertheless, we can help clients explore their own histories of resilience and triumph in pain and adversity beyond their lived experience. This empowers a client to continue to fight to survive the unsurvivable and increases their connection and belonging with others in their identified groups and with us as the counselor.


Through a cultural resilience framework, counselors can guide clients through traumatic loss in a way that connects them to the dignity inherent to how their ancestors navigated and overcame suffering. An individual’s cultural groups may also hold generational pain because of oppression and abuse inflicted on the culture. Therefore, it is strongly recommended that counselors explore cultural identities with their clients and highlight helpful aspects of their identified groups that can activate resilience while leaving behind the aspects of the group the client finds unhelpful. The counselor can normalize that culture does not have to be all or nothing, and each person can write the story of how their identified groups activate and empower their group resilience.

Drawing on community connection, resources and rituals that encompass a sense of support and belonging can aid counselors and protect our clients from traumatic grief, which can lead to significant mental health concerns such as mood disorders or posttraumatic stress disorder. Learn about and emphasize the culture-based holistic strategies that clients bring into therapy. This serves to decolonize our counseling practices and enhance our current methods, while also amplifying the voices of generations who have survived and created meaning systems that can contribute to our healing through traumatic loss.

Jessica Meléndez Tyler is an associate professor of practice at Vanderbilt University and a private practitioner. She is a licensed professional counselor, a licensed counseling supervisor, a board-certified telemental health provider and a national board-certified counselor. Her professional interests include working with suicidal clients and crisis counseling, women’s issues, trauma-informed care, cultural resiliency, collegiality, and the intersection of these topics for counselor education. Contact her at

Nancy Thacker Darrow is an assistant professor of counseling at the University of Vermont. She specializes in grief counseling and LGBTQ+ mental health and development. Through research and practice, she aims to dismantle systemic barriers that influence these specialty areas and counselor education broadly. Contact her at or through her website at

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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

Helping youth who self-harm

By Bethany Bray January 10, 2023

A teenager wearing a mask sits on stairs with her chin and hands resting on her knees. The teenager is looking straight head into the camera. A bookbag sits beside the teenager.

Ground Picture/

Self-harm behaviors in American youth rose sharply during the peak of the COVID-19 pandemic and continue to be a concern among counselors who work with children and adolescents.

In early 2021, FAIR Health completed an in-depth analysis of insurance claim records to compare changes between 2019 and 2020. The New York City-based nonprofit found the mental health claims for individuals between the ages of 13 and 18 doubled between March and April 2019 and the same months one year later.

That same age group saw a startling increase — nearly 100% — in the number of insurance claims for medical care received for intentional self-harm between April 2019 to April 2020. And the Northeastern United States (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont) saw the highest spike in claims for treatment of injuries in teenagers from intentional self-harm — a 333.93% increase — between August 2019 and August 2020.

This data tracks with what many counselors are seeing in their own caseloads: An increase in young clients who turn to self-harm to cope with the stress and upheaval that came — and continues to come — with the COVID-19 pandemic.

There is a strong correlation between social isolation and self-harm, notes Deanna Dopplick, a licensed professional counselor (LPC) at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury (NSSI) in St. Louis. As hard as it was for children and adolescents to have decreased connection with peers while schools were closed during the peak of the pandemic, it’s been equally challenging for them to return and reintegrate to the social dynamics of in-person school, she says.

Dopplick, an American Counseling Association member, is among the many practitioners who are seeing an uptick in client referrals for self-harm among children and adolescents. Her organization has “struggled to keep up” with the need for services, she says, and unfortunately, many prospective clients sometimes end up on a waiting list. In addition to new clients, Dopplick says she’s also seen an increase in relapses among clients who have returned to self-harm behaviors to cope after making progress in therapy previously.

As more counselors see youth who self-harm on their caseloads, Dopplick urges practitioners to focus on empathizing with these clients and fostering a trusting therapeutic relationship. The worst thing a practitioner can do, she says, is to panic or act fearful when a client discloses the behavior or dismiss it as attention-seeking.

“I have seen clients that have been in therapy for months or even years [before coming to SAFE], and the behavior has been so protected and shameful that they haven’t disclosed it. There is a stigma that self-injury is weird or different or ‘crazy.’ It’s not something that’s easy to open up about,” says Dopplick, who provides individual and group counseling for clients 12 and older. “We [counselors] need to make sure we’re meeting the client where they’re at, humanizing them and validating their experience. … It [self-harm] is so much more common than people think, and it doesn’t make [the client] scary or different. Empathy goes a long, long way with these clients.”

A way to cope

Michael Visconti is a licensed mental health counselor who treats children and adolescents in private practice in Boston. He estimates that one-quarter of his caseload at any time is exhibiting self-harm behaviors — a proportion that rose to roughly 50% during the peak of the pandemic. Many of these clients are referrals for self-harm from a local pediatric medical office.

The youngest client Visconti has counseled for self-harm behavior (in the form of intentional head banging) was six years old, but he finds it’s most common in younger teenagers, ages 12 to 15, he says.

Like Dopplick, Visconti emphasizes that there is a “direct correlation” between social isolation, feelings of hopelessness and self-harm behaviors in youth. “The more isolated an individual is, the less they feel they can reach out to others and express that emotion, so they turn inward,” Visconti explains. “Most often, it’s a maladaptive form of coping.”

While the intense isolation that occurred during the peak of the pandemic has lessened, all the same stressors that youth experienced before the pandemic (such as abuse, neglect or trauma at home, negative body image, social pressures and negative messaging on social media) remain, he notes.

In Visconti’s experience, the reasons that drive youth to self-harm often fall into a few common categories:

  • Managing emotions: When feelings are strong and uncomfortable, adolescents and young clients sometimes find it easier to experience physical pain rather than emotional distress. Self-harm offers an immediate and effective means of emotion regulation in the short term. Visconti says that in his experience, this is the most common pathway to self-harm.
  • Communicating: Some individuals make use of self-harm to outwardly display their emotional pain because they don’t have the means or opportunity to put it into words. This can be especially common among youth who live in invalidating family and home environments, Visconti says.
  • Punishment: Young clients sometimes turn to self-harm to punish themselves and “confirm” and internalize the negative narrative they have about themselves, Visconti says. These clients often believe that they are the problem and reason for their unhappiness, and self-harm is a way to reinforce these feelings. This is common among youth with poor self-esteem and/or a trauma history, he adds. Dopplick also finds that young clients who self-harm often struggle with intrusive thoughts that are intensely negative, such as “I am bad,” “There is something wrong with me” or “I am a disappointment,” so she spends a lot of time focusing on redirecting self-talk with clients at her program.
  • Seeking control: Some young clients turn to self-injury as a means to exert control in their life, albeit in a painful way. It can be a maladaptive way to find autonomy, Visconti explains. This was the especially the case when many youths felt that the “fundamentals of their life had been stripped” away during the pandemic, such as the routine of the school day, social activities, extracurricular activities and other things they enjoyed.

Asking the right questions

The crux of what defines NSSI is the intent behind the behavior, Visconti explains. Self-harm can be an impulsive phenomenon as well as something that is very deliberate, planned and well thought out. Visconti says that it’s not uncommon for him to see young clients who have created a self-harm “kit” for themselves, complete with harming tools as well as items to disinfect and treat wounds afterward.

When assessing for self-harm, counselors should not hesitate to ask clients directly about whether an injury was deliberate to determine intent, Visconti says. He often uses questions such as “Was that [injury] purposeful?” or “Did you place yourself in that setting with the hope that it harmed you?”

That second question can help uncover behaviors that are beyond the common ones that counselors may think of, such as cutting or burning. For example, Visconti once had a young client who slept on a mattress that had a metal spring poking out of it, and he purposely didn’t tell the adults in his life about it because he hoped that it would cut and injure him while he was in bed.

Asking questions about intent can also help uncover behaviors that a client has kept hidden or that escape the notice of peers or adults in a client’s life.

Dopplick has also seen self-injury behaviors that are outside of what a counselor may expect. This includes keeping a (non-self-inflicted) wound from healing, hitting or biting oneself, inserting objects under the skin, ingesting things that the client knows are toxic or dangerous (such as glass or household cleaners), head banging, hair pulling, picking of skin or nails and other behaviors.

In sessions, asking clients questions to determine the frequency and severity of self-harm impulses and actions is vital to understand the context of their behavior and level of risk, Dopplick says. For example, a client who has self-injured twice by a single method (i.e., rubbing themselves with an eraser to the point of burning) will need a different response than an individual who has injured themselves 100 times or uses multiple methods (e.g., cutting with a razor blade, punching walls).

Understanding the full context of a client’s NSSI can help a counselor identify the reasons why they engage in the behavior and, ultimately, personalize and tailor treatment to meet their needs. Dopplick encourages counselors to ask clients a range of questions, including:

  • Have they ever received medical attention for NSSI or needed attention but didn’t seek it?
  • What tools are they using to injure themselves? Do they have access to these tools?
  • How often are they engaging in self-injury?
  • Are their harming behaviors usually impulsive or preplanned?
  • Does anyone else, such as a parent or a friend, know that they’re self-injuring?

“Having the impulse to injure is different than following through with action,” Dopplick adds. “They may have impulses every day but may only injure once per week. It’s something to ask about: How are they managing their impulses?”

She recommends counselors ask clients to keep a log to track situations when they felt the urge to self-harm or engaged in self-harm, which she says can be helpful in therapy because it can shed light — both for the client and the clinician — on patterns. Dopplick encourages clients to record what they were doing and feeling before, during and after an urge to self-injure to help identify triggers.

Although NSSI is distinct from suicidality, the counselors interviewed for this article note that it’s important to assess clients who self-harm for suicidal intent because the two issues can sometimes overlap.

Visconti uses the Columbia-Suicide Severity Rating Scale and recommends it as a helpful way to screen both for suicidality and self-injury and parse out the intent and severity of a client’s behavior. The tool’s questions can help determine how chronic a client’s behavior and feelings are, he explains, and it can be easily used with many different client populations and treatment settings.

Discussing self-injury with a young client can be uncomfortable or worry-inducing for a clinician, Dopplick and Visconti admit. However, it’s vitally important for counselors to complete a thorough assessment to determine a client’s level of risk without becoming panicked and jumping to crisis response, such as talking about hospitalization.

“If you [the counselor] seem scared or overwhelmed or go straight into crisis mode, you won’t get all the information you need from the client,” Dopplick stresses. And “that will make them very hesitant to disclose self-injury again.”

She encourages counselors to keep an open mind when asking clients about their self-harm behaviors. Making assumptions about the factors that contribute or the reasons why they are engaging in NSSI “is the best way to shut down the conversation,” Dopplick adds.

Instead, “see the client as the expert on themselves and their behavior. Do not criticize, minimize [the behavior], come off in a punitive way or assume they’re doing it for attention or because their friends are doing it,” she stresses. “Really put the client in the driver’s seat instead of coming at them with assumptions.”

Finding healthy ways to cope

At its core, NSSI indicates that a client has unmet needs, Dopplick says. A counselor’s role then is to help the client identify and understand those needs and find ways to meet them without turning to self-harm.

“No one self-injures for no reason; there’s always an underlying reason, a function,” she notes. “For most clients, it [self-harm] is something that they’re hiding, something just for them, something that ‘helps’ them.”

Dopplick says that the counseling groups she leads for self-injury spend the majority of the time talking about the context and circumstances surrounding their self-harm, rather than the actual behavior. For young clients, this often includes the pressures their parents put on them or stress related to school or social relationships.

“We talk about the why and how more than the what,” Dopplick says. “The self-injury is not the actual problem; it’s what’s underneath it. All the underlying stuff — the why — is the problem, and [counselors] can miss the boat if [they] don’t explore it.”

Paige Santmyer, an LPC who works with teens and adults at a Christian counseling practice in the Atlanta area, agrees that helping clients identify what triggers their urge to self-harm is an important first step, followed by creating a plan to replace the behavior with healthier options. It also helps to identify the perceived “reward” they seek in self-harm, she says, to tailor a client’s treatment plan and coping mechanisms.

For example, if a young client struggles with feeling numb and turns to cutting themselves to feel something, Santmyer says she would teach the client mindfulness and guided imagery techniques that can help them connect to how they’re feeling. Or, depending on the client, they might respond to something creative such as using virtual reality to “go” hiking or zip lining to redirect and energize themselves, she suggests.

Young clients will need activities and techniques at the ready to replace the urge to self-harm; planning ahead is key. Santmyer brainstorms with clients to identify ways they can seek connection and soothe themselves when needed, such as doodling or drawing or talking to an accountability partner.

She also finds it helpful to have young clients create a “distraction box” filled with special or favorite items that can help to self-soothe and take their minds off the urge to self-harm. These items can include art, knitting or crochet supplies, essential oils, a favorite lotion, coloring or puzzle books, pictures of loved ones, an object with beads for counting or a kaleidoscope to look through. (For more on creating self-soothing kits with clients, read the Counseling Today online exclusive “Regulating the autonomic nervous system via sensory stimulation.”)

Similarly, Visconti says he focuses on helping young clients who self-harm find ways to redirect themselves away from the urge to injure. He gives clients a worksheet with 100+ ideas from Matthew McKay, Jeffrey Wood and Jeffery Brantley’s The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance to spark ideas and keep for future reference. Depending on the client’s age and needs, activities could include playing video games, visiting a friend, eating their favorite flavor of ice cream, writing a song, using an app to learn a new language, getting a haircut or painting their nails.

Managing distressing emotions

The counselors interviewed for this article agree that while clinicians need to tailor their work to fit their clients’ individual needs, many young clients who self-harm will need some combination of treatment that challenges negative self-talk and strengthens distress tolerance and emotion recognition and regulation.

Santmyer says that it’s common for young clients who struggle with NSSI to be disconnected from and confused about their emotions.

She focuses on emotion recognition with clients by asking them to think about where they feel strong emotions in their body and prompting them to talk about what it feels like and how they usually respond to those sensations. She also finds cognitive behavior therapy (CBT) helpful to guide clients to explore, challenge and reframe the fears and negative core beliefs that drive feelings such as worthlessness or perfectionism that trigger an urge to self-injure.

“Helping them understand and name the emotion they are feeling helps clients feel more in control of themselves instead of feeling compelled to manage the sensation itself through self-injury. Counselors can also use CBT to build insight into how emotions are giving them messages, how they can interpret them in positive or negative ways, and how those interpretations lead them toward or away from self-injury,” explains Santmyer, an ACA member. “Ultimately, clients will need to understand how they are perpetuating their self-injury cycles and practice changing their negative thoughts to change their self-harming choices into more thoughtful and healthy responses.”

Santmyer and Visconti also noted that dialectical behavior therapy (DBT) can be especially helpful to use with young clients who self-harm because of its focus on emotion regulation and distress tolerance. (Santmyer and Visconti are not certified in DBT but have studied it and draw from the method in their work with clients.)

DBT is a good fit for this client population because it’s practical and effective in a short amount of time and it teaches much-needed skills and coping mechanisms to manage stress and tolerate uncomfortable feelings, Visconti notes. In fact, he says he’s seen DBT techniques spark growth and healing in self-harm clients right away because of the skill-building component.

However, DBT is most helpful for clients who self-harm as an emotional outlet, rather than those who use the behaviors to communicate or exhibit their emotional pain, he adds.

Santmyer finds that the ACCEPTS skill from DBT is particularly helpful to strengthen clients’ ability to overcome distressing emotions and situations without turning to self-harm. This tool guides clients to think about or engage in:

  • Activities: Do something that requires thought and focus, such as writing in a journal, to shift their attention away from distressing emotions.
  • Contributing: Do something that involves focusing on other people (e.g., sending a card, asking a loved one about their day, doing volunteer work).
  • Comparisons: Put their situation in perspective by comparing it to something more painful or challenging, including thinking of a time when they were in greater distress and got through it.
  • Emotions: Find a way to disrupt the emotion they are feeling (e.g., angry, sad) and replace it with a different or opposite emotion (e.g., going for a walk to calm oneself, watching a happy movie).
  • Pushing away: Use a technique such as guided imagery to block painful feelings from their mind and delay the urge to self-harm.
  • Thoughts: Use a strategy to shift one’s thoughts to something neutral (e.g., counting backwards, reciting song lyrics, naming objects around them that start with a certain letter of the alphabet).
  • Sensations: Engage in activities that trigger safe sensations that distract them from distressing emotions (e.g., eating something spicy, feeling the water on their body during a shower).

Trust and validation

Getting to know the client and tailoring treatment to their individual needs must take priority when counseling youth who struggle with NSSI, Dopplick says. She suggests that practitioners first find ways to connect with clients — particularly those who have been referred to counseling specifically for NSSI — and talk about topics other than self-injury to forge a trusting relationship.

Believing the client and validating their experience and pain should be the counselor’s No. 1 priority, she stresses. Only then can a counselor begin to identify and delve into the reasons underneath their self-injury.

“Often [these clients] feel that no one understands or validates their pain, and they are compelled to continue self-harming as a way to express in their body what they feel they cannot express verbally,” Santmyer says. “The validation and compassion of the therapist will bring the safety that young clients need to explore the drivers of self-harm.”

Dopplick finds that she’s sometimes the first adult to tell a young client that she understands why they are distressed to the point of needing to self-harm or to emphasize that they’re not weird or “crazy” for engaging in NSSI. After validating the client’s experience, she explains that she can help them find other ways to cope.

It’s vital for counselors to keep an open mind and accepting demeanor with these clients, Dopplick stresses. “There’s a huge difference between expressing your concern in a caring way, rather than asking 1,000 questions and focusing on” a client’s self-harm behaviors, she says. “It’s important to approach it with curiosity. … They know themselves and know what this behavior does for them; you just have to help them figure that out, and then build off of that to get more information.”

When working with young clients who self-harm, Visconti says he makes sure to acknowledge how hard it is to disclose and discuss such a painful and deeply personal topic. He thanks them for trusting him with such vulnerable information and feelings. “I empathize [with clients], commiserate and then try and bring about a sense of hope and preservation,” he adds.

The most important technique a counselor can use with these clients is the therapeutic relationship itself, Visconti says.

He admits that young clients who engage in self-harm can be challenging, not only because it’s an uncomfortable topic to address but also because they often have multiple presenting concerns or mental health challenges.

However, he pushes back against the misnomer that talking about self-harm in therapy can increase the behavior, retraumatize or cause emotional harm for a client. Counseling involves delving into many different types of painful topics, he says, and the key is for practitioners to handle it with openness and warmth.

“The long-term benefits greatly outweigh that distress,” Visconti emphasizes. “It’s so crucial to the betterment of their client, and you’re not going to increase the likelihood [of NSSI] by talking about it — it doesn’t work like that.”

Challenges that can co-occur with nonsuicidal self-injury

Depression and anxiety are the most common diagnoses that can co-occur in young clients who engage in nonsuicidal self-injury (NSSI). However, there are many other challenges that individuals may struggle with simultaneously.

There is a high correlation between NSSI and eating disorders, as well as clients who have experienced trauma, particularly sexual trauma, as self-harm can be a way for these individuals to seek control, disconnect or cope with painful feelings, trauma flashbacks or the stress of continuing to live in an abusive environment.

It also can co-occur with obsessive-compulsive disorder in clients who use self-injury to satisfy urges for repetitive behaviors to manage or communicate distress. This can also be the case for individuals with autism.

“It’s very effective to disconnect: To disconnect with their brain, with their body and overwhelming feelings, and this [self-injury] gets it to stop. But that’s also one thing that makes it hard to stop doing,” says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for NSSI in St. Louis. “A lot of people think of self-injury as this impulsive thing, and it can be, but it also can be very obsessive. If they [a young client] can’t manage their stress at school, they may be thinking all day about injuring once they get home.”

The relief and other satisfactions that an individual seeks from self-harm lessen over time, which sometimes causes individuals to increase the self-harm behaviors and, eventually, turn to other risky behaviors, such as sexual promiscuity, restrictive eating or using substances, to seek similar feelings of reward or relief. So counselors who work with clients who disclose self-injury behaviors (or a past history of NSSI) should also screen for substance use, suicidal ideation, eating disorders, behavioral addictions and other high-risk or destructive behaviors.

This information came from an interview with Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives (

Supporting parents of young clients who self-injure

Counselors who work with children or adolescents who self-injure are in a position to offer support to adults in the client’s life who are misunderstanding or anxious and upset about the child’s behavior.

Understandably, parents often panic and experience intense worry when they find out their child is self-harming, says Deanna Dopplick, a licensed professional counselor at S.A.F.E. (Self Abuse Finally Ends) Alternatives, an outpatient program that specializes in treatment for nonsuicidal self-injury in St. Louis. Often, parents’ first response is to enact punishment, such as taking the child’s cellphone away to cut off contact with friends or locking up all the sharp objects in the home.

However, this won’t stop the child’s self-harm behavior — it can actually increase it, Dopplick says. A punitive response from the adults in a client’s life will only cause the child or adolescent to feel even more shame about their self-harm, and it can lead them to engage in harming behaviors that are more hidden and secretive. This includes injuring themselves in ways that won’t leave a mark or on parts of the body that are usually covered by clothing.

It’s also not helpful for parents to reward a child for going a length of time without injuring themselves, she adds. Counselors can offer psychoeducation to parents on why the punishment-reward cycle is not effective in situations of self-harm, and they can provide healthier alternatives.

“We have to remember that it [self-harm] is a coping mechanism. It’s not a healthy one, but it does not mean that the child is ‘bad,’” seeking attention or acting out, Dopplick stresses.

She finds that the book Healing Self-Injury: A Compassionate Guide for Parents and Other Loved Ones by Janis Whitlock and Elizabeth Lloyd-Richardson is a helpful resource to recommend to parents. The book offers guidance on ways parents can talk to their child about self-harm and support them in a healthy way. (Whitlock, one of the co-authors, is the director of the Self-Injury & Recovery Resources research program at Cornell University; Dopplick notes that Whitlock’s entire body of research can be helpful to counselor practitioners who want to learn more about the topic of self-harm.)

Parents often jump to the assumption that self-harm behaviors mean that their child is suicidal, says Michael Visconti, a licensed mental health counselor who treats children and adolescents in private practice in Boston. Research indicates that the majority of individuals who self-harm do not have suicidal thoughts, he notes.

So counselors can educate parents on the differences between suicidal ideation and self-injury and assure them that although self-harm behaviors are concerning, they don’t necessarily mean that their child wants to end their life, Visconti stresses.

Bethany Bray is a former senior writer and social media coordinator for Counseling Today.

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 mental health needs of older caregivers

By Lisa R. Rhodes January 6, 2023

a woman standing behind an older man with one hand on his shoulder and the other arm hanging down holding the man's hand

Luca Santilli/

Caregiving can take many forms. A woman in her 50s takes care of her husband who has a life-limiting disease. An adult child cares for an aging parent. Grandparents raise their grandchildren because their adult child is struggling with substance misuse.

A recent State of Aging and Health in America Data Brief on caregiving (published by the National Association of Chronic Disease Directors and the Centers for Disease Control and Prevention) refers to the growing number of caregivers that are providing assistance to their loved ones as “an important public health issue” and notes that middle-aged and older adults in particular provide a substantial portion of the informal or unpaid care in the United States.

Research shows that older adult caregivers are shouldering more demands today than they did five years ago. According to the report Caregiving in the U.S. 2020: A focused look at family caregivers of adults age 50+ (conducted by the National Alliance for Caregiving and AARP), the number of individuals caring for older adults (those 50 years or older) has increased by 7.6 million caregivers since 2015. And more than half of these caregivers are age 50 and older themselves, with 20% being 65 and older.

In addition, many older adults are caring for their grandchildren. A U.S. Census Bureau report on children’s living arrangements noted that of the children under the age of 18 who did not live with a parent, 53.2% lived with a grandparent in 2019.

Caregiving has the potential to enhance one’s quality of life by increasing one’s satisfaction and strengthening familial relationships, but it can also be stressful and negatively affect people’s mental health. Sara Kerai, a licensed professional counselor (LPC) who has worked with older caregivers for more than a decade, says that many of her older caregiving clients — those age 50 to 64 — struggle with psychological distress due to caregiver stress.

Caregiver stress is “unwelcomed stress and anxiety associated with taking care of a loved one when you don’t feel prepared,” Kerai explains. “Caregiving is both physically and emotionally demanding. There’s no downtime. There are no vacation days, no sick days, no federal holidays.”

The added responsibilities of caregiving that suddenly become a part of these clients’ lives leave them with less time to take care for themselves, which contributes to their stress. The counselors interviewed for this article agree that cognitive behavior therapy (CBT), dialectical behavior therapy (DBT) and psychoeducation can help older caregivers manage negative emotions and help them develop the skills they need to maintain their health and wellness.

Feeling depleted

Tending to aging parents, spouses, adult children or growing grandchildren can leave older caregivers feeling exhausted, overwhelmed, anxious and depressed.

“The caregivers that I meet, by the time they’re sitting in front of me, they’re just very depleted, emotionally overwhelmed,” says Kerai, who owns a private practice in Grand Rapids, Michigan.

Older caregivers may be caring for aging parents or spouses who have a long-term terminal or chronic illness, such as cancer, dementia or Parkinson’s disease, or they may be caring for adult children who have become incapacitated due to a disabling accident or illness. They may also be caring for grandchildren whose parents are wrestling with a mental illness or substance misuse.

For these caregivers, “it feels like a tremendous amount of responsibility, all the while [they’re] waiting for the next shoe to drop,” Kerai says, because they “are expecting bad news medically or are worrying about when their loved one might have a setback or take a turn for the worse.”

Older caregiver clients often have to handle their own work and family responsibilities while also performing caregiving duties such as scheduling medical appointments, taking their loved one to the doctor and advocating for proper medical care, and managing medications. They are also tending to their loved one’s personal hygiene needs and keeping abreast of their loved one’s financial and legal matters.

Caregivers of children may be dealing with teachers, school administrators and coaches; coordinating resources from community and social service agencies; transporting children to and from recreational activities; cooking meals; or handling custody issues through the courts.

Adrianne Trogden, an LPC-supervisor and an assistant professor of counseling at the University of the Cumberlands, says that older caregivers are “burning the candle at both ends” because they often have to manage their caregiving duties while also working a full-time or part-time job. “When they come home [from work], they’re never really just ‘off,’” she explains. “They have to come home and do more work.”

And these caregivers are often “on call all the time,” says Trogden, a member of the American Counseling Association. “They can be called at any moment for an issue related to the one they’re caring for,” which often leaves clients wondering what will happen to their loved one if something comes up while they are at work, she adds.

Mary Pierce, an LPC at Marriage & Family Health Services in Eau Claire, Wisconsin, says some clients feel they are carrying an extra burden. They sometimes tell her they feel as if they are living life for two people.

Caregivers may also feel unprepared for the amount of work involved in caring for someone else. “A sense of overwhelm may come with the initial diagnosis [of an illness] as they scramble to set up routines doctor visits, household help with groceries, etc.,” she notes.

Then as caregiving becomes more routine, the feelings of exhaustion and anxiety can lead to a deep sadness, Pierce continues. “After a time, depressed mood is more common, as the reality of the situation hits.” This is when clients realize “this is going to go on for a while,” she adds.

Although mental health conditions may arise as a result of caregiver stress, Pierce, an ACA member who specializes in family caregiving, says she is careful not to pathologize caregiving.

“It is a process of adjustment, and in most cases, a diagnosis of ‘adjustment disorder’ applies, with or without anxiety, depressed mood or both,” Pierce explains. “I also want to assess if anxiety or depressed mood predated the caregiving experience for [a] client.”

In addition to feelings of fatigue, anxiety and depression, these caregivers often experience trauma. “It’s traumatic to change a spouse’s diaper [or] to see your parents in a frail or diminished state,” says Kerai, who offers telebehavioral health services to clients in Michigan, Virginia, Maryland and Washington, D.C.

Jennifer Stuckert, an LPC and clinical director at Restoration Counseling of Atlanta, says it is not uncommon for older caregivers to feel residual trauma from how or when their loved one passes away.

The degree to which the loved one is suffering also matters. Clients “need a safe place to process their internal angst about this suffering that they’re going through and the suffering that their loved one is going through,” Stuckert says.

It can be traumatic to not know what will happen next, she admits. “You never know how long this person is going to be in a declined state and how long your life will be this way.”

The costs of caregiving  

Older caregiving clients often feel they must put their life on hold, which may result in feelings of isolation and guilt. Trogden, president of the Association for Adult Development and Aging, a division of ACA, works with several clients who are in their 50s and 60s and are raising their grandchildren, who range in age from an infant to the early teens. A lot of these clients “thought they were moving into retirement, to relax … and have less responsibility,” she says. But now these clients have increased responsibilities and many never expected to have to raise their grandchildren.

Many of these clients contemplate putting their plans for retirement on hold because of this new role as caregiver, Trogden continues. Some even wonder if they will ever be able to retire or if they’ll have to continue to work longer than they planned to care for their loved ones. And this can lead to grief over what they have given up to care for their loved one, she says.

These clients are often overwhelmed, Trogden adds, because they’re not able to take time off to see friends, enjoy their hobbies or even engage in self-care activities.

Kerai also finds that clients may feel a sense of isolation. Caregiving is a solo responsibility for many older caregivers, she explains, and they often feel disappointment, anger and resentment because other family members cannot or will not help.

“People’s worlds become very small,” she says. “They can’t socialize or do the things that were restorative for them.”

Some clients wrestle with guilt, Pierce notes. For example, she says clients may feel guilty for wishing their caregiving responsibilities would end because they know what that means — the decline or death of a loved one.

Older caregivers can also experience anticipatory grief. Kerai says that many of her clients wonder what will happen when their loved one’s condition gets worse, and they ask her, “How can I prepare for this?”

Pierce, who has treated caregivers and their families for a decade, often introduces the concept of anticipatory grief to clients who may not be aware of the term. In addition, as a parent or partner declines, there is ongoing grief, she says. Pierce had one client who described their grief as “losing my husband little by little, day by day.”

Helping to alleviate stress

Trogden, who is the chief operating officer for Counsel NOLA, a group counseling practice in New Orleans, finds DBT distress tolerance skills to be a helpful way for clients to learn to manage stress in a healthy way. She often teaches clients the STOP skill, which, she explains, is an acronym that stands for:

  • Stop: Take a pause and don’t immediately react to what’s going on. Maintain control of your body and emotions.
  • Take a step back: Get some distance from the situation and take a few deep breaths. Walk away for a moment if possible.
  • Observe: Pay attention to what is going on inside of your body and around you. Do a body scan to notice any tension in your body. What are other people around you doing?
  • Proceed mindfully: Take a moment to think about the possible outcomes of this situation and respond, rather than react. What is the outcome you want with this situation? What are the consequences of what you might say or do to respond?

Trogden works with her clients to develop ways they can apply the acronym in their daily lives.

Trogden also uses the five senses of self-soothing exercise with older caregivers in session to help them learn how to create a sense of peace and calm. She walks clients through the exercise in session and asks them to tell her what they see, hear, smell, taste and touch. For example, she may say to clients:

  • What do you see around you? Go look at something peaceful or visually interesting. Watch people around you, go outside in nature, look at art, and so on.
  • What do you hear? Listen to what is going on around you and the various noises you can hear. Listen to music that you find calming or to sounds in nature, for example.
  • What can you smell? Maybe smell a cup of coffee, light a scented candle or put on your favorite scented lotion.
  • What can you taste? Drink or eat something you like and see if you can tell the different ingredients. Eat or drink slowly to absorb and focus on all the flavors.
  • What can you touch around you? Touch something soothing nearby. For example, pet a domestic animal, touch a soft fabric or run your hands under warm water.

Trogden then assigns clients this exercise as homework to practice outside of session both when they are feeling overwhelmed and when they aren’t.

CBT exercises can also help clients manage feelings of frustration and stress. Kerai once worked with a middle-aged woman who was caring for her husband who was also middle aged and had been diagnosed with a life-limiting illness. This client was feeling frustrated about how to handle her husband’s frustration about his symptoms and prognosis, Kerai recalls.

In situations such as this, Kerai finds the “worst case scenario” exercise helpful because it can help older caregivers identify their negative thoughts and predictions and consider new ways of thinking about the situation. Here is an example of how this exercise might go in session:

  • Counselor: What are you most concerned about right now?
  • Client: When my loved one takes a turn for the worse, everything is going to fall apart. It’s going to be a mess.
  • Counselor: What is the story you are telling yourself? What are you expecting is going to fall apart?
  • Client: That everything is going to explode!
  • Counselor: I understand that it feels scary right now. In that statement, I hear you making some negative predictions about the future. The truth is we don’t know how this will all unfold. I do know you have a lot of people who love and care about you. You have been proactive about getting the support you need. Let’s talk about what we can control and what we can’t.

Kerai used this exercise with the woman who was concerned about her husband’s diagnosis and helped her figure out possible resources, such as a home health aide or a family member, who could assist her in caring for her husband.

Sometimes the caregiver may find that their loved one’s personality or behaviors are changing, Kerai notes. For example, the woman Kerai worked with noticed that her husband had become more irritable or demanding. Kerai says the following questions can help older caregivers gain insight into the mindset and behavior of their loved ones to understand how their world has also changed due to the caregiving relationship:

  • What do you think your loved one is asking for when they become demanding?
  • What do you think your loved one is afraid of?
  • What medications does your loved one take?
  • Have you noticed any side effects from the medication?

Kerai says these questions helped the client understand that medications (such as steroids) may have been causing her husband’s personality to change and that as a person with a life-limiting disease, he could be operating from a place of anxiety about his own mortality. The client’s husband, for example, may have been concerned about whether his wife would remain with him until the end.

To improve the client’s communication with her husband, Kerai suggested the client check in with him in the morning before starting her workday to discuss what the day would look like and to provide reassurance about when his needs would be met. This simple change helped her feel less angry and frustrated by his attempts to regain some control over his life, Kerai says.

Pierce also uses CBT techniques to help older caregivers identify their cognitive distortions, such as black-and-white thinking and exaggerating the negatives and minimizing the positives. She uses an exercise she calls “unhelpful versus helpful” thoughts to help clients identify both types of distortions. This exercise, Pierce says, helps older caregivers recognize negative or self-defeating thoughts so they can replace them with more positive, hopeful thoughts about their circumstances and their relationship with their loved one. For example, a client may think, “This will never end.” Then they can counter this negative thought with a more helpful one such as “This is not forever, just for now.” Or maybe a client worries that things will never be the same between them and their loved one. Then, they could reframe this unhealthy thought by saying, “We are both still here and I can make the most of the time we have left together.”

Dealing with anger

Stuckert uses psychoeducation to help older caregivers, especially those caring for aging parents with memory loss or physical impairments, process feelings of anger. “There is exasperation in these situations,” she explains. “No one gives you a rule book, so people are very overwhelmed.”

When clients lament how they must often repeat conversations multiple times or help their parent to complete simple daily tasks, Stuckert tries to help them understand that their parent’s brain is in decline — something that many people experience as they age.
Stuckert says she normalizes the feelings that adult children may have about their parents and helps them develop realistic expectations about the downward trajectory of their loved one’s remaining years.

She works to help clients “build compassion” for their parents and tells them, “You’re going to have to have gracious compassion for them. … Your parent is going through a normal life stage.” This is particularly important when agitation and frustration are high, she adds.

Stuckert also helps older caregivers understand that their parent’s mental decline may be gradual and that their parent may be struggling with fears and uncertainties about the end of their life, such as how they will die or how much pain they will be in. “They don’t like losing their power,” she explains. “They want to keep their agency as long as they can.”

Stuckert recommends counselors read Judith McKay, Matthew McKay and Peter Rogers’ book When Anger Hurts: Quieting the Storm Within, which helps people recognize their angry thoughts and find healthy ways to relate to themselves and others. She uses several exercises from this book to help caregivers recognize and understand what provokes their anger.

First, she says, counselors can have clients ask themselves the following questions when they are feeling angry:

  • Are there more effective strategies than anger for reinforcing others to meet my needs?
  • What were my trigger thoughts?
  • What can I do to meet my own needs to reduce my stress?
  • What stresses underlie my anger?

Counselors can then help older caregivers reframe angry thoughts and realize that although they may not be able to change their circumstances, they can change the way they respond to stress and develop alternative ways to relate to their loved ones and meet their own emotional needs, Stuckert says.

Pierce helps adult children resolve issues with their aging parents who have dementia by striving to keep the peace and acknowledging their feelings of grief.

“We talk about not engaging in arguments, but agreeing and then redirecting the parent,” Pierce explains, and “also not correcting the person with dementia to avoid making them feel worse about forgetting or being confused.”

Naming and processing grief

Older caregivers experience grief over the changes that caregiving can bring to their plans or dreams and their relationship with their loved ones. Offering empathy, unconditional positive regard and being genuine — the essence of a person-centered approach — is key in supporting clients in the grieving process, Pierce says.

Pierce often asks clients to use a self-rating exercise to help them process their grief and accept the changes that caregiving brings to the relationship. She once worked with a male client in his 60s who was caring for his wife who was diagnosed with frontal temporal dementia. Pierce asked him to think about his life before his wife was diagnosed and rate how much he felt like a husband. He said, “100%.” Then she asked him how much he felt like a husband three years after the diagnosis; he said, “50% husband, 50% caregiver.” And the client said that when his wife experienced a significant decline, he felt like he was “99% or even 100% caregiver.”

“Giving caregivers a framework to acknowledge the changes in their circumstances and, for some, to be able to let go of expectations that the care receiver will be able to continue being a full partner” is helpful, Pierce says.

Pierce works to help older caregivers not only acknowledge what has been lost but also recognize what remains in the relationship. For example, one of her former clients — a woman in her 60s — moved her husband who had dementia into a care facility after she was no longer able to continue caring for him at home. The woman felt sad that she and her husband were losing their connection and “forgetting the good times” they once shared, Pierce recalls.

“At my suggestion, the wife took her husband out for a drive and revisited local places where they had good memories,” Pierce says. “She reported that at the end of the afternoon, when she brought him back to the facility, he hugged her and said, ‘Thank you for today. This meant a lot to me.’”

Counselors can also help clients process their grief when they lose their loved one. John Self, an LPC at the Wellspring of Life Counseling & Play Therapy Center PLLC in San Antonio, once helped a woman in her 50s deal with the grief of losing her mother after being her sole caregiver for a year. When the client’s mother was diagnosed with cancer, her siblings refused to help, so she had to care for her mother while also working full-time until her mother was placed in hospice care.

“She would take off weeks at a time to care for her mom,” Self recalls. “She almost lost her job. It was a lot for her.”

This client spent most of her savings to care for her mother, Self says, so he helped her get financial assistance under the Family Medical Leave Act. This allowed her to work at a reduced rate for three months until her mother’s death.

Self also used the four tasks of mourning, developed by psychologist J. William Worden, with this client to help her with the grieving process. The four tasks include:

  • Accept the reality of the loss
  • Process the pain of grief
  • Adjust to a world without the deceased
  • Find an enduring connection with the deceased in the midst of embarking on a new life

This client, who was a Christian, found her faith helpful in accepting her mother’s death, Self says, so together they examined the woman’s spiritual values and the belief that her mother was now in heaven.

To help her process the pain of grief, Self encouraged her to journal her feelings and look through family photo albums to recall childhood memories and family gatherings as a way to honor her mother. The client also started scrapbooking and working with crafts to find ways to alleviate her feelings of loss.

The client shared with Self how difficult it was to continue living in her home because her mother’s bed and wheelchair were still present, but she couldn’t bring herself to remove them. Self reassured the client that over time as her grief began to dissipate, it may become easier for her to remove the objects from the home and adjust to this new life without her mother.

Self says he also encouraged the client to think about all the wonderful things her mother did as a parent and to find ways to celebrate her life. “With most patients, I try to give them some hope,” he says, and help them realize that their caring for their loved one can help to build their own resilience.

The need for psychoeducation and self-care

Despite the stresses of caregiving, the love and sense of duty most older caregivers feel toward their loved ones motivate them to provide caregiving for as long as they can. However, the counselors interviewed for this article say this devotion often leaves older caregivers with less — or no — time to care for their own health and wellness.

According to the Caregiving in the U.S. 2020 report by the National Alliance for Caregiving and AARP, caregivers’ health has been declining since 2015, and one in five caregivers who are 50 years or older say their role as a caregiver has made their health worse.

Some older adults are so embedded in their role as a caregiver, Kerai says, that they “don’t feel they have permission to take care of themselves.” They sometimes feel they “can’t leave their loved one’s side,” she adds.

The difficulty in taking care of oneself, or the reluctance to do so, is troublesome for older adults who may be facing the onset of chronic illnesses, such as high blood pressure and diabetes. Trogden says she talks to her clients about the importance of staying on top of their health, and she teaches them mindfulness techniques, such as deep breathing, to help them feel a sense of calm and to de-escalate from their daily stress.

Trogden also reminds her clients that they can’t be there for somebody else if they’re not there for themselves. She encourages older caregivers to do small, simple things to take care of themselves such as taking a bath, putting on body lotion, taking a walk or doing a mindfulness meditation because these activities can make a big difference.

Pierce talks to older caregivers about the sympathetic nervous system response and the need to try to calm themselves when they feel stress or anxious and unable to take a break. She teaches clients to pay attention to how they feel in their bodies — Are they tense? Is their heart racing? Are their hands shaking? — so they can know when they need to use a self-care activity, such as stepping outside and taking a few deep breaths or taking a mindful walk and noticing the sensation of their feet on the ground, to calm themselves. She also encourages clients to check in with their bodies after they engage in the self-care activity so they can notice the difference in their body.

Stuckert helps older caregivers brainstorm self-care activities using the “self-care menu” worksheet created by the Seattle School of Theology and Psychology’s Resilient Leaders Project. The self-care menu has a section with four blocked-out periods of time (five minutes or less, 15 minutes or less, 30 minutes or less, and 60 minutes or more) where caregivers can plan and write down a self-care activity.

For example, a client can do a whole body stretch for five minutes; listen to two of their favorite songs for 15 minutes; get a pedicure or a haircut for 30 minutes; and attend a religious service or read a couple chapters from their favorite book for an hour.

The counselors interviewed for this article agree that psychoeducation can help to encourage older caregivers to build a support network of resources, including respite care and caregiver support groups, to help them juggle their caregiving duties while also tending to their own health and well-being.

Psychoeducation about geriatric care is crucial for both clients and counselors. “For many counselors, it is difficult to help clients find resolution during the grieving process,” Self says.

Stuckert agrees that psychoeducation is essential to helping older caregivers. “The more they [counselors] understand the struggle of the aging process,” she says, “the better they’ll do” serving this clientele.


Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at

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