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Counselors Audience

Building client and counselor resilience

By Laurie Meyers December 26, 2018

Merriam-Webster offers two definitions for resilience. One is literal and drawn from physics: the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress. The second definition is a symbolic mirror of the first: an ability to recover from or adjust easily to misfortune or change.

In the past, many experts ascribed this ability to an innate quality that certain people possessed but others did not. More recently, however, researchers and mental health experts have concluded that resilience is multifaceted — something that is influenced by genetics, yes, but also something that can be built and enhanced over a lifetime (see sidebar, below).

“I believe we all have the capacity for [resilience],” says licensed professional counselor (LPC) Cara McCarty, “but it’s not something that’s earned or received without work. It’s not something that we just get for free. It’s something that you fight for, you have to work for, you have to earn.”

McCarty says that in the counseling profession, the idea of developing resilience — at its essence, the ability to rebound, bounce back and overcome — has most often been linked to trauma work. However, she believes it is something that counselors should be trying to nurture in all of their clients. Indeed, resilience is so central to McCarty’s counseling philosophy that she named her Oklahoma City practice Resilience Counseling.

McCarty says it was her initial work as a counseling intern with transgender clients that opened the door for her to see what she calls the “incredible power” of resilience. As she points out, transgender people are a minority even within the LGBTQ community, are marginalized by society and live every day in bodies that they don’t feel are their own. They often have co-occurring depression and anxiety and are pursuing a goal that often feels out of reach to them — to live fully as the gender with which they identify. Despite all of these challenges, they choose to keep going and pursue being themselves. This ability to endure in the face of existential obstacles led McCarty, who continues to work with transgender clients, to believe that resilience is the key to navigating all of life’s challenges.

LPC Karl Memmer has also based his practice on resilience. “I believe the concept of resilience captures the balance between the acceptance of the negative in our lives and the acknowledgment that we can all develop the skills necessary to overcome the adversities we all face,” he says. “Building resilience empowers individuals to take more control of their own lives, take responsibility for what they can and cannot control, and develop a greater sense of confidence in overcoming challenges. … I feel it is central to the practice of counseling as, ultimately, our jobs are not to take away the burdens of others but to help them organize the chaos in their own lives by listening objectively and helping them develop or enhance skills to more effectively take action and responsibility.”

Assessing and building resilience

What does resilience look like? McCarty says that in her experience, people with high levels of resilience are more “flexible,” meaning they are more easily able to adapt and adjust to life’s happenings as needed. This applies to everything from being inconvenienced by a simple mix-up in plans to being diagnosed with a serious medical condition or experiencing the sudden death of a loved one. People with high levels of resilience take in what has happened to them and ask, “What next?” she explains. Other people, such as those who struggle with anxiety, are less flexible, so they have to work harder at building their resilience.

McCarty isn’t aware of a scale or assessment tool to measure a person’s resilience. Rather, she says that she begins introducing the concept at intake. In her paperwork, she asks clients to describe past difficulties that they have overcome. “It gives me a window on how they view themselves,” McCarty says.

Clients sometimes leave this question blank because they don’t view their own challenges as serious or particularly difficult. In other instances, clients may perceive that they have failed to address the challenges in their lives. In either case, the responses give McCarty an opportunity to explain resilience to her clients, point out the ways in which they have already been resilient and discuss ways to continue building on that resilience.

“I think everything counts as a chance to be resilient, [such as] changing jobs or moving neighborhoods. It’s not just for major life events but for things that happen all the time,” she says.

McCarty’s aim is to help clients recognize that they are already using their personal strengths and attributes — such as grit, toughness and persistence — every day to do hard things on a smaller scale.

“For example, let’s say my client has been working on social anxiety and we’ve made a goal of attempting low-pressure conversation three times this week. My client reports they spoke to someone in the break room at work, they made small talk with their cashier and they interacted with someone while pumping gas,” McCarty says. “I might ask them how successful each of these were. Let’s say two out of three were positive. I might ask my client if they noticed a change in their anxiety with each interaction and if they felt the interactions got easier or harder. Assuming their anxiety was lower with each interaction and they felt more comfortable as a result, I would point out how their grit and persistence kept them moving forward.”

“In this example,” she continues, “even if the interactions were negative, the fact that the client kept trying shows grit and persistence and helps the client understand that it’s not about the result of the interaction, it’s about the attempt. The more attempts we make, the easier it is to keep going regardless of the result or outcome. Resilience is the culmination of this practice and work.”

Andrea Cooper, an LPC and licensed clinical professional counselor who works with Memmer at Resilience Counseling and Social Skills Center in the Richmond, Virginia, area, says that building resilience often begins with shoring up clients’ self-esteem. She asks clients to keep a thought record, which helps them monitor what they are feeling and how they are reacting to situations that they find difficult or unsettling. The goal is to uncover automatic thoughts tied to negative
self-perceptions.

“Someone who has ideas about contributing to a business meeting but doesn’t speak up may be listening to their own automatic thoughts,” Cooper says, “such as ‘No one will care. They will not think this is a very good idea. Who am I to speak up?’”

She explains that these negative self-messages are often an indication of false core beliefs, such as “I have nothing of value to contribute” or “I’m not smart enough.”

“Developing an awareness of that automatic thought trail gives the person an opportunity to interrupt their habitual response — not contributing — by choosing alternative statements to tell themselves, such as ‘I feel uncomfortable speaking up, and that’s an old habit. I have an idea worth sharing,’” Cooper continues.

The process may sound simple on paper, but disrupting negative automatic thoughts takes practice. “We generally start practicing with low-risk situations — such as contributing to a social encounter in the break room — so the client gains a sense of success with their new behavior,” Cooper says.

Memmer chips away at self-esteem issues that can hamper resilience by teaching clients to distinguish between thoughts, feelings and actions. One tool he uses to do this is a “thought pyramid.” He and the client start by drawing a pyramid on a piece of paper. The pyramid is divided into three sections: Thoughts are at the top, feelings are in the bottom left-hand side, and actions are assigned to the bottom right.

Memmer then asks clients for examples of thoughts — typically negative — that frequently pop up in their daily lives. Those thoughts — for example, “I’m a loser” — are recorded at the top of the pyramid. Next, emotions such as anxiety, sadness and hopelessness that accompany those thoughts are recorded in the bottom left space. Finally, Memmer and the client move to the bottom right-hand corner: actions.

Memmer asks clients what they typically do when they feel these negative emotions. They might respond by saying that they isolate themselves from their friends. Memmer then demonstrates how those actions are contributing to a negative feedback loop by asking clients how they feel when they isolate themselves. The answer (for example, “Like an undesirable loser”) lands them back at the top of the pyramid: their thoughts.

By using this exercise, Memmer is also highlighting that clients cannot change negative thought patterns just by “deciding” to feel or act differently. Rather, they must disrupt the cycle through identifying and reframing the negative thoughts.

As clients begin changing their negative beliefs, they often come to the realization that they cannot always control their daily stress and strife, but they can control how they react. This awareness allows them to feel more capable and empowered — more resilient, Memmer says.

Because Cooper believes that cultivating emotional and physical wellness enhances resilience, she encourages clients to take time between sessions to focus on mindfulness techniques such as guided meditation. Rather than asking clients to sit down and aim for 30 minutes of meditation on their own, she recommends that they use an app such as Headspace, which offers numerous guided meditations that focus on stress, anger, anxiety and other issues. Other meditations are geared toward helping listeners sleep better or develop stronger focus.

The important things in life

Cooper also believes that helping clients identify their values — what is most important to them — and evaluating how closely their lives conform to those core principles enhances resilience. She does this by listening to clients’ stories.

For example, a client might talk about being unhappy at work because he or she is supervised very closely by a manager and expected to provide continual incremental updates. This tells Cooper that the client is feeling smothered and values autonomy at work. The client can then work to change or improve the situation by setting boundaries in the current job or perhaps looking for a different position that offers more autonomy.

Cooper has also worked with numerous teachers who feel they are never really off the clock. Responding to parent phone calls and email inquiries extends their workdays well into the evening, leaving them little time to spend with their spouse, partner or children. When these clients identify family time as one of their primary values, Cooper helps them explore whether they can engage in more family activities on the weekends or whether they might benefit from improving their time-management skills.

“Once we can name [our] values, we’re more apt to seek them out and improve our quality of life,” she says.

Cooper asserts that being connected to others is also essential to building and maintaining resilience. “Connectedness is important [because] we are social beings and need some meaningful relationship to others,” she says. She adds that depression, isolation and loneliness often accompany each other.

Cooper points out that life phase changes are one common cause for social disconnectedness. Relocating for a new job or graduating from college or high school may be exciting life events, but they often result in the dissolution of previously established social circles. “We have to learn how to connect with new people,” she says.

One way that counselors can assist clients in building resilience is to help them find ways of establishing new connections. This might involve encouraging clients to explore their interests and engage in activities. “Do what you love and you are likely to encounter others who are like-minded,” Cooper advises. She adds that religious or spiritual connections and volunteer work can also lead to rewarding social contact.

In fact, resilience is not limited to the personal level. It is also manifested at the relationship level and the community level, says American Counseling Association member Matthew Fullen, an assistant professor at Virginia Tech who studies resilience in aging adults.

He explains that the counseling relationship itself can be a source of resilience for clients because of its supportive nature. It also helps demonstrate that resilience is developed with the help of relationships that lift people up and support them. Likewise, communities such as cultural or faith-based groups not only surround people with support but derive resilience
from their shared histories, traditions and experiences.

Fullen, a licensed professional clinical counselor in Ohio, believes that group therapy is particularly effective for building resilience precisely because of this community effect. As part of a study, Fullen ran a program at a day facility that offered support and rehabilitation for people 55 and older with disabilities that severely curtailed their functioning. The group spent a substantial amount of its time discussing resilience. Members not only shared times when they had been personally resilient but also pointed out examples of resiliency demonstrated by other group members.

“I remember someone saying, ‘Every day I have this physical therapy. It’s excruciating and it’s really hard, and there are times when I feel like I can’t take one more step. When that happens, I think about this group,’” Fullen recounts. He points out that the group member was able to call on the collective resilience of the group as a source of support and inspiration that increased the group member’s personal level of resilience.

Another incident had a particularly profound effect on the group, according to Fullen. One day, he asked group members to name someone who exemplified resilience to them. Fullen was expecting people to name family members or celebrities. Instead, a soft-spoken group member shyly raised her hand and said, “Judy. Judy is who I think of,” pointing to one of the people in the room. The woman explained that Judy came in daily for difficult physical therapy and never complained.

“I know she has a lot going on at home,” the woman continued. “Her kids are having problems, and it weighs on her, but she is still able to come in and be nice and helpful.”

It was a moment of revelation for everyone in the room, Fullen says, because it drove home the point that resilience isn’t something possessed only by people who are outwardly “successful.” It can also be embodied by those who are marginalized. In fact, participants in the group showed significantly increased levels of resilience at the end of Fullen’s study.

Counselor, heal thyself

As counselors attend to clients’ resilience, they must also make sure to build and maintain their own. “What we do as clinicians impacts others,” says ACA member Robert J. Wicks, an expert on secondary stress in clinicians and the author of books such as The Resilient Clinician, Bounce: Living the Resilient Life and Night Call: Embracing Compassion and Hope in a Troubled World.

“There is a Chinese proverb that says, ‘When the tide rises, the boats in the water do as well,’” he continues. “I think this is true, but as clinicians, that doesn’t mean that raising the psychological tide is easy.”

The primary risk to counselors’ resilience is bound up in an essential paradox: The seeds of therapeutic compassion and the seeds of secondary stress are the same. Therapy is performed through reaching out to others, but the pressure caused by the therapeutic connection puts practitioners at risk for compassion fatigue, Wicks explains.

Those in the helping professions need to recognize that no matter how prepared they are, the pain of those they serve is so omnipresent that it can catch practitioners off guard and drain them, he continues.

When working with physicians and nurses, Wicks gives them a reminder of their epidemiology studies: For every case of poisoning, there are at least a dozen cases of subclinical toxicity. The parallel to counseling? He believes that for every impaired clinician, there are a least a dozen cases of practitioners who are on the edge of compassion fatigue.

“The reality is that — and this is important — clinician impairment is most often a developmental process … not a cataclysmic event,” he asserts. He adds that clinicians must learn to recognize, and lean back, when their stress is high.

Wicks says that counselors can build and maintain their resiliency by:

  • Gaining skills in regulation of emotions
  • Decreasing maladaptive behavior patterns that result from poor self-awareness
  • Improving their ability to balance their personal and professional lives
  • Developing a willingness to honestly assess their own coping patterns
  • Taking responsibility for managing personality-based coping tendencies and attitudes that drive them
  • Uncovering disruptive maladaptive coping habits, including workaholism and other compulsions
  • Treating their body/mind/spirit with respect
  • Counteracting toxic emotions
  • Learning to self-nurture with healthy pleasures
  • Using positive interpersonal skills such as assertiveness, anger management and principled conflict negotiation
  • Employing realistic work and family balancing strategies

Wicks also stresses the importance of counselors regularly setting aside time to be alone and reflect. Practitioners may be able to give themselves this necessary breathing room by modifying their habits and practice style. For instance, Wicks suggests that practitioners make it a habit of arriving early to their offices so they have time to center themselves rather than rushing in with only minutes to spare. He also advises against counselors putting client sessions back-to-back, which can cause client issues and details to run together.

Setting aside this time can assist counselors in recognizing their own foibles, protecting their “inner fire” and accepting change and loss. “We all need time to adjust and grieve,” Wicks says.

Rodney Dieser, a professor of health, recreation and community services and affiliated faculty member in the Department of Clinical Mental Health Counseling at the University of Northern Iowa, has centered his research, practice and teaching on the importance of leisure to overall well-being. He is a proponent of sociologist Robert Stebbins’ “serious leisure perspective.” Dieser, a licensed mental health counselor, believes that leisure is an essential component of maintaining counselor resilience by helping to prevent burnout.

Summarizing Stebbins’ research, Dieser explains that leisure has three categories:

1) Serious leisure involves spending a large amount of time mastering certain skills as a hobby. An example would be learning to play an instrument over time and participating in the community orchestra.

2) Casual leisure is what most people think of as leisure. It requires little in the way of special training to enjoy. Examples include relaxing, going to a restaurant, reading, engaging in social conversations, resting on a hammock or going to the beach.

3) Project-based leisure involves taking on a project that is somewhat complicated but that doesn’t involve more “serious skills.” Examples include planning a family vacation, engaging in fundraising for a local community project or participating in other kinds of volunteer efforts.

Research has shown that leisure can relieve stress, provide healthy coping methods and offer protection from the negative health effects of extreme and prolonged stress, says Dieser, a member of ACA. With that in mind, Dieser has students in his introductory counseling classes design self-care plans that include one serious leisure, one casual leisure and one project-based leisure activity. 

“Leisure programs can minimize the impact of stress through enjoyable distractions that create psychological breathers or regrouping,” he explains. “Leisure pursuits serve as a source of protection against stress because they enable coping through social support and the application of self-determination. During a stressful event, groups of similar people or acquaintances, including [those based on leisure activities], can provide a source of relief, instill hope, serve as a catharsis in expressing feelings and help a person not to feel alone. Application of self-determination through leisure allows a person to feel they have some control in their lives when other parts of their lives are out of control. … [Finally], leisure experiences can create or restore a sense of optimism through pleasant experiences in the face of intense stress.”

Cooper reminds counselors that they are their own best instrument of practice when it comes to resilience. “Practice some of the things you try to teach clients,” she urges. “Take care of your physical health, take time for yourself [and] get enough sleep.”

 

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The science of resilience

The American Psychological Association defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of threat.” According to the October 2012 Science article “The science of resilience: Implications for the prevention and treatment of depression,” genetics play an important part in people’s responses to stress and trauma, but there are also important psychosocial factors that contribute to resilience. These factors include:

  • Positive emotion and optimism
  • Loving caretakers and solid role models
  • A history of mastering challenges
  • Cognitive flexibility, including the ability to reframe adversity in a more positive light
  • The ability to regulate emotions
  • High coping self-efficacy
  • Strong social support
  • Disciplined focus on skill development
  • Altruism
  • Commitment to a valued cause or purpose
  • The capacity to extract meaning from adverse situations
  • Support from religion and spirituality
  • Attention to health and good cardiovascular fitness
  • The capacity to rapidly recover from stress

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Neurocounseling: Brain-Based Clinical Approaches, edited by Thomas A. Field, Laura K. Jones and Lori A. Russell-Chapin
  • Counselor Self-Care by Gerald Corey, Michelle Muratori, Jude T. Austin II and Julius A. Austin

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/self-care-resources)

  • Self-care Resources for Professional Counselors

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@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.

Thriving in times of crisis

By Lennis G. Echterling December 10, 2018

I am now reaching the age when people assume that I have achieved a certain amount of wisdom. I admit that I usually enjoy playing the role of the sage as a professor, but at times it definitely has its downside. For example, a new faculty member once said to me, “Hey, Lennie, you’re the silverback gorilla in our department. What’s your advice about this proposed new policy?” I was so irritated that I wanted to hit him with a banana.

For me personally, a more serious downside of aging is that I am now facing a threat to my health, well-being and life. Two years ago, I was notified that I have cancer. A biopsy that I had fully expected to be benign instead turned out to be malignant. I received the call in my office, just before leaving to teach my crisis counseling class. Ironically, after decades of responding to the crises of others, I suddenly became my own case study.

When I entered the classroom late and out of breath, still reeling from the shock of the cancer diagnosis, I realized that I had taught my students well — they immediately sensed that I was troubled and kindly invited me to talk about it. Touched by their sensitivity and concern, I decided to take a risk and openly share with them my bad news.

As I told my story, I began to feel a mixture of profound emotional relief as a person and immense pride as a teacher because my students intervened in my personal crisis with empathy, skill and compassion. It turned out to be a powerful lesson, both for my students and for me. I believe that my students learned to trust the process of counseling, no matter when, where and with whom an intervention suddenly is required. The lesson I learned was to accept the gifts that others generously offer me in my own times of turmoil. That is the essence of counselor education — to practice our craft with one another to promote professional growth and personal healing.

Four principles of thriving

As counseling students, supervisors, teachers and practitioners, we all will have our share of personal, professional and family crises. So, I offer here four principles of thriving that emerged from my own life lessons in dealing with times of turmoil, threat and adversity.

The first principle of thriving is to be resilient. Resilience comes from the Latin word resilire. To resile means to bounce back. In physics, resilience refers to the elasticity of material that can endure strain. For each and every one of us, personal resilience involves not only surviving those inevitable crises ahead, but also truly thriving in our lives.

As I reflect on my two years of cancer treatment, I find that my personal experience has mirrored the typical reactions to a life-threatening situation. I appreciate now more than ever how adaptive negative emotions such as fear and anxiety can be because they focus our attention on the threat and press us to take appropriate action rapidly. But during this time, I also have been discovering deep and abiding positive emotions such as hope, compassion and heartfelt gratitude. Those emotions have broadened and enriched my ways of being. The truth is that both negative and positive feelings are essential for surviving and thriving in times of crisis.

My second principle for thriving is a reminder that you are not alone (and neither am I). Every culture has its folk tales and myths that portray a hero on a quest. No matter how talented and strong this protagonist may be, the person neither travels nor triumphs alone. Jason, the ancient Greek mythological hero, counted on his Argonauts in his search for the Golden Fleece. Somewhere over the rainbow, Dorothy was gifted with the Cowardly Lion, the Tin Man and the Scarecrow to help her find the Wizard of Oz. And in his Star Wars adventures, Luke Skywalker relied on Obi-Wan Kenobi, Princess Leia and Han Solo.

Like the protagonists in those archetypal stories, we also will encounter others who will have a profound impact on our life’s journey. To thrive in our future endeavors, we must accept the gifts that others offer us. To flourish in our personal lives and professional careers, we need to join with others to engage in the collaborative work of supporting, inspiring, challenging and encouraging one another. We are not islands unto ourselves in achieving our potential. We cannot succeed as completely, or as joyfully, on our own.

Third, thriving in our future involves remaining committed to learning throughout our lives. Our graduate training is not a mere dress rehearsal. It is an integral part of our lifelong dedication to continued professional development. A mind is like a parachute — it works best when it’s open. And actions do speak louder than words, so we must seek out mentors who exemplify what we aspire to become, because the most important lessons in life are not taught but caught. Passion, commitment and curiosity are highly contagious. For that reason, I regularly take a close look at my colleagues and my students. What do I want to catch from them?

The counseling profession is like a fidgety kid who is never still — it is constantly on the move as students and practitioners contribute to its vitality. The Mbuti of Africa have a ritualized song that offers a wonderful example of what every professional community should aspire to achieve. In the song, individual singers are responsible for specific notes, but no one carries the entire melody. As a result, only the community can sing the song.

My fourth and final principle for thriving is to make the journey your destination. In Travels With Charley, John Steinbeck wrote, “We do not take a trip; a trip takes us.” I am neither the person who originally entered my own training program nor the beginning counselor who launched my counseling career. Along the way, I have gained a sense of confidence and trust in my own abilities. I have questioned my old assumptions and, as a result, made new discoveries that guide my work. I aspire to continue going with the flow of my career and to be open to the enormous possibilities of future transformations.

Decades ago, as I was immersed in my own graduate education, I was fortunate to develop lifelong friendships with members of my cohort. We brought to our training a similar mixture of rough edges and fine potential, nagging doubts and yearning dreams, neurotic hang-ups and transformational hopes. We told our life stories to one another and threw ourselves into heartfelt discussions that lasted late into the night. Along the way, we would party together. My fellow students taught me how essential it is not only to work hard with your colleagues but also to celebrate with them.

More lessons to learn

Six months ago, lab results revealed a recurrence of my cancer. After completing 15 more radiation sessions, my skin was a raw and painful reminder of my vulnerability and mortality. I continue to Google for any innovative breakthroughs for my cancer, to remain committed to practicing a healthier lifestyle and to explore complementary approaches. I now face a regimen of medications, phototherapy sessions, appointments and lab tests.

I have become accustomed to the role of the patient, but I endeavor to thrive throughout the process. I cherish my loved ones. I give extra hugs to my family and dear friends. And I take every opportunity to show my gratitude for the countless acts of kindness that others bestow on me every single day. My hopes and dreams for the future, which serve as the personal beacons that light my way, are to savor and cherish all the meaningful, loving and joyful moments that remain in my life. I have many more lessons to learn from my students.

 

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Lennis G. Echterling is a professor of counseling at James Madison University. Contact him at echterlg@jmu.edu.

 

Letters to the editor: ct@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, go to 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.

Some thoughts on thoughts: The inner critic and self-talk

By Whitney Norris December 6, 2018

There’s no doubt about it: Words are powerful. As a professional counselor, I return to a few themes often because of their relevance to a wide variety of presenting issues and goals that clients bring to my office. Self-talk is among my five most-visited topics in therapy. Still, I have found that the subject usually isn’t treated with the deference it deserves. Its impact on our mental health and general wellness is significant and, in my opinion, well worth exploring with our clients — but always first within ourselves as counselors.

When I use the term self-talk, I’m referencing that voice in our heads — all the thoughts in our minds that sound like one or both sides of a conversation. The unmistakable reality is that we’re constantly talking to ourselves, regardless of whether we realize it. Much has been written on the topic using various terminology. One of my favorite terms used is inner critic. I appreciate this wording because of its intent to externalize our negative self-talk and help us refrain from mistakenly overidentifying with it. Regardless of the label used to describe our negative self-talk, however, key themes emerge in our understanding of its origins, impact and proposed remedies.

Origins, impact, remedies

Many different views exist about the origins of the nature of our internal dialogue. Peggy O’Mara, an author and editor whose work centers around children and motherhood, states simply, “The way we talk to our children becomes their inner voice.” Other authors and researchers also claim that our self-talk mirrors the way we were spoken to and dealt with as children. Geneen Roth explains that as children, we learned to internalize the messages our parents sent us, for better or for worse, as a survival strategy. For example, as children, it’s best that we internalize messages such as “Don’t run out into the street.” However, those messages that sound more like “You’re worthy of love and acceptance only when you accomplish something” don’t do us any favors, either as children or later as adults.

When I delve into this topic with clients, I usually tell the following story of an experience that forever shifted my view of the importance and impact of negative self-talk. It also served as the beginning of the end of my then-thriving inner critic.

While in graduate school, I was given the amazing opportunity to intern at a treatment center where, one evening, I was invited to observe an eating disorders group. During my first visit to the group, the group therapy agenda was set to include the reading of a letter that had been assigned to one of the group members the previous week. After discovering the extreme nature of a group member’s self-talk and its connection to her disordered eating, her therapist had asked her to write a letter to herself from her inner critic, just as she experienced it inside her head on a daily basis.

During the group therapy session, this woman was asked to pick the person in the group whose voice sounded most like her inner critic. The friend she chose was a champ, following through on what he was asked to do, which was read the letter aloud to her, knee-to-knee, in the tone in which it was clearly written. The scene was heartbreaking — not only watching the emotional reaction of the woman who was being read to and hearing the awful things written in that letter, but also watching the friend who was tearfully reading those words, of which he didn’t believe a single word.

Although years have passed since I witnessed that scene, I still can’t tell the story without tearing up. It was an incredibly powerful object lesson about what our unchecked negative self-talk can turn into and just how toxic it can be for all of us and for our relationships. I think most of us can relate to this on some level with a look in the mirror. I encourage you to take a moment and imagine yourself in this woman’s shoes. If others could see and hear your inner critic, how would that change the way you talk to yourself?

Now let’s take it a step further. Not only does this inner critic mirror something we likely have no desire or intention of reflecting, but it is also self-sustaining. Imagine that you have the most healthy, robust self-esteem of anyone you’ve ever known. Then you hire an assistant who is with you continuously and who never ceases to criticize you. Even with your world-class self-esteem, your assistant’s constant monologue about your work and your worth would eventually wear you down. Without anyone else there to defend you (which is the case when this is all playing out only in our heads), you would slowly move toward believing the negativity and criticism, regardless of whether it was true. Like a slow and steady gas leak, this toxicity would filter into the way you think, slowly poisoning your view of yourself and the world around you — likely without you even realizing it was happening.

In many respects, our self-talk is no different than this hypothetical “assistant.” Regardless of whether the messages are true, if we listen to them for long enough, we will eventually come to believe them. The more deeply we believe something, the more likely we are to see the world through that lens of self-fulfilling prophecy.

Brené Brown illustrates this beautifully in her 2017 book, Braving the Wilderness: “Stop walking through the world looking for confirmation that you don’t belong. You will always find it because you’ve made that your mission. Stop scouring people’s faces for evidence that you’re not enough. You will always find it because you’ve made that your goal. True belonging and self-worth are not goods; we don’t negotiate their value with the world.”

In his book The Four Agreements, Don Miguel Ruiz posits that our acceptance of someone else’s abuse is contingent on the severity of our abuse of ourselves. He claims that we will only leave an abusive situation when the abuser treats us worse than we treat ourselves. Regarding a solution to this pattern, Ruiz goes on to say, “We need a great deal of courage to challenge our own beliefs. Because even if we know we didn’t choose all these beliefs, it is also true that at some point we agreed to all of them. The agreement is so strong that even if we understand that it is not true, we feel the blame, the guilt and the shame that occurs if we go against these rules.”

The process of seeing, challenging and replacing these rules is often a core element of therapy. We can’t go back and unsend the messages we’ve received. However, as Ruiz alluded to, we can make the choice to face the blame, guilt and shame that solidify our loyalty to these imprisoning messages. If we never make ourselves aware of these internal beliefs, we will likely continue to shoulder their burden unknowingly and to our great detriment.

So, then, what is the solution? As with many truths, it’s simple but not necessarily easy. In her excellent book Women, Food and God: An Unexpected Path to Almost Everything, Roth explains it this way: “Freedom is hearing The Voice ramble and posture and lecture and not believing a word of it. … Listening to and engaging in the antics of The Voice keeps you outside yourself. It keeps you bound. Keeps you ashamed, anxious and panicked. No real or long-lasting change will occur as long as you are kneeling at the altar of The Voice.”

Roth cites “living as if” as the solution for silencing our inner critic — living as if we don’t believe a word of it. When helping clients move toward healthier self-talk, I take a similar approach:

1) Name the lies that your inner critic is known to speak to you (they can usually be boiled down to a few major themes).

2) Label them as lies (some form of “Is this standard true for me but no one else?” or “Can I imagine speaking this ‘truth’ to a child?” usually does the trick).

3) Treat them as lies regardless of how you feel in the moment.

Every time we act out of the truth rather than a lie we’ve been led to believe, that voice becomes a bit quieter until, eventually, it fades into the background. Sure, it takes practice, but starting down the path to a healthier internal world really can be that simple.

Positive self-talk

I started with the negative side of the coin because, unfortunately, I think many of us are more familiar with it than with the positive side. I do not, however, want to suggest that it is only the negativity of our self-talk that makes it so compelling. Our positive self-talk can be equally transformative and, quite frankly, much simpler.

Similar to the inner critic, positive self-talk as a concept garners a substantial amount of attention via many different perspectives and traditions: modern psychology, meditation, mantras, affirmations, etc. The most recent mainstream perspective aiming to increase focus on the significance of our internal world is positive psychology.

In his highly entertaining 2011 TED Talk, Shawn Achor, author of The Happiness Advantage, stated, “We’re finding it’s not necessarily the reality that shapes us, but the lens through which your brain views the world that shapes your reality.” He posits that, as the adage says, we should work smarter not harder. We’re better off spending our energy remaining positive in the present moment than striving for the next thing that promises to make us happy or successful (and probably won’t deliver).

In his work with businesses, Achor reports, “What we found is that only 25 percent of job successes are predicted by IQ; 75 percent of job successes are predicted by your optimism levels, your social support and your ability to see stress as a challenge instead of as a threat.”

Near the end of his talk, he gets more practical: “We’ve found there are ways that you can train your brain to be able to become more positive. In just a two-minute span of time done for 21 days in a row, we can actually rewire your brain, allowing your brain to actually work more optimistically and more successfully. We’ve done these things in research now in every company that I’ve worked with, getting them to write down three new things that they’re grateful for for 21 days in a row — three new things each day. And at the end of that, their brain starts to retain a pattern of scanning the world not for the negative, but for the positive first.”

If you’re anything like me, you are thinking, “Nope. Sorry, I just can’t believe it could be that easy. Something that affects so much of us so deeply can’t shift significantly with an intervention so simple.” I hear you, and I by no means want to oversimplify a profound topic such as self-talk. As I mentioned earlier, many different factors play into our self-talk, many of which are the stuff of therapy. However, I do believe that the jumping-off point can be as simple as a small consistent habit such as practicing gratitude.

This concept applies across the board, well beyond the scope of gratitude specifically. As Achor mentioned, a daily practice of noticing and acknowledging something shifts how we operate on a subconscious plane. We can change our thinking on a fundamental level, in whatever category, by sheer force of focus. That focus is changing our internal world over time in a way that can bring more lasting change than any amount of in-the-moment, conscious white-knuckling. As Kristen Neff aptly states in Self-Compassion: The Proven Power of Being Kind to Yourself, “Who is the only person in your life who is available 24/7 to provide you with care and kindness? You.”

One of the biggest real-life examples of this for me came from an experience during my college years. One day, a friend invited me to a weekly small group she had been attending for a while. She explained that the group wasn’t studying anything and didn’t have a specific agenda. Group members simply spent their time together talking about the ways they had seen God show up in their lives over the past week. Looking back, I’m sure I went to this group to prove that nothing good could come from warm-and-fuzzy share time without some intellectual bounty involved. What I found, though, surprised me. At no other time have I been more aware of daily divine intervention in my life as when I was attending this group. Do I believe now that God was moving more at that point in my life than at others? No, not at all. What was different was merely the fact that I was looking for it and paying attention. So, I found it.

For those who perhaps need a more research-based example, keep reading. This topic also rose to the surface while I was working at a residential treatment center soon after finishing graduate school. It was a small facility, and I was the rookie therapist, so, naturally, one afternoon I found myself scrubbing some graffiti off one of the bathroom walls next to my office. Apparently, I was using my outside voice while saying “I love my job” over and over to myself (sarcastically, in case that’s not evident).

At that point, one of my supervisors walked past and said, “Hey, you know that actually works, right?” After pausing a second to take in my more-than-slightly aggravated facial expression, he proceeded to tell me about an article he had read on a common practice of Navy SEALs. In doing some fact-checking, I found that Navy SEALs have used positive self-talk as a part of their training curriculum for years, resulting in significantly higher passing rates in their training program.

Eric Barker, in his book Barking Up the Wrong Tree: The Surprising Science Behind Why Everything You Know About Success Is (Mostly) Wrong, says we should pay close attention to what Navy research has shown us about the impact of self-talk: “A Navy study revealed a number of things that people with grit do — often unknowingly — that keep them going when things get hard. One of them comes up in the psychological research again and again: ‘positive self-talk.’ Yes, Navy SEALs need to be badass, but one of the keys to that is thinking like ‘The Little Engine That Could.’ In your head, you say between three hundred and a thousand words every minute to yourself. Those words can be positive or negative. It turns out that when these words are positive, they have a huge effect on your mental toughness, your ability to keep going. Subsequent studies of military personnel back this up. When the Navy started teaching BUD/S [Basic Underwater Demolition/SEAL] applicants to speak to themselves positively, combined with other mental tools, BUD/S passing rates increased from a quarter to a third.”

Simple steps

Let’s sum up some of the practical pieces of positive self-talk. As I mentioned earlier, elements of our internal world create barriers to the simplicity of what I presented here about changing our self-talk. This is where a wise, trusted friend or personal work with a therapist can help you navigate what gets in the way of harnessing the power of healthy self-talk.

When trying to help clients (or myself) understand how self-talk should best sound, I try a few different avenues, asking questions that challenge the internal beliefs that function as the cogs of the internal self-talk machine. If we force one gear (the negative) to stop turning and instead focus our efforts on movement of the positive gear, our mind will automatically begin moving in the direction of wellness.

Even our simplest intentional daily actions change our brains and the brains of our clients. It really is that simple.

 

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Whitney Norris is a licensed professional counselor and somatic experiencing practitioner in Little Rock, Arkansas. In 2017, she co-founded Little Rock Counseling, where she practices as a trauma specialist. She also provides case consultations and private practice business coaching for professionals. Contact her through her website at whitneynorris.com.

 

Letters to the editor:  ct@counseling.org

 

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Related reading, from the Counseling Today archives:

A protocol for ‘should’ thoughts

Quieting the inner critic

 

 

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

The use of evidence-based practices with oppressed populations

By Geri Miller, Glenda S. Johnson, Mx. Tuesday Feral, William Luckett, Kelsey Fish and Madison Ericksen December 3, 2018

Therapy must always be tailored to the individual; there is no one-size-fits-all model. However, certain approaches have been empirically verified for use with a variety of clientele. It is critical that all counselors, especially those working with client populations that are oppressed, have both an overview of evidence-based practices and specific techniques related to these approaches in their clinical toolboxes to help them provide the best counseling services possible.

Counselors are frequently required to use evidence-based practices and need to know how to use them effectively in counseling clients who are oppressed. Specifically, the unique development of the therapeutic relationship between oppressed clients and privileged clinicians must be understood and addressed. Multicultural counseling experts Derald Wing Sue and David Sue maintain that the dynamics of oppression shift the influence of the therapeutic relationship. Thus, counselors must alter their application of evidence-based practice techniques.

Solution-focused brief therapy and low socioeconomic status

Take a moment to think about what the basic needs of your own life are. What is impossible for you to live without? For many of us, our basic needs are continually met. Therefore, they often go unnoticed — they are woven into our everyday lives and ways of being in the world.

For others, questions such as “Will I eat today?” or “Will I have a safe and warm place to sleep tonight?” are asked daily. Often, the answer is “no.” Concerns such as clean drinking water, access to hygiene products and finding adequate shelter affect an inordinate number of individuals in the United States. School counselors and licensed professional counselors have a moral and ethical obligation to address these matters, with the intention of removing barriers and cultivating a safe space for clients in both the therapeutic relationship and the environment beyond our office walls.

Glenda Johnson (one of the co-authors of this article) worked as a school counselor and an advocate in a school system in which the majority of students came from low socioeconomic status (SES) backgrounds. Many of the students were on free or reduced lunch plans because their families’ financial resources were severely limited. At the core of Johnson’s work was the intent to ensure that every child’s basic needs were met while they were at school. She emphasized the importance of working collaboratively with other school staff members to build a team and a foundation for connecting these students and their families to resources.

It is also vital to assess an individual’s behaviors, emotions and reactions through a holistic, biopsychosocial approach rather than focusing only on the school context. Learned behavior concerns, inattention, difficulty with emotion regulation (anger), sadness and loss of hope are often the result of a lack of resources. Johnson recalls that if a student acted out, one of her first questions would be, “Did you have breakfast this morning?”

Johnson shares an anecdote that highlights the powerful act of providing a safe, therapeutic space for students to identify and voice their emotions openly with peers. As a school counselor, she infused the identification of various emotions into a game of musical chairs, and what transpired was completely unexpected. A student identified a “sad” emotion and explained that their father recently had lost his job. The student was experiencing fear about not having enough food to eat during this time. Then, other students began to share similar stories without prompting. The game of musical chairs transformed into a collaborative and touching experience as the students identified common ground and connected on deeper levels of understanding and empathy.

When providing services to individuals from a low SES, counselors may find it helpful to use a strengths-based therapeutic approach. The evidence-based practice of solution-focused brief therapy (SFBT) zeros in on the therapeutic relationship and the clinician’s way of being. In this relationship, there is an acknowledgment of reality but also an emphasis on solution-focused thought and reframing. Focusing on strengths, the counselor and client work together to identify and move toward making small changes in any area because a small change in one area often leads to change in another area.

SFBT often introduces the “miracle” question: “Suppose that when you go to sleep tonight, a miracle occurs that solves your problem, but because you were sleeping, you did not realize what happened. When you wake up in the morning, how will you realize a miracle happened? What will you notice that you are doing differently?” These questions enhance and expose glimpses of solutions that an individual may struggle to identify in everyday life situations.

Additionally, SFBT places great value on successes. The counselor and client celebrate achievement and may use scaling to note the client’s progress. When working in a school system, the counselor could develop a creative and motivating way for children to rate themselves and their progress toward goals. For example, Johnson created a rating scale, complemented by the colors green, yellow and red, for kindergartners and first-graders. Green identified a completed goal, yellow identified progress toward a goal and red identified room for improvement. Similarly, she used a rating scale of 1-5 for students in second through fourth grades. Under this scenario, a student could check in with a rating, such as, “I am at a 3 and working toward a 5.” The counselor might respond, “What would it take to get to a 3.5?” The scale provided a visual for children to identify, track and celebrate their successes.

In SFBT, the counselor acknowledges client strengths and walks alongside these clients as they create and work toward their goals and future successes. “Flagging the minefield” is another technique counselors can introduce to help clients generalize and apply what they learn in counseling to future situations. Flagging the minefield is a particularly important facet of SFBT because it assists individuals in recognizing potential obstacles or barriers that will appear in their lives. The counselor and client work together to identify tools and resources the client can apply in other settings and relationships.

When working with students living in poverty, counselors should introduce a strengths-based approach and identify and gather resources to assist students and their families in removing barriers and meeting basic needs. Cultivating a safe, therapeutic relationship with students that focuses on solution building can assist them in building a stronger sense of self.

Motivational interviewing, SFBT and rural adolescent substance abusers

Adolescence is a vulnerable time and a critical period for developmental outcomes. During this stage of life, adolescents are exploring and forming their peer relationships and personal identities while beginning to distance themselves from family. Experimentation with substances often begins during this time. In 2012, Tara Carney and Bronwyn Myers found a correlation between the early onset of substance use and an elevated risk for later development of substance use disorders. Additionally, because early substance use may impact the growth of the adolescent brain, it has the potential to heighten one’s risk for delayed social and academic development.

Adolescents living in rural areas are marginalized in multiple ways. Children are an underserved minority population, as are rural populations. Sheryl Kataoka, Lilly Zhang and Kenneth Wells (2002) found that among youth with a recognized mental health need (estimated at 10 million to 15 million people), only 20-30 percent receive specialized mental health care. Rural communities are more likely to have fewer clinicians or require a long drive to see those clinicians, making it more difficult to obtain care. These disadvantages are exacerbated by the tumultuous nature of adolescence.

Motivational interviewing and brief interventions are two evidence-based practices particularly suited to this population because these approaches are generally influential in their therapeutic role while also being cost-effective. Motivational interviewing facilitates behavior change through exploration and resolution of ambivalence, and it focuses on being optimistic, hopeful and strengths-based. It uses principles of empathy, discrepancy, self-efficacy and resistance, and offers specific techniques such as OARS (Open questions, Affirmations, Reflective listening, Summarizing). SFBT emphasizes solutions, changes clients’ perceptions and behaviors, helps clients access their strengths and uses techniques such as exception to the problem, specification of goals and the miracle question.

Individual interventions with the use of the same interventions for multiple sessions are ideal, and research suggests that the earlier the intervention, the better the outcome. Early intervention shows better results than both preventive measures and later interventions because it reduces the need for more specialized interventions and provides applicable and useful tools and tactics for adolescents as they enter into various student, peer, familial and professional roles.

Challenges certainly exist when working with children and adolescents, particularly because many biological, environmental and social shifts occur organically during this time. As children and adolescents rapidly transition on a continuum of development, they become “moving targets.” Interventions that prove effective for those ages 11-12 often cease to be effective by ages 13 or 14. It is vital that counselors remain aware of this across the life span. Although adolescents are beginning to distance themselves from their caregivers, familial relationships and parental involvement remain crucial during this period.

To appropriately and competently involve the families of rural adolescents, some understanding of cultural values is necessary. In 2005, Susan Keefe and Susie Greene identified core Appalachian values, including egalitarianism, personalism, familism, a religious worldview, a strong sense of place and the avoidance of conflict. In the Appalachian region, assuming authority without demonstrating an authoritarian attitude is important. Language tends to be simple, direct, honest and straightforward. Family is extremely important, exemplified by the adage “blood is thicker than water.” Individuals’ relationship to the land is complex, and it can be beneficial to explore how clients view economic deprivation. In 2016, Sue and Sue also pinpointed some tendencies of rural clients, including having a “street-smart” attitude and way of being, depending on systems due to living in poverty and valuing survival at all costs.

As a result, subtle techniques such as stages of change, motivational interviewing and SFBT may be useful for this population. In stages of change, the intervention is matched to the stage of the client’s readiness to change (precontemplation, contemplation, preparation, action, maintenance, termination). Motivational interviewing facilitates an invitation to engage, and its strengths-based, hopeful tone can be helpful for clients living in an environment populated by deficits such as poverty and lack of education. The practical nature of brief therapy fits well with the no-nonsense worldview of clients coming from rural backgrounds.

Unfortunately, published rural studies often focus on specific regions or populations. Few interventions have been tested in rural settings, and the evidence from systematic reviews is often too general and not specific to the rural context. Ideally, rural communities could review interventions tested with various target populations in a range of settings. Such information is not usually available, however, and the strength of evidence is unlikely to be the only factor considered in choosing an intervention. The research on rural adolescent populations is limited, and little consistency exists across studies related to measurement tools. Furthermore, disseminating evidence-based practices to schools, families and community settings in rural areas is difficult due to the lack of resources.

However, it is important to note that there have been great improvements in substance abuse treatment and prevention with children and adolescents who live in rural areas. A 2016 Monitoring the Future survey of eighth-, 10th- and 12th-graders by the National Institute on Drug Abuse found the lowest ever reported rates of use for all illicit drugs, including alcohol, marijuana and nicotine. As further research is conducted, it will be important to delve into this information to identify what is already working with these individuals and what can be improved to better serve them moving forward.

Evidence-based practices with transgender clients

Transgender individuals face discrimination on multiple fronts. Many experience familial rejection, unequal treatment, harassment and physical violence during daily living. The rate of substance abuse within the transgender community is three times higher than that of the general population. There is a profound lack of competent health care for transgender individuals, and the care that is available may be inaccessible to a majority of the transgender population. The rate of unemployment within the transgender community is also three times greater than that of the general population, due in part to factors such as workplace discrimination, poverty and homelessness. Transgender people also face discrimination and mistreatment in shelters.

With high rates of homelessness, substance abuse and mistreatment, transgender people also have frequent interactions with law enforcement, where they can be subject to police brutality and discrimination. Within the criminal justice system, a high rate of physical and sexual assault is perpetrated against transgender individuals, and they are often denied medical treatment while incarcerated or detained.

Poor health outcomes for transgender people correlate with risk factors such as economic and housing instability, lower educational attainment, lack of family support and other intersectional factors such as race, ethnicity, immigration status and ability.

According to the 2015 U.S. Transgender Survey, 18 percent of transgender people who sought mental health services experienced a mental health professional attempt to stop them from being transgender. This correlated with higher rates of serious psychological distress and suicide attempts and an increased likelihood of running away from home, homelessness and engaging in sex work.

Research conducted in 2015 by Samantha Pflum et al. emphasized the lack of access to transgender-affirming resources and communities for individuals living in rural locations. The history of mistreatment and abuse of lesbian, gay, bisexual, transgender and gender-nonconforming clients by medical and mental health professionals must be acknowledged. Gender and sexual minority clients still face discrimination within the helping professions, and for individuals holding multiple marginalized identities, these experiences are compounded.

Even well-meaning providers are likely to make mistakes when working with marginalized clients. According to Lauren Mizock and Christine Lundquist, one of these mistakes is education burdening, or relying on the client to educate the provider about transgender culture or the general transgender experience. Resources exist to facilitate competence in these areas, and clinicians have a responsibility to refrain from placing the burden of their education on the client.

Some counselors participate in gender inflation, or focusing on the client’s gender to the exclusion of other important factors. Other counselors engage in gender narrowing, applying restrictive, preconceived ideas about gender to the client, or gender avoidance, which involves ignoring issues of gender altogether. Gender generalizing occurs when a clinician assumes that all transgender clients are similar. Gender repairing operates from a belief that a transgender identity is a problem to be “fixed.” Gender pathologizing involves viewing transgender identity as a mental illness or as the cause of the client’s issues. Finally, gatekeeping occurs when a provider controls client access to gender-affirming resources.

Acceptance of a client’s gender identity is ultimately not enough to provide competent, affirmative services. Understanding the nuances of these common mistakes will help clinicians provide a safe therapeutic environment that is affirming of these clients’ identity and humanity.

The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association, has developed competencies for counseling transgender clients (see counseling.org/knowledge-center/competencies) that focus on the following eight domains:

  • Human growth and development
  • Social and cultural foundations
  • Helping relationships
  • Group work
  • Professional orientation
  • Career and lifestyle development competencies
  • Appraisal
  • Research

Counselors can work within this framework to:

  • Promote resilience by using theoretical approaches grounded in resilience and wellness
  • Conceptualize the development of a transgender individual across the life span
  • Understand internal and external factors influencing identity development
  • Consider how identity interacts with systems of power and oppression (especially for minority transgender individuals)
  • Examine counselors’ own internalized beliefs and how those beliefs affect attitudes toward transgender clients
  • Reevaluate approaches to working with transgender clients as new research emerges

One intervention that has been identified for use with this population by Ashley Austin and Shelley Craig is transgender-affirmative cognitive behavior therapy (CBT). Transgender-affirmative CBT modifies CBT interventions to address specific minority stressors, such as victimization, harassment, violence, discrimination and microaggressions, that transgender people commonly face. This approach uses psychoeducation to help clients understand the connections between transphobic experiences and mental health issues such as stress, anxiety, depression, hopelessness and suicidality. Experiences are processed through a minority stress lens to help clients move from a pathologizing-of-self mindset to an affirming view of themselves as people coping with complex circumstances.

Clinicians are advised to affirm the existence of discrimination and to help these clients identify influences on their mental health by using the transgender discrimination inverted pyramid (see below). 

Transgender individuals internalize messages at each level, and it can be beneficial to have a visual for how these messages trickle down and influence mental health. Clinicians can empower transgender clients by assisting them in challenging internal and societal transphobic barriers. A few examples are challenging negative self-beliefs, connecting with a supportive community and advocating for self and community.

Another approach recommended for use with transgender clients by Joseph Avera et al. in 2015 is the Indivisible Self model, an Adlerian wellness model refined by Jane Myers and Thomas Sweeney that emphasizes strengths. There are five wellness factors of self in this model:

  • Creative Self: Cognitions, emotions, humor and work
  • Coping Self: Stress management, self-worth, realistic beliefs and leisure
  • Social Self: Friends, family and love)
  • Essential Self: Spirituality, self-care, gender identity and cultural identity
  • Physical Self: Physical and nutritional wellness

This model easily can be adapted to a transgender-specific lens, especially regarding the Essential Self, by exploring gender and cultural identity and how they influence client experiences and beliefs. Used in conjunction with the ALGBTIC transgender competencies, the Indivisible Self model offers helping professionals both a conceptual and practical framework for working effectively with transgender clients.

For all clients, and transgender clients in particular, intersectional factors magnify the experience of oppression. Sand Chang and Anneliese Singh recommend addressing the intersectionality of race/ethnicity and gender identity for both clients and clinicians. This involves:

  • Challenging assumptions about the experiences of transgender and gender-nonconforming people of color
  • Building rapport and acknowledging differences within the therapeutic dyad
  • Assessing client strengths and resilience in navigating multiple oppressions
  • Providing a variety of resources that are affirming to transgender and gender-nonconforming people of color

In addition, assisting clients in locating social support is advised. Social support increases healthy coping mechanisms and helps with self-acceptance, thereby reducing psychological stress related to discrimination. Social support can also help to normalize and validate emotions related to discrimination.

Conclusion

Evidence-based practices have consistently been shown to be helpful to clients, but counselors must remember that they operate within the context of a relationship. To use evidence-based practices effectively, we must hold on to our humanness. The implementation of a single technique will look very different depending on who is in the room and what they are bringing with them.

Often, the expectations for using evidence-based practices might create pressure for counselors to follow a strict formula for treatment. Process variables such as honoring the personal relationship between the counselor and the client, maintaining a “therapist’s heart” and respecting the unique aspects of the client may seem to be at odds with the procedure for using a specific intervention. A working knowledge of multicultural issues can provide some context for how to shift evidence-based practices to fit the client rather than pressuring the client to conform to a prescribed, generalized format.

Using interventions with a solid evidence base is good practice. Adjusting their implementation on the basis of the unique identity of the person sitting across from us is great practice.

 

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

Geri Miller is a professor in the Department of Human Development and Psychological Counseling (clinical mental health counseling track) at Appalachian State University (ASU) in North Carolina. She is a licensed professional counselor, licensed psychologist, licensed clinical addictions specialist and substance abuse professional practice board certified clinical supervisor. She has been a volunteer counselor at a local health department since the early 1990s. Her clientele has primarily consisted of women with little opportunity for jobs or education and who experience barriers of poverty. Contact her at millerga@appstate.edu.

Glenda S. Johnson is an assistant professor in the Department of Human Development and Psychological Counseling (school counseling program) at ASU. She is a licensed professional counselor and a licensed school counselor in North Carolina. Her scholarly focus includes school counselors delivering comprehensive school counseling programs, students who are at risk of dropping out of high school and the mentoring of new counseling professionals.

Mx. Tuesday Feral received their master’s degree in clinical mental health counseling and a certificate in systematic multicultural counseling from ASU. They are the support programs director for Tranzmission, a nonprofit organization serving the Western North Carolina nonbinary and transgender community through education, advocacy and support services. Tuesday offers training and workshops in trans cultural competence and cultural humility on local, state and national levels.

William Luckett received his master’s degree in clinical mental health counseling from ASU with a certificate in addictions counseling. He has interests in somatic therapy approaches, mindfulness, religious and spiritual topics in counseling, and substance abuse counseling. He currently provides in-home counseling to rural families in Virginia.

Kelsey Fish is a student in ASU’s clinical mental health counseling program and a clinical intern with Daymark Recovery Services in rural Appalachia. Her clinical interests include expressive arts therapy, adolescents, and gender and sexual minority issues.

Madison Ericksen is a graduate of the clinical mental health counseling program at ASU. She has specialized training and interest in trauma-informed practices that use mindfulness, eco-based and expressive art therapies as complementary treatments alongside traditional therapy. She provides strengths-based and resiliency-focused outpatient counseling for children and families.

 

Letters to the editor:  ct@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.

 

Helping families cope with cancer

By Laurie Meyers November 26, 2018

Cancer. The word alone can evoke terror amid visions of painful treatments and possible early death. Even though many advances have been made in cancer treatment, and despite the fact that heart disease is the actual No. 1 cause of death for adults in the United States, cancer is the diagnosis that many people fear the most.

Receiving a cancer diagnosis is often a devastating blow, not just to cancer patients themselves but to their families. At a visceral level, it is easy to imagine how frightening a cancer diagnosis must be for the patient, but many people — including the families themselves — often underestimate the emotional toll the disease can take on loved ones.

Dark times

Cancer casts such a dark shadow that licensed clinical marriage and family therapist Maya Pandit often encourages clients to refer to it as the “C-word” in an attempt to rob the term of its power. Cancer “is such a ‘big bad’ — not just because it can cause death but because the treatment is difficult and painful,” she says.

For family members, this means grappling with the fear of losing their loved one while hoping for a “cure” that often requires debilitating treatment. Pandit, who is trained as a medical family therapist, a specialized form of family therapy for individuals, couples and families who are coping with physical illnesses, notes that watching a loved one suffer can be more difficult than enduring the suffering oneself.

Managing physical illnesses such as cancer can be isolating and bewildering for patients and their families alike. That feeling of isolation, coupled with the stress of diagnosis and treatment, often strains family relationships — not just between the patient and other family members, but among family members themselves, Pandit explains. Her goal is to help families and couples cope with the reality of the diagnosis while providing support for the patient and one another.

When families are confronted with a cancer diagnosis, their coping strategies often follow a kind of all-or-nothing approach, Pandit says. For some people, the reality of their loved one’s illness is so painful that they refuse to talk about or even acknowledge it. Instead, these family members go on as if the cancer doesn’t exist and everything is fine. In contrast other people attempt to manage their anxiety by becoming hypervigilant and centering all aspects of daily life on cancer, Pandit says. Operating under either of these extremes only makes responding to the crisis more difficult, she adds.

As Pandit explains, getting each family member’s “illness story” is an essential step because it allows counselors to uncover the emotions and difficulties that have arisen from the diagnosis. Then counselors can begin helping the family find a more balanced way to cope. The illness story encompasses each family member’s experience of the crisis, which Pandit solicits by asking questions about when the symptoms started, when and how their loved one was diagnosed and how it felt for the family member to hear the diagnosis. These basic questions encourage a conversation that can help to verbally unlock clients, allowing Pandit to begin unwinding the emotional knots that keep family members from facing the cancer.

With clients who are hypervigilant, Pandit’s goal is to “open the door” to the thought that the cancer already plays a big role in their lives, and if they allow it to always be the primary focus, it will consume all family interactions.

“I often do an exercise in which I ask family members to fill out a pie chart of their lives and how much cancer has taken over,” she says. “We talk about the ways cancer has impacted their daily lives and the creative ways to take back what they can.” Activities such as watching TV shows and movies together or reading the same book and then discussing it serve not only as a distraction but also give family members something to talk about that isn’t related to cancer.

On the other hand, Pandit says that asking open-ended questions or talking about some of the common challenges that families coping with cancer face often helps resistant clients become more willing to speak about what they are experiencing. “If I make sure to be patient and as matter-of-fact as possible, even the most closed people open up at least a little,” she says. “I find that people want to talk but sometimes need time, space, a person who won’t shrink at the topic and, occasionally, some privacy.”

Pandit adds that the most frequent feedback she receives from family members is that once they have opened up and talked about their struggles, they feel lighter. “Talking about how people feel more often than not makes them feel as if they are not alone — that they can handle things one day at a time,” she says.

Family dynamics

Counselors should also keep in mind that each family member has his or her own individual and unique relationship to the person with cancer, says licensed professional counselor (LPC) Kerin Groves, who has worked with older adults in retirement communities, assisted-living residences, nursing homes and home care settings. “Relational dynamics are part of the family system, which often includes old baggage and unfinished business such as wounds or secrets from the past,” she says. “It is imperative that therapists ask each [person] about that individual relationship.”

Among the questions that Groves, an American Counseling Association member whose specialties include grief and loss, suggests that counselors should ask: “Who is this person to you? What does this diagnosis mean in the context of your relationship? What is the nature of your relationship to the patient, both past and present?”

“In that relationship, what are the sparkling gems and what are the sharp rocks? For example,” Groves says, “I have worked with family members of cancer patients who had deeply conflicted negative feelings about the patient, but they were aware that it was not socially proper to say so. They could either stuff their true feelings and experience inner shame and guilt, or they could speak out and experience open shame and guilt — quite a lose-lose scenario. In these situations, a therapist can best serve the family by providing a safe space for whatever needs to be vented, with no judgment.”

“Setting aside any conflicts in family relationships can be as simple as asking for it,” she says. “A counselor should not be afraid to pose the question: What relationships are you worried about right now that are distracting you? What do you need from [a particular family member] in order to set this aside for now? And what does [that family member] need from you? What needs to be said between you and [the family member] in order to move forward with more peace?”

“A counselor can be a rational outside resource in scary times,” Groves continues. “Family members make many critical decisions, and they need a safe place in which to explore options out loud and be heard, encouraged, supported, validated and attended to.”

A source of nonjudgmental support is particularly important because family members often fail to recognize or validate their need for emotional support, Pandit says. “It’s like, ‘You [the patient] are the one with cancer. What right do I have to be upset?’”

Pandit discourages family members from engaging in what she calls the “pain game” — a kind of comparison to determine who is in the most pain. She tells families that pain is pain and that it needs to be addressed, regardless of who is harboring it or the circumstances of those around them.

Mary Jones, an LPC who counseled patients and families during her 20 years in an oncology facility, agrees. She says that most of the adult family members with whom she worked, both in family counseling sessions and in a support group for caregivers, experienced debilitating emotional and physical side effects. These clients regularly reported being unable to focus, having trouble making even small decisions and becoming easily overwhelmed. With their worlds being transformed, sometimes overnight, by a loved one’s cancer diagnosis, some clients felt so disoriented that they wondered if they were going crazy, Jones says.

These family members were often irritable, especially if they were not sleeping well. They felt a pervasive sadness but were often afraid to cry lest they further upset other family members and friends. Physical symptoms such as backaches and stomach issues were also common. Not surprisingly, Jones says, the turmoil often affected these family members’ work lives and personal relationships. 

As Groves points out, counselors may not be working with cancer patients or families in a typical 50-minute therapy session. “Counselors working in cancer treatment centers, infusion clinics, oncologist’s offices and other medical settings may do mini-interventions of 15 minutes between physician visits, or two-hour support group meetings, or brief encounters in hallways or treatment rooms. In these settings, a counselor’s role should simply be [to act as] a calm presence. They are to listen, support, be a container for powerful emotions — including angry rage or hysterical crying — and provide warmth and acceptance.”

A life-threatening illness typically necessitates a major shift in roles and responsibilities within families. One of the things counselors can do is help clients prepare for and cope with these changes in family structure, says licensed marriage and family therapist Ryan Wishart, who also specializes in medical family therapy. For example, a mother with breast cancer who will no longer be capable of doing the bulk of the child-rearing would need the father or other family members to step in and shoulder more responsibility in that area. If the person with cancer is the family’s primary breadwinner but is too sick to work, it may require other family members finding additional means of financial support. Housework may need to be distributed differently, and older children may have to become more independent.

Wishart helps families assess and redistribute their duties by creating a deck of cards that have major roles, responsibilities and chores written on them. “We discuss who ‘owned’ which cards prediagnosis and ways that they can be redealt,” he says.

Groves raises a similar point. “There can be very practical concerns that lie under the surface and get ignored in the medical crisis,” she says. “For example, if one family member insists that the patient be able to go home but dumps the caregiving duties on to someone else, emotions can erupt. A counselor can help by walking the family through the practical options that are both available and realistic.”

Giving care

Caregiving is often one of the most difficult, emotional and divisive issues faced by families with a loved one who has cancer. Family members must work through questions such as what kind of care to pursue, whether a loved one can be cared for at home and who will provide the care.

“Many people get quickly overwhelmed with the details of the cancer journey,” Groves says. “There are just too many decisions and no crystal ball to see the outcomes of each choice. Treatment plans that are too aggressive are uncomfortable for many people, but cultural norms may prevent family members from disagreeing or questioning a medical professional. Palliative care can seem inhumane to some, sending the message that they have given up or don’t want to be bothered with the patient anymore. In addition, I have seen well-meaning doctors who refuse to give up and wait until just before the patient dies to call in hospice — much too late for the family and the patient to benefit from the supportive services they could have received in making the journey through death.”

Families may also disagree about what treatment should be pursued, forgetting that the choice ultimately resides with the patient unless he or she is no longer competent to make the decision. But even after the family has decided the where, when and how of care, providing it can be a time-consuming endeavor that is both emotionally and physically taxing. In addition, caregiving often requires difficult role adjustments or role reversals. For instance, parents battling cancer may become like children to their own children. Relationships may take on decidedly unromantic aspects when one spouse or partner needs to play a more parentlike role for the other spouse or partner.

It can be especially challenging and humbling for parents to give up so much personal control to their children, even if those children are now adults themselves, says Cheryl Fisher, an LPC whose areas of specialization include counseling families and individuals with cancer diagnoses. However, counselors can help these parents see this shift in a different light. Fisher, an ACA member, says she often reminds parents of all the years they spent getting up in the middle of the night or staying up late to give care to family members. Now it is their time to receive and accept care from others, she tells them.

With adult children, Fisher says, the adjustment usually involves probing to see what aspects of caregiving they feel confident about and which ones give rise to discomfort. Personal hygiene is a particularly sensitive area, she points out, because sons are typically uncomfortable with the thought of bathing their mothers and daughters are typically uncomfortable with bathing their fathers. Fisher validates this discomfort, letting her clients know that it is perfectly acceptable to look for home health care support for that particular task. She then talks about other areas of caregiving with which the adult children might be comfortable, such as housekeeping, cooking, doing yardwork or providing transportation.

Fisher also helps adult children who are geographically distant from their parent come up with ways that they can participate with caregiving. For instance, they may be able to contribute financially or pragmatically, such as by locating home health care support or paying for respite care. Perhaps they have enough vacation time to fly in every few months to visit and give assistance to the parent. Distance caregiving can also consist of smaller personal acts such as sending cards and care packages or FaceTiming with a parent while the sibling or other family member who provides most of the in-person care gets a much-needed break to take a nap or make phone calls.

Pandit says that couples going through a cancer diagnosis often don’t know how to talk to each other about the ways that caregiving changes the dynamics of their relationship. She helps these couples explore means of ensuring that caregiving doesn’t take over the whole of their relationship — for example, by dedicating time to just being partners again through activities such as a regularly scheduled date night. She also encourages couples to make sure they continue to talk about things other than the cancer.

Cancer foments a significant amount of fear and guilt, and caregivers often feel that if they make a “wrong” decision or take time for themselves, their loved one will get worse or even die, Jones says. This makes it even more difficult to convince caregivers to engage in self-care. Jones explains to caregivers that to properly take care of their loved ones, they must also take care of themselves. With male caregivers, she found it particularly helpful to tell them to picture themselves as a car. As a car, the caregiver must go to many destinations. Cars, of course, require gasoline to run. So, Jones would ask, what happens when the car makes a lot of trips without stopping to fill up the gas tank?

Similarly, Jones would direct women to picture themselves as a pitcher full of resources and imagine that everyone surrounding them was holding a cup. With so many cups to pour, unless the caregiver refilled her own pitcher, her loved one’s cup would eventually go dry.

Jones also recommends that clients who provide care to a family member with cancer literally schedule self-care for themselves. Making an appointment for self-care — just like making an appointment for the next cancer treatment — helps reframe it so that the caregiver starts viewing self-care as a means of survival, not a selfish desire, Jones says.

True self-care goes beyond taking breaks, getting enough sleep and eating healthy regular meals, and the source is different for everyone. Jones urges clients to identify the things that make them feel nourished. “What recharges your batteries? What fills your cup back up?” she asks. Jones says she finds even a little time interacting with nature rejuvenating, but for others, it may be practicing yoga, meditating, spending time with animals or reading a good book.

Something else that Jones urges counselors to do is to ask caregivers to identify things they can “outsource” that would make life easier. This might involve thinking of friends willing to volunteer a few hours of house cleaning each week, asking a neighbor to walk the dog or seeing if a church care group would be willing to make and deliver 10 days’ worth of casseroles.

Because caregivers are continually fighting burnout, guilt and isolation, Jones thinks that group therapy is a particularly effective method of support. Among others who understand their struggles, caregivers and other family members can more freely give voice to emotions that they don’t necessarily feel comfortable expressing anywhere else. They can admit to being tired, angry, resentful or hopeless without fear that they will be judged poorly. Groups are also a good place for brainstorming and solving problems, Jones says. Individuals can share their challenges, and other group members can talk about what has worked best for them.

Coping with the unknown

The treatment process for cancer is usually hard on everyone. Pandit says the constant ebb and flow of watching a loved one struggle and not knowing for certain that it is going to be worth it in the end is often agonizing.

Groves agrees. “An unknown prognosis is very hard for families [and patients] to tolerate,” she says. “The fear of the unknown is powerful. Facing a known outcome is certainly frightening, but at least there is little or no ambiguity. With a terminal prognosis, there are fewer choices to agonize over. There may be more powerlessness but fewer regrets.”

A terminal diagnosis can sometimes be a “strange kind of blessing,” Pandit says. Knowing the end is coming often encourages loved ones to say things they might never express otherwise, both to the person who is dying and to those who will be left behind.

“Whether the diagnosis is terminal or chronic, a good counselor will bring up universal existential concerns … [such as] fear of incapacitation, of death, suffering, aloneness, meaninglessness, and normalize them,” Groves says. “This allows family members to recognize that their fears are common to the human experience and that it is safe to talk about them. The counselor may not have a solution but does offer accompaniment on the journey.”

That perpetual state of suspended animation that accompanies an unknown diagnosis is painful, but for some family members, it is still preferable to admitting that it is time to let go. Cancer patients are often the first to recognize this truth, and as long as they still have all of their faculties, it is ultimately their choice whether or when to discontinue treatment, Fisher notes. However, family members sometimes remain in denial and may refuse to acknowledge the patient’s impending death, even pushing for continued treatment.

Jones recalls a female patient whose husband had accepted that the time had come to cease treatment but whose adult children kept insisting that the family could “find another way.” The constant badgering was completely exhausting to the patient. She finally turned to Jones and said, “I need you to look my kids in the eyes and say, ‘Your mom has three to six months to live.’” Jones followed the woman’s wishes and then urged the children to ask themselves how they wanted to spend the last months of their mother’s life.

Fisher had a 36-year-old female client with a terminal diagnosis who had moved into inpatient treatment. The woman’s mother kept bustling into the room with vases of sunflowers and other things. Her stated intent was to make the room pretty until her daughter could come back home. The daughter, in obvious distress, yelled, “Mom! I’m not coming home!”

Fisher asked for some time alone with the client and helped her come up with the words that she needed to say to her mother, which were, “I’m going to die, and I need you to be here with me.”

“Counselors often worry too much about techniques and forget to just listen,” Groves says. “Our presence is our best intervention.”

 

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Supporting the client who has cancer

“Fear is the constant companion of the cancer patient,” says Kerin Groves, a licensed professional counselor (LPC) and American Counseling Association member. “Fear that the diagnosis is wrong, fear of telling young children too much or not enough, fear that the surgeon didn’t get it all, fear that the chemo or radiation missed a few rogue cells, fear [during] remission [of] the cancer coming back, fear of getting a new type of cancer, fear of long-term effects of chemo or radiation, fear that tiny bump or growth is cancerous, fear of going out in the sun after skin cancer, fear of every stomachache or headache, fear of loss of sexual function or cognitive function, fear of social stigma with body disfigurement and so forth.”

“These chronic fears are exhausting and can exacerbate into an anxiety or mood disorder,” Groves continues. “Acknowledging fears is the best way to take the power out of them, so invite a patient to tell you all the fearful thoughts that run through their head. They can write them down or say them aloud, with no rules and no judgment. ‘Let’s release them all,’ I tell patients, ‘like taking out the trash. We don’t need them stinking up the house.’”

One of Cheryl Fisher’s current clients had cancer for many years before achieving remission and outliving the original prognosis. However, the client recently reported that she can feel her fear returning. She told Fisher that she doesn’t want to let the fear in because she is concerned about what it might do to her mentally and to the cancer itself. Fisher, an LPC and ACA member, told the client that when people fight back against what they’re feeling, it causes stress hormones to rise. So, ultimately, she says, it is better to face the fear head-on.

“When I’m sad or angry or afraid, I like to pull it outside of my body and look at it,” Fisher told her client. “Fear, you’re here. What is prompting this? What is it trying to tell me?”

The client told Fisher she was afraid that she was already living on borrowed time. As a consequence of this belief, the client was in essence just waiting for the cancer to come back, Fisher explains.

To counter the client’s sense of helplessness and being “stuck,” Fisher acknowledged that neither of them could prevent the cancer from returning, but she asked the client to consider what she did have control of. Did the client have things she had been putting off that she would like to do? Did she have things she was holding on to that needed to be said?

Another of Fisher’s clients was a newly diagnosed cancer patient who seemed to want Fisher to “somehow absolve her from her journey with the diagnosis.”

“I don’t have a magic wand,” Fisher told her. “There’s nothing I can say that will lift you from this journey that you have to go through, but I can promise that I can be there with you side by side during the journey. I can’t solve this for you, I can’t make it go away, but I promise you I will be there with you.”

Fisher notes that being an unflagging source of support is perhaps the most essential role that counselors can play with clients who are seriously or terminally ill. Sometimes, a cancer patient’s family or friends cannot or will not endure their inherent fear and stress to be by their loved one’s side, but counselors can step in and fill that gap, she emphasizes.

“Existential concerns are within all of us, with or without cancer, but cancer and other critical illnesses have a way of bringing them to the forefront,” Groves says. “The work of [Viktor] Frankl and his logotherapy concepts are very valuable for counselors to read and learn. While in a Nazi concentration camp, Frankl came to understand that each of us has a choice in how to respond to our circumstances, no matter how horrific. When all a human’s [other] choices are taken away, we still have the choice of facing our suffering with dignity. This can be empowering for a cancer patient, when presented by a sensitive counselor who honors the values and humanity of the patient.”

— Laurie Meyers

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books and DVDs (counseling.org/publications/bookstore)

  • Counseling Strategies for Loss and Grief by Keren M. Humphrey
  • Mediating Conflict in Intimate Relationships, DVD, presented by Gerald Monk and John Winslade

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Resources for Professional Counselors

Podcasts (aca.digitellinc.com/aca/store/5#cat14)

  • “When Grief Becomes Complicated” with Antonietta Corvace (ACA252)
  • “Integrated Care: Applying Theory to Practice” with Eric Christian and Russ Curtis (ACA149)

Webinars (aca.digitellinc.com/aca/store/5#cat46)

  • “ABCs of Trauma” with A. Stephen Lenz (CPA24329)
  • “Children and Trauma” with Kimberly N. Frazier (CPA24331)
  • “Counseling Students Who Have Experienced Trauma: Practical Recommendations at the Elementary, Secondary and College Levels” with Richard Joseph Behun, Julie A. Cerrito and Eric W. Owens (CPA24339)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@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.