Tag Archives: Counselors Audience

Counselors Audience

Fatphobia: How can counselors do better?

Compiled by Bethany Bray November 23, 2022

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Michael Poley/canweallgo.com

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

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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

A beginner’s guide to alexithymia

By Jerrod Brown November 8, 2022

Alexithymia is a complex, subclinical phenomenon characterized by cognitive-affective functioning impairments that can affect as many as 10% of the general population. Typically, individuals with alexithymia struggle to recognize, identify and describe their feelings. This often includes trouble discerning between emotions and physiological sensations. Because alexithymia is a known risk factor for a wide range of psychological and physical health problems, this psychological construct has significant implications for professionals working in the field of mental health. In fact, the failure to accurately identify the presence of alexithymia can significantly impact the intake, screening, goal-planning and therapeutic processes. Therefore, mental health professionals should become familiar with the wide array of disorders, traits and experiences often associated with elevated rates of alexithymia. 

Unfortunately, many mental health professionals lack the necessary training and expertise to accurately identify and effectively treat the unique and complex symptoms of alexithymia. A strong contributor to this predicament is the lack of training and educational programs that offer workshops and coursework dedicated to this important and complex topic. The goal of this article is to provide mental health professionals with a basic introduction to alexithymia by highlighting information in four essential areas: (a) symptoms and red-flag indicators, (b) diagnostic comorbidity, (c) screening and assessment and (d) intervention and treatment considerations.

Symptoms and red-flag indicators

Symptoms of alexithymia can vary from person to person and are often influenced by many neurological, biological and psychosocial factors.

The cognitive factors associated with alexithymia can include: 

  • Deficits in the regulation of thoughts, emotions and bodily processes 
  • Difficulty with introspection
  • Inhibition and impulsivity issues
  • Limited imagination and fantasy life
  • Constricted patterns of thought
  • Reliance on concrete thinking almost to the exclusion of symbolic thinking
  • The affective factors associated with alexithymia can include:
  • Blunted or limited personal experience of emotions
  • Difficulty identifying and describing emotions
  • Emotion dysregulation
  • Failure to identify the causes of personal feelings
  • Inability to seek and use support systems to help with emotional problems
  • Limited use and understanding of verbal and nonverbal emotional cues
  • Poor emotional awareness
  • Emotional avoidance and suppression 
  • Difficulty distinguishing between emotions (e.g., telling the difference between anxiety and anger)
  • Weak affective theory of mind
  • The social factors associated with alexithymia can include:
  • Interpersonal communication characterized by coldness, flatness and a lack of emotion
  • Lack of empathy
  • Loneliness
  • Nonassertiveness
  • Perspective-taking deficits
  • Social conformity
  • Verbal and nonverbal communication deficits
  • Weak social attachments
  • The physiology factors associated with alexithymia can include:
  • Physical sensitivity to the experience of different sensations
  • Tendency to mistake affective responses as physiological experiences or dysfunctions

Diagnostic comorbidity

Alexithymia often co-occurs with a diverse array of psychiatric, trauma-based, neurocognitive, neurodevelopmental and substance use disorders, so it is likely that mental health professionals provide services to clients impacted by alexithymia on a regular basis. In particular, individuals with alexithymia are quite prone, but not limited, to presenting with another disorder that features affective symptoms. It is important to note that alexithymia can be viewed as a risk factor for psychopathology as well as other conditions. The following highlights some mental health conditions often associated with alexithymia.

Substance use and other addictive disorders. The prevalence rates of alexithymia are higher among individuals with substance use and addictive problems than the general population. In addition, individuals with alexithymia appear to be at risk for more severe alcohol-related problems than those without alexithymia. This has led some researchers to posit that alexithymia could place a person at risk for alcohol use problems. Failure to consider the role of alexithymia in alcohol use could undermine the effectiveness of any interventions.

Stress-related disorders. Research has consistently linked alexithymia to physiological stress markers as well as stress-related disorders. For instance, individuals with alexithymia often exhibit elevated levels of chronic stress on measures of cortisol awakening response and cortisol secretion during the dexamethasone suppression test. Other evidence includes increases in inflammation and atypical immune responses, which could be consequences of prolonged exposure to stress.

Posttraumatic stress disorder. Posttraumatic stress disorder (PTSD) is a condition characterized by heightened reactions, anxiety, intrusive memories and nightmares, and other-related symptoms. The onset of PTSD is precipitated by exposure to a traumatic event (e.g., violence, accidents, natural disasters). Some of the same traumatic experiences that lead to PTSD could also contribute to the development of alexithymia. As a result, mental health professionals are encouraged to screen for alexithymia in clients presenting with PTSD.

Insecure attachment. Research has found higher rates of alexithymia among people with insecure attachment patterns compared to people with secure attachment patterns. Insecure attachment patterns may also cause the impacted individual to experience trust issues, fears of abandonment, general discomfort and decreased coping abilities. And both insecure attachment patterns and alexithymia have been linked to increases in emotional and behavioral problems. Therefore, attachment-based therapists are encouraged to become informed about alexithymia. 

Traumatic brain injury. Traumatic brain injury is temporary or permanent brain damage caused by a blow or some other wound to the head. Common symptoms of traumatic brain injuries include impulsivity, aggression, emotion dysregulation and poor coping skills when under duress. Research shows that many people who suffer from a traumatic brain injury also experience alexithymia.

Neurodevelopmental disorders. Alexithymia has also been found to be elevated among people diagnosed with  neurodevelopmental disorders, including attention-deficit/hyperactivity disorder, autism spectrum disorder, fetal alcohol spectrum disorder, and intellectual and developmental disability. Routine screening for alexithymia among people diagnosed with a neurodevelopmental disorder may lead to improved treatment outcomes.

Hypothalamic-pituitary-adrenal axis dysfunction. The hypothalamic-pituitary-adrenal (HPA) axis may play a role in alexithymia. This system is responsible for regulating stress responses and ensuring the body adjusts to evolving environmental conditions. Exposure to stressful situations can elicit chronic hyperactivity of the HPA axis. In such instances, a person becomes at risk for stress-related physical and mental health problems. Because of the potential connection, I recommend counselors also become informed about the HPA axis when learning about alexithymia. 

Somatic symptoms. Individuals with alexithymia tend to score higher on measures of physical distress than the general population. These physiological differences could help explain the higher prevalence of anxiety and depression symptoms among those with alexithymia. During times of distress, people with alexithymia may experience and complain more about psychosomatic-based symptoms.

Dissociative tendencies. Dissociation occurs when there is a disconnection among a person’s cognitions, emotions and actions. The presence of dissociation could play a role in the emergence of alexithymia or vice versa. This is particularly salient in people who have experienced trauma such as neglect and abuse. In such cases, the development of dissociation and alexithymia could serve as an adaptive response that prevents a person from being overwhelmed.

Sleep disturbances. Individuals with alexithymia often report comorbid sleep problems. These can include difficulties with staying awake or falling and staying asleep. Emotional problems that are similar to alexithymia have also been observed among individuals experiencing sleep deprivation. 

Language problems. Individuals with alexithymia often struggle with verbally expressing their own emotions. In addition, individuals with alexithymia have trouble comprehending the verbal communications of other people. Therefore, problems with language processing could be an important causal influence on the development of alexithymia.

Executive dysfunction. Individuals with alexithymia commonly exhibit deficits in executive function, which is a set of cognitive, affective and behavioral skills that enable a person to plan and perform specific tasks. In particular, cognitive flexibility, inhibition and working memory are often described as the primary aspects of executive function. It is important to note, however, that many other constructs fall under the umbrella of executive function. The symptoms of alexithymia and deficits in executive function may be exacerbated by various forms of extreme stress and trauma. When this occurs, it can significantly impede goal achievement and adaptive functioning.

Immune function dysregulation. A growing number of studies have reported an association between alexithymia and immune system dysregulation. The same stressors that cause alexithymia could also alter how the immune system functions. A grave consequence of immune system dysregulation includes proneness to a diverse array of psychosomatic illnesses. Encouraging the client with alexithymia to maintain regular contact with their health care provider is warranted.

Emotional regulation deficits. Individuals with alexithymia often present with emotional dysregulation issues. For example, individuals with alexithymia usually struggle to express or understand their feelings and the feelings of others. As a result, many mistake the symptoms of alexithymia as a lack of empathy. Consequences of emotional dysregulation include difficulties with establishing and maintaining relationships across the life span. In some instances, this could lead to a breakdown in the therapeutic alliance. 

Worry and rumination. Individuals with alexithymia typically experience high levels of worry and rumination. Worry is generally distinguished by fears of danger, whereas rumination is characterized by thoughts about loss and failure. These repetitive cognitive processes are common in internalizing disorders (e.g., anxiety, depression).

Deliberate self-harm. Empirically based research has found an association between alexithymia and a history of substance abuse and deliberate self-harm. Such self-injurious behaviors could be an attempt to cope with emotional dysregulation, which is frequently exacerbated by alexithymia.

Suicide risk. Alexithymia could serve as a risk factor for suicidal behaviors. Individuals with alexithymia are prone to depression, anxiety and other affective problems, all of which are also predictors for suicidal behaviors.

Screening and assessment

Clinicians should carefully screen for alexithymia prior to the development of mental health and substance use treatment plans. The Toronto Alexithymia Scale (TAS-20) is one instrument counselors can use to screen for alexithymia. The TAS-20, which is commonly used in neuroscience studies, is a 20-item, self-report questionnaire that measures skills in the areas of emotion recognition, emotion description and perspective-taking. Several empirically based articles have been published pertaining to the efficacy of the TAS-20.

When screening, clinicians should watch for increased symptom reporting. Individuals with alexithymia are prone to confusing emotions and feelings for physiological problems with their bodies. In turn, this group is disproportionately likely to overreport and seek medical care for physiological problems. This is another example of maladaptive coping in the context of alexithymia. 

Ground Picture/Shutterstock.com

As mentioned in the previous section, individuals with elevated stress and anxiety, burnout, or a history of trauma are predisposed to alexithymia. Therefore, systematic screening and assessment for alexithymia is encouraged in these groups. Trauma-informed counselors would also benefit from learning about alexithymia. 

Emotional numbing and emotional suppression are two other areas that mental health providers should consider during the intake and treatment planning process. Emotional numbing is the affective process of minimizing or eliminating the experience of feelings. Like alexithymia, this could be viewed as a temporary coping strategy that is deployed to protect against the consequences of trauma. And emotional suppression is a common way that individuals with alexithymia regulate their feelings. This may be traced back to difficulties in recognizing and understanding emotions that characterize alexithymia.

It is also critical that mental health professionals obtain information from collateral informants when screening for alexithymia. In many instances, the client may lack insight into their own symptoms, which renders self-reported information as insufficient. So conferring with family members, friends and co-workers can help illuminate the nature of the client’s symptoms and their impact on global functioning. In addition, consulting with any other professionals that work with the client can be informative.

Intervention and treatment considerations

Individuals with alexithymia typically have worse mental health treatment outcomes than those without alexithymia. In an effort to address this quandary, research has focused on identifying interventions that help improve outcomes for individuals with alexithymia. This section highlights potential considerations that mental health professionals should make when treating alexithymia.

The symptoms of alexithymia likely undermine the development of therapeutic alliances with mental health professionals. Specifically, difficulties with recognizing and describing affective experiences as well as perspective-taking make it difficult to develop interpersonal closeness with others. 

In addition to limiting the development of the therapeutic alliance, alexithymia could be associated with poor treatment engagement. In combination, these suboptimal outcomes in the therapeutic process contribute to an increased likelihood of negative short- and long-term treatment outcomes in individuals with alexithymia.

The difficulties that alexithymia presents in terms of the therapeutic alliance and treatment engagement are particularly salient in substance use treatment settings. Clients with alexithymia may be dependent on the use of substances to cope with the affective symptoms of their condition. The failure to account for and address alexithymia during the therapeutic process decreases the likelihood of good treatment prognosis.

Individuals with alexithymia are also prone to poor treatment attendance and adherence, which can be expected among clients with poor treatment engagement. Thus, failure to complete treatment programs and relapses are common in clients with alexithymia.

The research literature on the treatment of alexithymia has grown in recent decades, and there is now a substantive list of interventions worth considering when treating clients with alexithymia (see table below). Psychoeducation offers one promising treatment option for clients with alexithymia. A limited but growing body of research indicates that supportive and psychoeducational approaches to therapy may be effective in treating alexithymia. Interpretive approaches to therapy, however, appear to be less effective with this population.

Alexithymia intervention table by Jerrod Brown

Mindfulness training may also be a critical component to incorporate in the treatment of alexithymia. For instance, mindfulness-based training has been linked to increased emotional effectiveness. So using mindfulness-based approaches may result in improved emotional awareness among clients experiencing alexithymia. 

Music therapy also holds promise as an intervention for clients with alexithymia. This therapeutic approach is particularly well suited for clients who struggle to describe thoughts and feelings with words. Thus, clients with alexithymia may find it easier to express their emotions in music therapy.

Individuals with alexithymia generally struggle with emotional clarity, which is the ability to recognize and understand the causes of one’s emotions. Development of emotional clarity could help a client with alexithymia not only benefit from treatment but also protect against victimization in their personal life.

Clinicians can also help clients with stress management. A common risk factor for alexithymia is the experience of extreme stress. It is unsurprising, then, that individuals with alexithymia often struggle with stress management. Thus, the development of stress management skills remains a critical target in any intervention for clients with alexithymia.

Conclusion 

Alexithymia is a complex and important topic all mental health clinicians need to know. Since elevated rates of alexithymia are found in a host of trauma-based, substance use, neuropsychiatric, neurocognitive and neurodevelopmental disorders, it is likely that mental health professionals will encounter clients impacted by this subclinical, cognitive-affective deficit on a regular basis. Unfortunately, in my experience, few professionals working in the field of mental health have received sufficient education and training pertaining to the topic of alexithymia. 

I strongly encourage all helping professionals to become informed about alexithymia. Here are three ways counselors can begin this process:

  • Seek professional consultation from recognized alexithymia experts.
  • Review key journals in the field on a regular basis to stay abreast of the latest peer-reviewed research on alexithymia.
  • Continue to seek education and training on the best ways to screen for alexithymia and the best intervention techniques to use with clients who struggle to identify and describe their emotions.

 

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Important facts about alexithymia 

Here are some important reminders mental health professionals need to consider when learning about the topic of alexithymia: 

  • Alexithymia is a threat to emotional, social, and physical health and well-being.
  • Alexithymia is not considered a mental health disorder and is mentioned only once in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. 
  • Alexithymia is a trait found elevated among people diagnosed with neuropsychiatric, neurocognitive, neurodevelopmental, trauma and stressor, and substance use disorders.
  • Numerous empirically based articles have been published on the topic of alexithymia. 
  • Alexithymia can amplify stress and its impact on emotional, social, behavioral and physical health.
  • Clients with alexithymia have difficulty understanding, processing, recognizing and describing emotions.
  • During times of increased stress, worry and conflict, people impacted by alexithymia frequently experience an increase in psychosomatic-based symptoms.
  • Alexithymia can impede the therapeutic alliance, especially when mental health providers lack an awareness and understanding of this topic.
  • When becoming trauma informed, it is also important to become alexithymia informed. 
  • Professionals are strongly encouraged to seek out additional training and consult with experts to better understand the implications of alexithymia within mental health and substance use treatment settings.
  • Academic-based institutions and continuing education training programs are encouraged to offer curriculum and workshops pertaining to the mental health implications of alexithymia.

 

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Jerrod Brown is an associate professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health and in trauma, resilience and self-care strategies for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center in St. Paul for the past 19 years. Contact him at Jerrod01234Brown@live.com.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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

Incorporating clients’ faith in counseling

By Lisa R. Rhodes November 2, 2022

A South Asian Muslim woman in her 20s lives at home with her Muslim family and has been struggling in her relationship with her parents. She feels they interfere with her ability to make decisions for herself and treat her like a child.

The woman decides to go to therapy. After listening to the client talk about the issue, the counselor says, “If you move out, this will no longer be an issue.” But this advice was not helpful, and this woman sought out a different clinician, which led her to Nadia A. Aziz, a licensed professional counselor (LPC) at the Empowerment Therapy Center in Manassas, Virginia.

“The client felt the counselor wasn’t informed on how to deal with issues in a culturally informed manner,” Aziz recalls. “The counselor failed the client by not incorporating [her] values” into treatment.

In South Asian cultures, which embrace the spiritual teachings of Islam, Hinduism, Sikhism and Buddhism, it is expected that adults live at home with their families until they either get married or move away for work or college, explains Aziz, who is South Asian and Muslim.

“A counselor suggesting moving out of a family’s home would be insensitive to the [client’s] cultural and religious needs because the client was not able to move out and it wasn’t a realistic expectation,” she says. 

 Aziz, a member of the American Counseling Association, worked with the young woman in therapy to set healthy boundaries and develop assertive communication skills so she could express her feelings and needs to her parents in a way that was respectful of her family’s cultural and religious beliefs.

An evolving practice

This scenario is an example of what many clinicians fear — not knowing how to respond to the religious and spiritual needs of a client. J. Scott Young, a licensed clinical mental health counselor and professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, says his research on religion and spirituality in counseling, which includes conducting counselor surveys, shows that many mental health professionals feel anxious and uncertain about incorporating a client’s faith into therapy.

“They don’t want to do anything unethical,” Young explains. “They’re worried that they don’t know what to do to help people with [these] issues.”

The uneasiness counselors feel stems from a long history of prohibiting the intersection of religion and spirituality in the therapeutic process. In the third edition of Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice (published by ACA), Young and Craig S. Cashwell point out that “religion has long been a highly controversial topic in the mental health disciplines.” They also note that Sigmund Freud and B.F. Skinner, two pioneers of psychology, considered religious and spiritual belief systems to be frivolous.

However, the counselors interviewed for this article all agree the counseling profession, and the mental health field in general, has evolved over the years to regard religion and spirituality as important additions to counseling education and practice. And they stress that with the proper education, training, and focused introspection into their own religious and spiritual beliefs, counselors can effectively bring a client’s faith into the therapeutic process, if that is the client’s desire for treatment. 

In 2009, the Association for Spiritual, Ethical and Religious Values in Counseling (ASERVIC), a division of ACA, developed the Competencies for Addressing Spiritual and Religious Issues in Counseling to serve as a guideline for counselors seeking to incorporate a client’s religion and spirituality into practice. The competencies work in tandem with the ACA Code of Ethics.

Jesse Fox, an ACA member and the current president of ASERVIC, says evidence-based research into the importance and efficacy of religion and spirituality have made them topics for therapeutic exploration. 

“The evidence base for interrelationships between spirituality, religion and mental health has grown exponentially,” says Fox, an associate professor of counselor education at Stetson University. “In the most recent systematic review in 2012 produced by Harold Koenig at Duke University Medical School, there were over 3,000 published peer-reviewed studies documenting the connection between spirituality, religion and health. In fact, the number of studies grows exponentially every year.”

This empirical work has mapped out how these domains — religion, spirituality and health — of human experience function psychologically, he explains. 

“The net effect is that mainstream mental health models have recognized that spirituality needs to be considered alongside of other dimensions of wellness like emotional health or physical health, as well as intersectional models of identity like race and sexuality,” Fox says.

Religion and spirituality continue to be important to many in the United States. According to a 2022 Gallup Poll, 81% of U.S. adults believe in God. Statistics such as this, Fox says, suggest that religion or spiritual matters will likely be “an aspect of a client’s identity” in counseling.

Young, an ACA member, says research has shown that people who have a faith or religious commitment that supports them tend to experience less anxiety and depression, more stability in their primary relationship, and more stability and commitment in their work and career. This commitment “seems to be sort of a buffer against some of the stressors that they might otherwise face,” he explains. “And if that’s that case, [it] sort of helps to support their mental health as well.”

People often use spirituality or religion to make meaning of their lives, notes Young, who treats clients at Triad Counseling and Clinical Services PLLC, which has offices in High Point and Greensboro, North Carolina. “In counseling, we talk to people about their childhood, their parents, their family drama … [and] their sex life — all these are very personal things for people,” he says. “At times counselors are hesitant to discuss spirituality or religion for fear that it is too personal or that they may misstep.” 

Know thyself, know the client 

The counselors interviewed for this article say that before attempting to bring a client’s faith into therapy, counselors should thoroughly explore their own religious and spiritual beliefs, or the lack thereof.

“If counselors have not taken the time, or realized the importance of taking the time, to know themselves — their values, their beliefs, their own spirituality and religious preferences — then that’s not going to be a good match for clients who have needs in that area,” says Amy Evans, a licensed professional clinical counselor in Minnesota. 

“The challenge is making sure we do not push our own values, worldview and perspectives on our client,” Evans stresses, which is something both the ACA Code of Ethics and ASERVIC competencies make clear counselors should not do. “To make sure we’re not doing that, we have to know ourselves,” she adds. 

Aziz says she was able to explore her religious and spiritual identity in undergraduate and graduate school, where she took courses in multicultural counseling and faith-based counseling, as well as other classes that encouraged self-discovery, self-awareness, and exploring one’s own values and biases in the realm of religion and spirituality.

Justin K. Hughes, a LPC in Dallas who offers religious/spiritual integration, most commonly for Christians, says he learned important tools for bringing a client’s faith into treatment from his own experience receiving counseling as an undergraduate student and from the counselors he worked with during his Christian seminary training and clinical internship. 

Hughes, owner of Dallas Counseling PLLC, says these mental health professionals set the model for him by being respectful and humble and always asking questions to assess his needs and learn more about his religious and spiritual experiences. He says he now mirrors these traits in his own practice. 

Faith and self-disclosure

While it is important for counselors to feel comfortable with their own faith and belief systems, the counselors interviewed for this article agree that it is not necessary for clinicians to share this part of their lives with clients. If clients do inquire about their faith, they advise clinicians to be thoughtful in how they respond. 

Young, a past president of ASERVIC, says he doesn’t discuss his spiritual views in session unless the client brings up the topic, and even then, he is careful not to divulge too many details. 

“I have, on occasion, had a client who really wanted to know how I see these things, so I always preference [my response] with ‘We’re here for you,’” Young explains, noting that he will then try to explore what salience religion and spirituality holds for the client and what the client may be trying to learn by asking about his beliefs. 

Lemonsoup14/Shutterstock.com

 “I do not try to deflect or redirect if they are truly curious,” Young says, “but I do want to understand why it is important for them to know my beliefs.”

Aziz says her faith is evident in the photograph she posts on Psychology Today’s directory of mental health providers and her practice’s website. “I wear the head scarf, the hijab, [so] it’s kind of hard to miss,” she says. “A lot of times I do get contacted through those avenues, so I am implicitly disclosing that I am Muslim, and they are looking for a Muslim therapist.”

If clients inquire to know the specifics about her faith, Aziz says she always brings the discussion back to what the client is looking for and what they need in treatment. Although a discussion of Aziz’s faith may sometimes be helpful in building rapport with a client, she is mindful that it is not relevant to the therapeutic process. 

“A lot of times it is [about] setting boundaries with them,” she says, “and making sure they understand that the counseling session is not about me, it’s about [them], keeping the focus on them.”

Hughes, who specializes in treating obsessive-compulsive disorder (OCD), anxiety and related disorders, is a member of the International OCD Foundation, which has been examining the role of religion and spirituality in the treatment of OCD during the past couple of years. 

Hughes says he is “usually fairly open about being a Christian” with clients if they bring it up. For example, some of his clients have asked, “Are you a Christian?” “Would you be willing to pray with me?” and “I’m not very religious. Are you OK with that?” He only provides specific information if he feels it will be a therapeutic benefit for the client, which he notes varies case by case.

Counselors do not have to share the same religious or spiritual beliefs as their clients to be effective in therapy, yet for some clients, having a match in faith may matter to the client. Evans, an associate professor and program director of the master’s in counseling program at Bethel University in St. Paul, Minnesota, says research shows that what matters in practice is the quality of the therapeutic relationship and the counselor’s responsiveness to the client. 

“If a counselor is trained well and really considers the client’s worldview, culture and values — then that can be helpful to the [therapeutic] relationship,” says Evans, an ACA member. A counselor’s training and ability to modify therapeutic techniques to meet the client’s needs is what is most helpful in practice, she stresses, not the counselor’s faith.

Young acknowledges that a counselor’s faith may be important for some clients. If there’s not a match in faith, it may be barrier for some clients who may not feel as safe in the relationship as they should, he explains. But “as long as the counselor is open and meeting the client where they are [and] they’re not anti-religious or struggle with it themselves,” Young says, “it really shouldn’t make much of a difference.”

Broaching the topic

Counselors must first determine a client’s therapeutic needs to find out if they would like to include their faith in counseling. The counselors interviewed for this article suggest bringing up the topic of religion and spirituality in the first session and including it on intake forms. 

“One of the most important things is to … broach the topic,” Evans says. “If we don’t let clients know it’s OK to talk about it [religion and spirituality], they may not know it is acceptable to bring it up.”

Evans says counselors should also inquire about a client’s faith on the intake form. Then during the first session, they can ask open-ended questions in response to what clients have shared on the form. Evans provides a few examples of things counselors can say to initiate this conversation: 

  • It sounds like your spirituality/religion is important to you. 
  • How might you envision bringing your spirituality/religion into the therapeutic work we are doing?
  • You mentioned that spirituality/religion is an important part of your life. How might it relate to the therapeutic goals we have agreed to focus on?

Evans says partnering with the client to agree on goals, including goals surrounding the client’s faith, helps builds the therapeutic relationship so it can be effective and have positive outcomes for the client.

Aziz also brings up the client’s faith during the intake process. “I ask [clients] if there is anything they want me to know about their cultural or religious beliefs and if they are looking for faith-based counseling,” she says. 

Aziz notes that about 70% of her clients are South Asian and follow the teachings of Islam, Hinduism, Sikhism or Buddhism, and about 30% are from a different cultural background or faith. So she first works with clients to help them identify their own values. “That gives me a better understanding of what they’re looking for in session, and I tend to take the counseling sessions in those directions,” she says. 

Blending faith and counseling

Once counselors assess the religious or spiritual needs of the client, or the lack thereof, they can work with the client in treatment to resolve any issues or explore new insights. Young says bringing a client’s religion or spirituality into practice should be a collaborative process that is not one size fits all. 

One approach, he continues, is to ask open-ended questions that explore the client’s thoughts and feelings around their religious or spiritual practices and traditions. For example, he says counselors could ask:

  • When or where do you feel most connected to the larger whole?
  • What brings you the greatest sense of peace in your life?
  • What rituals, if any, do you practice that bring you comfort (prayer, meditation, walks in nature, etc.)?
  • Have you thought about using these rituals or practices to help resolve problems?
  • Do you have an understanding about a higher power? How is this helpful to you?

Evans co-authored, along with Jennifer Koenig Nelson, an article exploring adapting counseling to clients’ spirituality and religion, which was published in Religions in 2021. In it, Evans and Nelson argue that using the therapeutic approach of cultural humility to incorporate a client’s religion or spirituality into practice can result in positive outcomes for the therapeutic relationship and the client’s treatment goals. Citing Joshua Hook and colleagues’ 2013 article published in the Journal of Counseling Psychology, they define cultural humility as “having an interpersonal stance that is other-oriented in relation to another individual’s cultural background and experience, marked by respect for and lack of superiority toward another individual’s cultural background and experience.”

Cultural humility “relates to positive outcomes and reduces power dynamics in the [therapeutic] relationship,” Evans says. “The openness allows the counselor to step back and have the client determine what is most salient to them, rather than the counselor pushing for the client to focus on certain parts of their identity.” 

The counselor operating from a stance of cultural humility “allows for the client to determine if spirituality/religion is something important to them [or] salient to the work they are doing in counseling,” Evans continues. The client can then decide if they want their faith brought into counseling.

In their article, Evans and Nelson suggested an adaptation to Hook and colleagues’ guidelines for integrating cultural humility into therapy that focuses on religion and spirituality. Their revised guidelines are:

  • Remain humble when engaging with clients around spirituality and religion.
  • Do not assume you understand the client’s spirituality and religion based on prior training, knowledge or experiences.
  • Explore spirituality and religion with the client to determine what is positive and what might be detrimental in relation to their beliefs.
  • Remain curious about the spirituality and religion of the client as it relates to the presenting issues and ask questions when appropriate.

Aziz finds creative ways to incorporate the client’s faith into session when appropriate. If a client is having a hard time controlling their anger, for example, she may integrate the client’s religion into a breathing and mindfulness exercise to help them learn to respond to stressful situations in a healthy way. 

In this scenario, Aziz would first ask the client to come up with a word or phrase that is connected to their faith and has a calming effect. The client must be able to repeat the word or phrase with ease. A client may choose the word “patience” as their mantra for breath exercises, for example, because it reminds them of the Islamic scripture “God is with those who are patient,” Aziz says. 

She would ask the client to relax and clear their mind of any thoughts. Once the client is settled, she would ask them to take four deep breaths in through the nose, hold for a count of six and then breathe out through the mouth for a count of six. While engaging in this breathing exercise, they would focus on repeating their mantra in their mind. This exercise is a helpful way for clients to calm their body and mind and focus on inner peace, Aziz notes. 

Asking clients to select a mantra that resonates with them makes it more likely that they will follow through with the practice on their own, Aziz says, because it helps to make the practice personal to them. And that approach works with clients whether they are religious or nonreligious, she adds. 

“If the client requested faith-based counseling, they usually gravitate toward phrases that have religious significance” to them, she says, noting that she may also talk to the client about why the phrase is important to them.

The guided imagery “wise being” exercise (see lifepluswork.com/guided-imagery-wise-being) is another technique that counselors can adapt to incorporate a client’s religion/spirituality, Aziz says. This technique, she explains, allows clients to tap into their own faith and values.

Aziz begins the exercise by asking the client to imagine a safe space where they would feel comfortable having a personal conversation with someone they view as a wise being. The purpose of the conversation is to allow the client to discuss their problem or issue with the wise being without judgment and to receive guidance from the wise being on how to resolve or approach the problem, Aziz says.

“A lot of times people might pick a spiritual guide based on their faith,” Aziz says. For example, a Muslim client may select the Prophet Muhammad, a Christian client may select Jesus Christ or a Buddhist client may select Buddha.

After the client selects their wise being, Aziz asks them to imagine the guide walking toward them to begin the conversation. “It is almost a spiritual moment for them to have this conversation,” she notes. They “may have felt the presence of their spirit guide” during this exercise. And the exercise often provides clients with clarity or helps lead them to what they want to discuss in counseling, she adds. 

Aziz leaves the decision to share the details of this conversation with her up to client. Sometimes, it takes clients a few sessions before they are ready to share what they felt or experienced in that moment, she says. 

If a client chooses to discuss the exercise with her, Aziz often asks, “Why do you think [the] wise being said what they said?” Then together they process the client’s feelings about the wise being’s message and its meaning. She asks, “How are you going to incorporate [the wise being’s advice] into your life?” 

Overcoming challenges

Integrating a client’s faith into session may not be easy for some clinicians. Young reminds counselors that they don’t have to be an expert on a client’s religious or spiritual beliefs to be effective.

“Counselors don’t have to have the answers for [a] client’s faith questions,” he says. “It is an important part of faith development for people to struggle with questions that do not have clear answers.”

Young advises counselors to remember that staying present for the client, being curious about their experience and not projecting their own values onto the client can help to navigate the ups and downs of practice if they are focusing on a client’s faith or another area of the client’s life. 

Hughes says counselors must be willing to meet challenges and make reasonable mistakes when bringing a client’s faith into practice, and they must be willing to use compassion to correct themselves. But when counselors deal with religious and spiritual sensitivities, they don’t feel they have any space for errors.

Counselors don’t want to violate the code of ethics, Hughes says, but even if they’re doing therapy competently, they may sometimes ask irrelevant questions or make a human gaff. For example, he once worked with a Jewish client who often brought details about her faith into therapy. But when he attempted to define the Hebrew word “shalom” in reference to the client’s therapeutic goals, the attempt “fell flat,” he recalls.

“I have studied some of the original Hebrew and knew what I was talking about technically,” Hughes explains. But the client “corrected me from her personal understanding, and because I am neither Jewish nor living her life, she had the right to define what the word meant to her in relation to her goals.” This exchange highlights the need for communication and questions as well as the importance of never taking things for granted, he adds.

Fox, executive director of the Episcopal Counseling Center in DeLand, Florida, says navigating a client’s faith can be challenging for counselors when they realize the diversity of religious and spiritual perspectives. 

“You encounter a myriad of worldviews, practices, frameworks of meaning, [and] it can be daunting about where to start,” Fox says. It can be hard for counselors to “discern when a client’s religious or spiritual life has become unhealthy,” or if the real dangers of imposing their values onto the client have become evident, he adds.

Fox and Aziz recommend counselors find a mentor or supervisor or seek additional training if they have questions or want guidance on discussing faith with clients. “I think there’s a lot of benefit to talking to colleagues and supervisors [to get] a different opinion or view of things,” Aziz says.

Be curious

The counselors interviewed for the article agree that clinicians should take advantage of opportunities through professional channels and in their community to learn more about the diversity of religious and spiritual traditions of their clients.

“We learn best by engaging with individuals who are different from us,” Evans says. “Get out there, get to know people, … and be curious.”

She suggests attending different religious services and reaching out to local religious leaders who are open to sharing information about specific religious and spiritual practices.

“[Do] what makes sense clinically,” Evans says. “Start exploring things. … Take the time to be curious and investigate and interact with people outside [your] regular circle.” 

Most professional trainings about religion and spirituality are Christian in nature, Aziz notes, so counselors who are seeking guidance about other religious or spiritual traditions should consider reading books or researching multicultural blogs. 

Evans, Fox and Young recommend counselors take advantage of the resources offered by ASERVIC, including Counseling and Values (their official publication and one of the oldest peer-reviewed journals on the topic of spirituality and religion), their annual conference and webinars. 

Fox serves as co-investigator of the Spiritual and Religious Competency Project (srcproject.org), an initiative funded by the John Templeton Foundation, which aims to provide mental health professionals with basic competencies to address the spiritual and religious aspects of their clients’ lives. His team of researchers are “testing methods of training mental health professionals in spiritual and religious competence” and are tracking how mental health professionals may utilize this training nationwide. They are also “using implementation science to discover the best ways to make this type of training more likely to happen in mental health care in the future,” he says.

The project’s early research has found that more mental health training programs are open to including religious and spiritual studies, but staff lack the training to confidently teach and supervise students, Fox explains.

“Over the next five to 10 years, we are hoping that through our efforts we see this gap close so that every client who brings religion and spirituality into their counselor’s office will be met with competent help,” he says. 

Young is also hopeful about what the future holds for the integration of religion and spirituality within counseling. He says the more research that is done in this area and the more conversations that takes place among counselors, the more possibilities there are to expand the reach of religion and spirituality in clinical practice for the benefit of clients.

 

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

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

Learning to be fierce in the face of intraprofessional challenges

By Emily St. Amant October 5, 2022

I started my counseling program in 2007, so after working 15 years in the field, I have … thoughts. One of the most difficult things for me along my career journey has hands-down been dealing with other people. And I am not talking about my clients; I’m referring to other professional behavioral health providers. Looking back, I’ve had some truly memorable encounters that taught me what no book, class or training ever could. 

I want to preface this with the acknowledgment that the people whose actions I’m discussing here aren’t all good or bad. There’s a spectrum ranging from having a bad day to having a bad character, and we all bounce around on that to some extent. I’m sure others could reflect on some of my less-than-stellar moments, where I was acting out of a bruised ego or was simply hungry, and I took out my own stuff on others. We all have a shadow side. Pretending we don’t is what gets us into trouble and what causes real harm to others.

In general, I do not feel we are preparing counselors to work in an agency or organization with other types of treatment providers, other types of professionals and even our fellow professional counselors. I don’t have time to address all of that in this article, so I’ll focus on one key area I personally wasn’t adequately prepared to navigate: my working relationships with others. This is especially true in times when there was a value or priority conflict between me and the other person. There is a certain idealism that plagues training programs, including ones in the counseling field.

I have learned a lot from my experiences working in various agencies and organizations over the years. I’ve encountered people who were exceptionally kind, generous, compassionate, patient and wise. And I’ve also encountered people who shocked and angered me with the lack of empathy and respect they showed to myself and others. Later, I realized I was more disappointed and hurt than surprised or angry. I have encountered several individuals in the workplace who, if nothing else, clearly demonstrated the kind of person I do not ever want to be.

With this article, my goal is to empower other clinicians to protect themselves and be better prepared to effectively manage difficult situations in the workplace. At the same time, I hope that we will all do a better job of ensuring we are not acting in such a way that others need to protect themselves from us. Let us never be cut off from hearing what others have to say — whether it’s about our attitude, work performance and quality, or the way our behaviors affect others. And we need to stay open-minded about what others know that we do not yet understand. I admit I have failed in this endeavor in the past and will certainly fail in the future, but I think the key is to be sincere and genuinely not want to. I never want to be remembered by others as someone who hurt them or let them down.

For me to be the best counselor I can be, I can’t stop reflecting on my own personal and professional demons, deficits and errors. I can’t stop being open to feedback and seeking out opportunities for growth. Being a counselor isn’t just a professional identity or set of skills to master; it is a way of being. Who I am as a human being is shaped and molded by the values of the counseling profession. We counselors all in turn shape and mold what it means to be a counselor. Who we are as counselors not only impacts the care we provide our clients but also shapes our experiences in the workplace, the broader health care field and our world.

Learning the hard way 

Something I wish I’d been explicitly told is just because you work in mental health doesn’t mean that everyone you encounter in the workplace will care about you. In fact, if you work with enough people for enough time, you are guaranteed to cross paths with someone who does not have your best interest in mind. They will not care about your success, well-being, and physical and mental health if it gets in the way of their agenda or bottom line. Even in a nonprofit setting, people still report outcomes of some kind to their managers, financers and stakeholders, no matter what impact this has on you. Even if you play a vital role on a team that collaborates on initiatives and projects, that doesn’t always mean you will be given credit or that the workload will be distributed equally. There will always be people who are willing to sacrifice your health and career for their own benefit. They may use you to build themselves up while also holding you back or to avoid having to do the work themselves or face the consequences of their own actions. Some will see you only through the lens of what you can do for them. It’s almost as if they’re asking, “How can I use your labor, skills and expertise to shape my own reputation? How can you make me look good?” People in more powerful positions and people who hold greater influence will essentially ask you, “How can you help me?” I have had almost that exact question directed at me explicitly, but more often that intention goes unspoken. We should be cautious to avoid creating exploitative and harmful power dynamics. We should be asking those we supervise, manage and work alongside, “How can I best serve and uplift you? How can we work together toward the greater good?”

Ego is a thing. You will work with people who lack awareness of or concern for how their own behaviors impact others around them. Some therapists I’ve worked with have appeared to be two separate people: They act one way in front of management and their clients and a completely different way with their peers or subordinates. Some people will be averse to any feedback, act spitefully or haughty, or seem to be easily threatened for no clear or rational reason. I’ve encountered other clinicians whose behaviors and/or explicit statements communicate they think they are superior because of their training, education, theoretical orientation, clinical focus or specific profession. Egos are walls. They get in the way of us being able to engage with others productively and deeply. One thing I’ve realized is that if you’re dealing with someone’s ego, you’re more than likely fighting a losing battle.

You will also encounter co-workers, managers, supervisors and directors who have poor boundaries. You may witness workaholism be glorified and rewarded, and you may have unrealistic performance expectations placed on you. People are routinely punished and shamed for attempting to strike a healthy work-life balance. This can happen directly; for example, I had a past manager say to me that if I didn’t work 60 hours in a week (without overtime pay, mind you), I “didn’t care about the kids.” The retaliation for boundary setting can also happen indirectly with people being fired for “not being a good fit” or being passed over for promotions if they don’t routinely work overtime. You will also see firsthand why ethical codes are necessary regarding boundaries with clients. There’s a reason codes explicitly state not to do something: Counselors are really doing those things. 

You will meet other mental health providers who plain and simple are not healthy themselves. There is a level of gatekeeping that should happen within the mental health professions, but the gray area between observably impaired and functionally problematic is inadequately addressed in practice. There is a difference between being a “wounded healer” and not being on a healing path at all. I often use the metaphor of a “healing train.” None of us will ever get to the destination of being completely healed and perfect; what matters is staying on that train and resetting ourselves when we veer off track. Yes, practitioners are trained and have skills that are helpful to their clients even if they have never experienced a specific clinical concern themselves, but this is not the same as a counselor who believes they can be an effective provider without doing their own personal work. We all have our “stuff,” and many of us are drawn to the helping field because of our own personal experiences. No matter how much training and education we receive, if we aren’t doing the deep and difficult work of examining our own weaknesses and healing from our traumas and pain points, then we put our efficacy as a clinician at risk. This is why self-care is an ethical imperative for counselors. We can’t lead others somewhere we’ve never been before.

Truths that guide me 

These lessons have taught me a few truths along the way — ones I wish I had known from the start because they could have guided me as I managed difficult interactions or situations.

The first and most important truth is that most of the time how other people treat me has nothing to do with me. We are all working out our own “stuff” in the best ways we can, and we often experience someone wrestling with themselves as they impact us negatively. Just because someone is educated, charming, brilliant, credentialed, licensed, published or highly renowned doesn’t mean they are immune to the human experience.

You will never know everything, and that is OK. It is genuinely OK that you can’t be the best at everything. This should be obvious, but I think this is at the heart of a lot of defensiveness and problematic interpersonal behavior. Everyone turns to counselors and therapists for answers and solutions, but we ourselves are fallible, limited human beings. That is not just OK — it’s why we are so good at what we do in the first place. Because we are imperfect human beings, we can help other imperfect human beings find meaning, purpose, joy and peace. So it’s OK to not have a perfect answer to why things are the way they are and how to best live, change and cope. When we refuse this truth and believe that someway, somehow we have managed to be special and the exception, then, of course, it will be uncomfortable and painful to be confronted with the reality that implies otherwise because we will always fail at perfection. If it feels unbearably embarrassing and shameful when others find us out, which will happen, then that is something to carefully examine and reflect on. We are setting ourselves up for failure if we place unrealistic expectations on ourselves, and in turn, we are also setting those around us up for failure because this will without a doubt morph into unrealistic or even exploitative expectations of other people. This shame can lead us to act out and engage with others in harmful ways. The work of being a counselor calls for radical self-compassion, but this is impossible without also reflecting on who we are in relationships and how we are extending that compassion to others.

Success is collective. By lifting others up and supporting them, we ourselves benefit. By sabotaging or disenfranchising others, we hurt ourselves as well. I need to make sure I am doing my best to live this truth by how I engage with others, and I need to be prepared to set boundaries and make needed changes if others in my life are not. I would have left some relationships and jobs much sooner than I did if I had only believed in myself and my intentions more. Do not trust anyone who acts in a way that pushes others down in any way; just because you aren’t their current target doesn’t mean you never will be. If someone doesn’t give credit where credit is due, they are a selfish person who will never be your true ally or partner. If someone seems frequently jealous and doesn’t get excited about the success of others, they may very well be more likely to try to hold you down and sabotage your health and success. Collective action is required for success, and this has to include communities holding people accountable for their actions and inactions when needed. We should all aim to align ourselves with people and organizations that are doing the work to uplift those around them and to stand up for others as well.  

Boundaries are everything. Boundaries help us navigate the reality that we are responsible for both ourselves and each other. Yes, the adage “with great power comes great responsibility” is true, but any level of influence comes with responsibility, no matter how small or insignificant it may seem. All too often we do not acknowledge the real impact we have on each other as humans, possibly to assuage our guilt and enable our avoidance of this burden of responsibility. Any encounter between two people is an opportunity for either healing and growth or, alternatively, harm and suffering.  

Personal relationships, workplaces and workplace relationships are all vital parts of our lives that have the potential for great positive impact as well as negative or harmful consequences. I like to think of the range in terms of spice levels:

  • Mild: unhealthy
  • Medium: toxic
  • Hot: abusive
  • Scorching: violent

Anyone in a mild to moderate situation has the choice to stay and accept things as they are or work for positive change. If it’s hot or scorching, the only real way to get relief is to get away and seek emotional “burn” care.

Not all “defensiveness” is bad. It’s unacceptable how a lot of us are taught to “manage” our defensive behavior. It’s upsetting when you are confronted with someone pointing out how sensitive you are to constructive feedback, but early in our counseling careers, we need to know that our internal emotional protective system isn’t our enemy. We need to be taught to trust ourselves, to listen to how we feel and to know that sometimes defending ourselves and others is what we absolutely need to do. By not teaching this balance of managing unhealthy defensiveness, that’s often ego-driven, with the reality that there are other people who can and will harm us if we don’t protect ourselves, we set a lot of people up to essentially be conditioned to be complicit in their own abuse or oppression. Yes, we need to remain open to feedback that’s constructive and comes from someone who genuinely cares about us, but we also need to have discernment and the wisdom to know what feedback we should absorb and what we should shield ourselves from.

We must take responsibility for setting our boundaries, and we must allow others to do the same. Remember the only thing you can really control are your own words, actions and reactions, including how much you tolerate other people and situations. Emotional responses are automatic and unconscious, and although we have influence over these responses, we can’t expect ourselves to have complete control over them. They exist for a reason, and one of the main reasons we have intense emotions and anxiety is to protect ourselves. 

I’ve had clients who have asked me to help them “just deal with” the situation that’s causing them harm, but as the saying goes, “You can’t heal in the same environment that is making you sick.” Leaving is often the best solution in relationships that cause us harm, be it with an intimate partner or an employer. I now realize that when I stayed in an unhealthy or harmful situation, I was not taking responsibility to care for myself or to consider how I was affecting the other person or environment. I am not referring to what could amount to blaming the victim of abuse or the recipient of boundary violations for another’s action; it is absolutely inappropriate to place any level of responsibility on the receiver of another’s behavior. However, by staying in an unhealthy environment or indirectly enabling unhealthy behaviors, I was essentially teaching that person that what they were doing was acceptable because I stayed put and tolerated it. I was not doing my part to stop them from not only harming me but also negatively affecting others. Oof! 

It’s important to know where the line is between what you are responsible for and what the other person is responsible for. Without this line, it can be a slippery slope toward excusing, enabling and even rewarding unhealthy behaviors in the workplace and our personal lives. 

If you set enough boundaries, you are guaranteed to get pushback. And it will be uncomfortable. To take a lesson from Nedra Glover Tawwab’s book, Set Boundaries, Find Peace: A Guide to Reclaiming Yourself, the only people who have a problem with others setting boundaries are the people who are benefiting from another’s lack of boundaries. We need to be prepared for how others may react when we stand up for ourselves and refuse to be taken advantage of or treated poorly. 

People who see relationships as only transactional or who want to use you for their own purposes will absolutely get irritated or angry for your refusal to comply with their attempts at control or manipulation. Often to further manipulate the situation in their favor, they label the boundary setting or the accompanying response as the problem. This allows them to preserve their reputation at the further expense of the other person being harmed. 

All too often, we blame the person reacting to another’s behavior instead of addressing the source. This criticism, invalidation and punishment of the reaction to abuse is what is called “reactive abuse.” This line of reasoning can also be taken to its logical conclusion and turn into excusing and enabling harmful or outright criminal behavior (for example, blaming the victim of assault for what they were wearing). This is commonly discussed in the context of abusive intimate partner relationships. However, I’ve seen this play out in the workplace, and it can lead to ruptures in trust and morale and causes real psychological harm. 

Abusive behavior is always the fault of the person doing the abuse. Unhealthy behaviors are always the responsibility of the person acting inappropriately. How we manage these encounters to protect ourselves and others are, in fact, our responsibility. By standing up for ourselves, setting boundaries, and leaving harmful and abusive situations, we are also helping others. We are teaching others what’s right and what’s wrong and what they can and cannot get away with.

Not everyone deserves access to your softness. Too often I believe counselors and healers of all kinds are expected to be “nice” and to be available for everyone for anything all the time. This is far from what’s healthy, sustainable or realistic. Just because we’ve chosen a helping profession doesn’t mean we have to sacrifice our own well-being, safety or sanity. It’s taken me years to learn and truly believe that yes, I am kind and sweet and silly, but I am not “nice.” I am fierce. And that fierceness is not a flaw; it is one of my most valuable strengths.

A part of who we really are is defined by how we meet life’s most uncomfortable and distressing challenges. As counselors, we will experience some of these challenges in the workplace, so we need to be prepared to navigate these and to support others as they navigate them as well. We need more humanity, compassion and humility built into the systems that train and cultivate providers whose very effectiveness depends on their own humanity, compassion and humility.

I leave you with these three reminders: You are not a leader if you don’t build up those around you, those coming up behind you or those who are in your charge. You are not successful if you hinder the success of others. You are not a healer if you are not allowing yourself healing.

 

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Keep pushing to be better

I’ve learned so much from people who have shown me grace and patience. They showed me what’s possible and what I want to be. And I’ve also realized what I do not want to be from those who were self-focused, judgmental, and, to be perfectly blunt, haughty and elitist.

Some of my most painful and anxiety-filled moments with managers, co-workers and educators in the mental health field have taught me that I never want to:

  • Be someone who can’t be taught something new and is unable to value perspectives that differ from my own.
  • Advocate for “the way things have always been.”
  • Argue that “it’s really not that bad so nothing needs to change.”
  • Support something because “I made it through it, so everyone else should have to also.”
  • Hire people who are experts at something I am not and then fail to listen to or consider their input and feedback.
  • Assume I know what is best for another person.
  • Manipulate or coerce others into doing something against their will.
  • Use an offer of “feedback” or an explanation that I’m “just trying to help” as a way to rationalize violating someone’s boundaries.
  • Forget we all carry unseen burdens.
  • Doubt the validity of anyone else’s sincere effort or report of emotional pain.
  • Yell at a colleague. (Yes, really.)
  • Expect those I manage or supervise to meet my social and emotional needs.
  • Jump to conclusions and assume I’ve been told the whole story.
  • Throw someone else under the bus to make myself look good.
  • Make promises I can’t keep or say yes when my actions say no.
  • Disregard the needs of others and forcefully try to get my way.
  • Punish or delegitimize someone because they defend themself when they have been wronged or harmed.
  • Publicly call out people for what they’ve done wrong or criticize others in front of colleagues.
  • Tell someone else they are providing inadequate or subpar care or work because they aren’t doing things my way.
  • Look down on other helping professionals in the field who provide services to people in other ways aside from psychotherapy.
  • Consider myself a superior clinician because “I do a deeper, more meaningful and more important” type of therapy.
  • Promote the further disenfranchisement and oppression of already marginalized people.
  • Fail to look at the whole person and their situation.
  • Cause someone more harm because they were already struggling.
  • Put my own pride and ego ahead of anyone else’s health, success or well-being.
  • Fail to use my power to stop someone from hurting or mistreating others and enable them to continue perpetrating harm.
  • Allow unsupportive, counterproductive and inadequate people to persist without consequences or be rewarded.
  • Make others work harder and longer hours to pick up my slack, or if I’m their manager, tolerate someone being ineffective and causing an inequitable workload to be placed on others.
  • Offer mentorship but fail to mentor and focus on my own advancement instead.

I’ve also had the privilege to work with some from truly inspiring and wonderful people. I’ve witnessed many examples of bold and commendable actions that have left me amazed, and looking back, there have been so many seemingly quiet and mundane encounters that really were so important and affected me more than I realized at the time. These encounters taught me that I always want to strive to:

  • Give credit where credit is due.
  • Help others network and introduce people who may share common interests or support each other professionally.
  • Show others how much they mean to me.
  • Be there for others when they need it most.
  • Genuinely care about others, not just their work performance but their humanity.
  • Listen with patience and kindness when others express their concerns and how their work environment is making them feel.
  • Ensure others feel connected and that they know they belong.
  • Tell people you see how hard they are working.
  • Praise in public. Offer constructive feedback and conduct disciplinary actions in private.
  • Show up and be present during meetings.
  • Keep my word and do what I’ve said I’ll do when I’ve said I’ll do it.
  • Recognize if the success and/or advancement of others depends on me in any way, and if it does, then act accordingly and timely.
  • Remind people to care for themselves and encourage them to do things they enjoy outside of work.
  • Set boundaries and have a life. Log off on time, take time off, etc.
  • Stand up for myself and others.
  • Speak the truth to those who have more power than I do.
  • Make work fun and connect meaningfully with those around me.
  • Push back against things that are unethical or fraudulent.
  • Leave relationships and jobs that I’ve outgrown or those that are toxic and harmful.
  • Trust that others are doing the best they can.
  • Give support when it’s asked for and when it is not.
  • Take responsibility for my actions.
  • Be true to myself. By letting my playfulness, weirdness, creativity and passion be seen, I give others permission to be true to themselves as well.

Becoming the best version of yourself requires work and self-reflection. Here are some reflection questions I offer specifically related to the topic of hand:

  • What would it be like if I let go of my need to be perfect?
  • What would change if l gave myself permission to get things wrong while I am trying to get things right?
  • Am I living out my values in all my relationships?
  • How do I impact my clients, peers, mentees, co-workers and supervisees?
  • How do I see those I serve, manage and supervise? Am I seeing them as individuals I have responsibility for, or do I only see them for what they can do for me or how they reflect on my personal reputation?
  • How am I supporting and building up those I counsel, manage, supervise and work with?
  • Do I really have this person’s best interests at heart? If I do not, what am I willing to do about that?
  • What am I doing to ensure my clients, co-workers, peers, supervisees, mentees and others feel truly safe, valued and uplifted?
  • What boundaries do I need to strengthen?
  • Am I taking on anything that is actually someone else’s responsibility?
  • How can I be fierce and brave? Am I ready to take on the challenge of being assertive?
  • How can I prepare myself in case I experience pushback and negative consequences when setting boundaries and speaking truth to power?
  • Am I doing my part to take responsibility for how I impact others?
  • Am I open to receiving feedback? No, really, am I?
  • Are my own needs met? How am I ensuring I am getting my needs met and in a way that is healthy?
  • What am I doing to care for my own mental health, physical well-being and overall life satisfaction?
  • What priorities do I need to shift? What do I need to do more of? What do I need to distance myself from or let go of?

 

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Emily St. Amant is a licensed professional counselor and board approved clinical supervisor (in Tennessee). She serves as the counseling resources and continuing education specialist in the Center for Counseling Policy, Practice and Research at the American Counseling Association. Contact her at estamant@counseling.org. 

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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

‘Not a monster’: Destigmatizing borderline personality disorder

By Scott Gleeson October 3, 2022

Rose Skeeters, a licensed professional counselor in Eau Claire, Michigan, said she’s been in a room full of counselors who scoffed at the mention of treating an often-dreaded diagnosis: borderline personality disorder (BPD). 

The contemptuous response among clinicians is one Skeeters is used to. It’s also a common scenario that’s being replicated in private practices and agencies across the country. In a 2022 literature review of mental health workers’ attitude toward people diagnosed with BPD (published in the Journal of Personality Disorders), Karen McKenzie and colleagues found that mental health professionals have largely negative views of BPD — ultimately impeding proper treatment.

“BPD doesn’t just have a stigma in society; it’s in our profession too,” says Skeeters who was diagnosed with BPD in her early 20s before her mental health career fully launched. “Part of why I tell my story and experience with BPD is because it’s a diagnosis that is seriously misunderstood, and the mind of someone with borderline personality isn’t empathized with enough. There are clients out there struggling with this who need our help.”

Skeeters, who hosts the podcast From Borderline to Beautiful, is among a growing wave of clinicians who specialize in the treatment of BPD, which has become one of the most common personality disorders. BPD was first conceptualized as a mental illness by Otto Kernberg in 1975, and then it was officially introduced as a disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980. This disorder is characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self and strong emotional reactions. 

The high suicide risk and explosive emotional behavior often associated with BPD are among the many concerns that can prompt eyebrow raises among clinicians and a high referral rate. BPD is also frequently underdiagnosed, largely because it has varying and dynamic symptoms that can initially present as other disorders. Societal stigma doesn’t help either, with BPD being a diagnosis closely tied to hostile behavior in popular culture. During the recent controversial trial between former couple Amber Heard and Johnny Depp, for example, Heard was assessed and diagnosed with BPD by a forensic psychologist and portrayed as angry and impulsive, which was used as a way to discredit her by Depp’s legal team. 

Skeeters has the unique perspective of viewing this disorder from an “in recovery” client purview as well as from a clinical lens now as a professional counselor. She notes that despite the distorted perception of the diagnosis, recent research on the effectiveness of psychological treatments for BPD (such as Sophie Rameckers and colleagues’ article published in the Journal of Clinical Medicine in 2021) illustrates BPD to be highly treatable and the most healable among personality disorders.

“The biggest misconception about borderline personality is that it isn’t treatable,” Skeeters says. “It may be difficult to treat because emotions can rev up from 0 to 60 very quickly for someone with BPD, and in those moments, the logic of reality just isn’t there for that person. But this is not a life sentence and it’s not hopeless to get better. With proper treatment, clients can become self-aware and recover.” 

A trauma-informed approach 

Alisha Teague, a licensed mental health counselor in Jacksonville, Florida, says she’s seen the stigma associated with BPD perpetuate or even exacerbate symptoms for clients because of the damageability to one’s self-esteem. That’s why when working with clients, she makes determined attempts to redefine the disorder’s meaning by zeroing in on its symptomatology.

“Clients with borderline personality are so much more used to being rejected of love than actually healing,” notes Teague, the founder of the private practice Out of the Box Counseling. “When you call it ‘abandonment disorder,’ that helps them grasp a key part of the disorder while empathizing with themselves. I’ve seen clients say, ‘Oh, that’s why I have low self-esteem.’ Then when you tie in attachment theory, a client with BPD can see their behavior is tied to [a] fear of losing the closest person [to them]. That helps us move right into paths to push for secure attachment.” 

Lauren Lucas, a licensed clinical social worker for Fox Valley Institute in Naperville, Illinois, says she also treats BPD by first exploring the deepest root of the behavior. And trauma is often an underlying concern. In a 2021 literature review published in Frontiers in Psychiatry, Paola Bozzatello and colleagues found that up to 90% of clients diagnosed with borderline personality have experienced some type of childhood trauma or neglect. Similar studies have determined BPD is more prevalently linked to trauma than genetics. 

Lucas recommends counselors take a trauma-informed approach when working with these clients. “Nine times out of 10, a trauma is present for someone with borderline personality,” Lucas says. “Even if it’s ‘little t’ trauma, when clients can understand how their past pain shaped their world, it frees them up for self-acceptance. So often with BPD, there’s this reaction to fear of abandonment that’s driving their behavior.” She finds that being direct about what could be causing some of this plays a crucial role in the client’s movement and growth.

Lucas adds that a client experiencing BPD is often  plagued with self-hatred or self-loathing emotions, making a psychodynamic approach a direct pathway for clients to have empathy for themselves. “Sometimes the biggest hurdle can be a client’s self-shaming,” she says.

Shame is also a core feature of BPD, as noted by Tzipi Buchman-Wildbaum and colleagues’ 2021 meta-analysis published in the Journal of Personality Disorders. Christine Hammond, a licensed mental health counselor in Winter Park, Florida, says that for clients with BPD, feeling “seen and heard” with their root trauma (and in general) can help to offset those lurking shame emotions and accelerate their empathy for others. 

One way for clients to feel seen is by using a family systems approach — whether it be exploring upbringings or reconciling with family members directly and indirectly in session. “My approach for most personality disorders is to not necessarily treat the individual but the family as a unit itself,” Hammond says. Roles and dynamics within the households, she explains, often provide a blueprint for what’s happening in present day. 

“A lot of times, in a family dynamic, clients are used to matching volume for volume or verbal assault with verbal assault. It’s the only way to survive or be heard,” Hammond says. “Seeing that some of this isn’t their fault can lead to more empathy for themselves. The goal isn’t to hang out in the past or stay in trauma-land for too long, though. It’s to find paths forward.” 

An alliance based on patience and transparency  

As with any client, a therapeutic alliance is necessary for one’s emotional safety and well-being. Because people with BPD often struggle with mistrust, Hammond acknowledges that counselors may need to build trust gradually. 

“Part of the challenge as a therapist is accepting clients constantly pushing back and sometimes trying to sabotage because that can happen when they’re attempting to undo the deepest wounds of mistrust,” Hammond says. “No matter how safe therapy can be in their mind, trusting someone … takes building that stability over time because they’ve maybe never had it in their entire life.”

Because a lot of counselors are afraid to work with someone diagnosed with BPD, clients are used to constantly changing clinicians, Hammons notes, which only adds to the feeling that nobody understands or relates to them. But counselors can work against that pattern by simply being there, she adds. 

Sara Weand, a licensed professional counselor in Philadelphia, says that offering clients a safe haven through an alliance can be essential when they may be consumed with emotional turbulence. 

“The biggest thing you can do to build trust is honoring that their feelings are real,” Weand advises. “So many times, therapists can get lost in the facts, but that merely perpetuates invalidation. It takes a special skill to be able to meet the person where they’re at and accept them there before launching into work.”

Weand views the therapeutic alliance as a partnership where she and the client are working together toward a goal. This partnership, she says, relies on two things: the counselor understanding that they do not know everything and the client realizing that what they’ve been doing isn’t working. 

She often explains this concept to clients by comparing this alliance to being in a rowboat together with the goal of reaching the other side of the lake. “It’s not my job to row a certain way if it [the responsibility of rowing] is theirs. And it’s also not me rowing back if there’s a hole in the boat,” she says. “It’s important to have mutual responsibility. That may be fostering a healthy relationship of push-pull for the first time in their life because they can see I’m not going to ditch them or abandon them like maybe they have been in other parts of their life. But I’m also going to push them regularly.”

Lucas echoes Weand’s point about client accountability, noting that she’ll often be transparent from the start so clients know what they’re in for. 

“The need for a sense of safety and security is paramount, and as a clinician, you’re not going to make any progress without that,” Lucas explains. “I personally find that being direct can be really refreshing for clients with BPD when forming the alliance. We talk about how coming to therapy is not always going to be comfortable and pleasant. I can still provide unconditional positive regard while also not always agreeing or saying yes. Finding a way to articulate that with care and security can help work against the fear of abandonment or black-and-white thinking.” 

A proper barometer for diagnosis 

Transparency is also important when it comes to diagnosing BPD. Yet another casualty of the stigma tied to BPD is a reluctance among some clinicians to properly assess and diagnosis this disorder. In particular, practitioners who work with an eclectic mix of clients often have trouble determining if and when to diagnose a client with BPD, especially if another diagnosis such as posttraumatic stress or major depressive disorder exists, Skeeters says. 

Skeeters strongly believes a diagnosis, if accurate, is necessary to convey to a client for their well-being and stresses that clinicians shouldn’t sway away from delivering one.

“It’s always important to give clients [the] truth. If a clinician is afraid of how a client may act, then that is their own stuff coming up,” she says. “You wouldn’t tell someone who has diabetes they have something else or that ‘you maybe or could have diabetes.’ If you’re walking on eggshells because you don’t want to hurt the person, it will likely make it worse in the long run because one thing someone with BPD is craving more than anything is trust. Telling them the truth, even if it’s hard, will help toward that.”

In fact, Skeeters admits that one of her biggest complaints is that her BPD wasn’t diagnosed earlier. “In some ways I feel like I lost out on years of my life because therapists misdiagnosed me or were too scared of delivering the diagnosis. I was told that I had bipolar II and was treated for an eating disorder when the underlying issue was tied to borderline personality,” she says.

Hammond, however, cautions clinicians to consider the client’s age and development before giving them a diagnosis. She says timing is everything and resists assigning a BPD diagnosis to her teen clients because, as she points out, a client’s maladaptive behavior can more thoroughly be inspected in adulthood. “I hate adolescent diagnoses,” she stresses. “I go to Erik Erikson’s eight stages of personality development, and a client needs to be developed enough before diagnosing in my opinion.” 

Lucas also pays close attention to the delivery of the diagnosis, and she trusts her intuition on when the right time may be to discuss this with clients. 

“The approach I take is first having a discussion on what a diagnosis means to them,” Lucas explains. “Then I’m acknowledging their trauma and how it affects their behavior in the here and now. If they experienced neglect growing up and are struggling with their partners in relationships today, then I might say, ‘Here’s what we may call that.’ It’s never an easy conversation. But to my surprise, there’s a tremendous amount of relief that can come when a client is able to name why they’re acting the way they are. The language in the delivery matters just as much as the diagnosis.” 

Skeeters takes time to explain the diagnosis to her clients. She begins by saying, “This is what I’m theorizing with a diagnosis,” and then she describes why and how it applies to treatment. A diagnosis, when delivered from a collaborative sense, can bolster self-awareness and, as a result, improve a client’s work ethic in therapy, Skeeters notes.

DBT as the ‘gold standard’ treatment method 

The method of choice for BPD is undoubtedly dialectical behavior therapy (DBT), which combines standard cognitive-behavioral techniques for emotion regulation and reality testing with concepts of distress tolerance, acceptance and mindful awareness that largely spawns from meditation practices. Marsha Linehan, the psychologist who developed DBT in the late 1970s as a result of her own mental illness, defined the dialectical component of DBT as “a meditation-focus,” which is accepting things the way they are while simultaneously pushing for change to achieve happiness. Allowing clients to engage in both of these experiences at once paves the way for an increased emotional and cognitive regulation by helping them learn the triggers that lead to undesired explosive and reactive states. 

Weand, a DBT instructor in Philadelphia, describes DBT as a balance between meeting a client where they’re at while also pushing for change. DBT is all about building a client’s skill set to face their inner conflict in a way that projects outward in a healthy manner, she explains. 

“DBT is the gold standard of treatment for BPD for a reason, and that’s because it works,” Weand says. “It allows the therapist the opportunity to validate the client and really connect on a human level. The skills are all practical, but the meditation-focus creates room for slowing it down and honoring feelings as real. CBT [cognitive behavior therapy] can work as a standard therapy, but for people with BPD who feel so deeply, sometimes, painful shit is just painful shit and you can’t necessarily reframe that.”

“DBT can be effective with suicidal ideation,” Weand adds, “but it’s important to have proper boundaries as a therapist and refer to advanced care because DBT is not suicide prevention.” 

One treatment that is often complementary to DBT is eye movement desensitization and reprocessing (EMDR), which, as Lucas points out, can help with the dissociation a client with BPD may experience when they are unable to regulate intense emotion. 

“One of the biggest things EMDR can help with is the acceptance piece of regulation,” she says. “We cannot change what happens to us, but we can change how we react” to it. 

Hammond says that DBT’s focus on mindfulness can help to bolster a client’s self-awareness and therefore improve their ability to control or manage explosive and eruptive behavior. The overall gain from DBT isn’t necessarily removing a behavior; it’s slowing things down so that triggers can be managed and dysregulation can be altered, she explains. 

“We usually don’t see the behavior completely go away,” Hammond adds. But it provides clients “with a higher level of awareness and really knowing themselves.”

Untangling black-and-white emotional thinking

A common symptom of BPD is black-and-white emotional thinking (i.e., splitting), which involves seeing people or situations as all good or all bad. Skeeters says that type of intense relational trauma is a byproduct of an “emotional playground” that clients with BPD can find themselves trapped in and reactionary to when reenacting old wounds with partners. For that reason, if clinicians are working with a couple and one of them has BPD, then that individual’s treatment must come before couples therapy can begin. 

Nopphon_1987/Shutterstock.com

“Growing up, I viewed the world through a hyperbolic lens,” Skeeters recalls. “I was very sensitive and assumed that others viewed it that same way too. In my effort not to become abandoned, I ended up becoming this tyrant with dysfunctional beliefs. It can feel like other people are making you out to be a monster and that just makes it worse. I didn’t know that other people weren’t hyperbolic or lacked empathy the way I did. When it came to my relationships, to even start the path to recovery, I had to be brutally honest with myself and know how my behavior affects others around me when I’m on that emotional playground.”

Lucas says that the best way to address black-and-white emotional thinking and encourage accountability is through preventive measures and psychoeducation. 

“Because folks with BPD have more extreme experiences with emotions, it’s important to provide tools of regulating and grounding for moments of being triggered,” she notes. “When it’s showing up in a relational aspect, it’s [about] helping clients understand the way their brain may be operating in those moments [and] why they might fixate on how things should be or need to be. When someone is splitting or seeing in black and white, it can be difficult to see the gray area or the nuance of an argument or situation in a relationship. When we look at those patterns, not naming them as good or bad per se, but honor where they’re coming from and why they’ve served someone, then they can be adjusted better.” 

Weand says she’s noticed that most of her client’s black-and-white thinking comes after a big fight or a relationship failure. “I’ll have a client come in and their biggest pain is that ‘people think I’m crazy’ and [they] just want to feel like they’re not a monster,” she said. “They truly fear they’ll be doomed to be [perceived] this way their entire lives. The reality is they may be doing [and saying] things that look crazy [and that affect or hurt others]. … But once you show them where it comes from and that it can be regulated, there’s hope.”

Confronting countertransference 

Transference and countertransference can be ongoing issues when treating clients who have BPD, so counselors need to do their own work by becoming more self-aware and going to therapy themselves. 

Teague acknowledges that her own personal experiences with a family member who has BPD once challenged her ability to work with clients who are diagnosed with the same disorder. It took personal tragedy to push her to do her own self-work to develop the self-awareness and emotional availability that she now uses in helping clients with BPD.

“In 2020, I was smacked in the face by so many terrible things: a tragedy with a client happened, a friend from high school died [and] then everything with George Floyd came about,” Teague recalls. “I didn’t realize it right away but all of my own personal trauma was coming up. If I didn’t go back to therapy to do my own work and forgive myself to become self-aware, then I wouldn’t be able to work with this type of population. You need to have that awareness because countertransference is bound to come up for some types of cases. You need to have the tools within yourself first.”

Weand acknowledges that she needs to keep her caseload low and have only 10 clients so that she has full emotional availability for clients with BPD. “We have to be honest with our own limitations,” she said. “Mood-dependent behavior is tiring, so by setting those limits and having those boundaries, we’re giving our clients the best fit in a therapist.” 

Hammond said she’s seen therapists fret when working with clients experiencing BPD, and she can often trace it to their own inner struggles that may need to be worked out elsewhere. 

“Obviously, if you have countertransference that makes it unhealthy for the client, then a referral is necessary,” she says. “But I see too often therapists might have their own issues or misconceptions with BPD or don’t have the right education on it so they’re very quick to toss them [the client] to somebody else.” She acknowledges that this tendency is not helpful, and she hopes clinicians will develop healthier attitudes toward clients with BPD moving forward. 

“When you look closer, you can see that BPD clients are some of the most creative, imaginative and passionate people we have in the world,” Hammond says. “That’s why it’s so sad they’re misconstrued because I greatly enjoy working with them — seeing them fight to improve and then [eventually] get there is one of the most healing and powerful things you can do as a therapist.”

 

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Scott Gleeson is a licensed clinical professional counselor in the Chicago suburbs, specializing in trauma and relational dynamics. He spent over a decade writing for USA Today, where he won national writing awards from the Associated Press and NLGJA: The Association of LGBTQ Journalists. His debut contemporary novel, The Walls of Color, and its sequel, Spectrum, will hit bookshelves in 2024 and 2025, respectively.

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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.