Tag Archives: body image

‘But my clients don’t get eating disorders’

By Laura H. Choate January 11, 2021

Almost all counselors encounter clients who engage in behaviors such as extreme dieting, excessive exercising, fasting, emotional overeating and binge eating. These symptoms can be initially mild and overlooked or even viewed as normative in our thinness-and-appearance-obsessed culture. Sometimes it is hard to tell the difference between a client who is experimenting with the latest fad diet and a client who is quickly spiraling downward on the path toward a destructive eating disorder. There are two reasons this can happen.

One reason is a lack of counselor awareness. Few counselors receive much training in the area of eating disorders treatment, so they might not be aware of the need for further assessment when a client has initial problems related to eating, weight and body image. The problem is that without effective assessment and treatment, these types of symptoms have the potential to escalate into full-syndrome eating disorders such as anorexia nervosa, bulimia nervosa and binge eating disorder.

Once eating disorders have developed, they frequently become serious, complex, chronic disorders with significant biopsychosocial consequences, including potentially lethal medical complications, poor treatment outcomes, high rates of remission and high mortality rates. Anorexia nervosa in particular is associated with the highest mortality rate of all psychiatric disorders, and both anorexia nervosa and bulimia nervosa are associated with suicide attempt rates that are considerably higher than those for the general population. Suffice it to say, even the most highly trained, seasoned counselor is not equipped to work with this population alone; all clinical guidelines call for a team approach to the treatment of eating disorders. Therefore, regardless of whether we are specialists, we need to establish relationships with other providers in our communities and know when to make referrals for specialized services.

The second reason that initial symptoms might be overlooked or dismissed is that we are not just counselors, we are also individuals who live in a society in which we are all bombarded daily with messages about weight and appearance. We are all exposed to cultural ideals that equate thinness with beauty, happiness and success and that dictate strict standards regarding an ideal body shape. We all have to manage these pressures for ourselves, and few of us are exempt from developing biases and blind spots around these issues. Because of countertransference reactions in this emotionally charged area, we might unintentionally misjudge a client’s pain due to our own struggles and experiences. Therefore, when working with clients who present with issues such as body image, chronic dieting and pressures to be thin, it is extremely difficult to separate our own personal values from what is best for our clients.

So, even though you might never intend to work as an eating disorders specialist, all counselors need adequate preparation to recognize disordered eating symptoms in their clients, to know when and how to provide appropriate referrals, to understand the importance of a multidisciplinary approach to treatment, and to effectively manage personal values. To illustrate, I include three scenarios that highlight some of the complex concerns that can arise for counselors when working with clients who have problems related to eating, weight and body image.

Scenario 1: April’s intermittent fasting goals

April attends an initial session with Karyn, a licensed professional counselor with three years of experience. April reports that she has been on an extreme intermittent fasting diet for the past six months, allowing herself to eat only during a two-hour window per day. She adheres to a vegan diet because she believes it is the healthiest option for keeping a low weight. She also engages in binge/purge episodes three or four times per month (during which she does not adhere to a vegan diet but eats anything she wants). Her body mass index (BMI) is in the low to normal range.

Although April is reporting occasional dizziness, she does not want to give up her diet because she still has not reached her weight loss goal. Instead, she wants to get rid of her binge/purge behaviors, improve her body image and improve her self-esteem. She wants to work exclusively with Karyn even though Karyn does not have a specialized background in treating issues related to weight or binge eating.

Karyn believes April’s goals seem reasonable for individual treatment because she does not appear to be underweight. In addition, because April’s symptoms do not meet criteria for a diagnosis of anorexia nervosa or bulimia nervosa, Karyn does not consider April’s problems to be severe. In fact, Karyn knows a bit about intermittent fasting and its current popularity, so she believes that she can help April evaluate her diet plan.

Implications for counseling practice:

The ACA Code of Ethics states that counselors must know their scope of competence and practice within their areas of training and experience. Karyn is taking a risk in her agreement to treat April because without additional medical assessment, she has no way of knowing the extent of April’s disordered eating behaviors or how her symptoms are affecting her physiologically. It is likely that April is experiencing medical complications even though she does not appear to be underweight.

American Psychiatric Association practice guidelines state that in treating eating disorders, we should always work as part of a treatment team that includes at minimum a therapist, a dietitian and a medical professional. By agreeing to work in isolation and ignoring the need for collaboration, Karyn would not be able to adequately address the medical components of April’s weight loss — and without a medical referral, she would be working outside of her scope of competence, which could cause potential harm to April. In addition, she seems to ignore the fact that April’s behaviors could possibly be progressing to a severe eating disorder.

One way to address these potential problems is for Karyn to inform April that in order to begin treatment, she will need to agree to see a medical professional for evaluation. Based on these results, Karyn might also need to work with a nutritionist, in addition to possibly making a referral to a mental health professional who has more expertise in treating emerging
eating disorders.

Scenario 2: Nila’s secret and Asha’s dilemma

Nila is a 15-year-old who is in counseling at her mother’s insistence. Nila tells her counselor, Asha (a child and adolescent counselor in a general private practice), that her mother is too intrusive in her life, is always telling her that she should lose weight, and tries to control all of Nila’s food intake.

A few weeks into therapy, Asha notices that Nila has swelling in her neck area and has a large scrape on the fingers of one hand. When asked about this, Nila reveals that she has been trying to diet according to her mother’s demands but “just can’t stick to it.” Subsequently, she has engaged in binge eating by sneaking food from the pantry and eating it quickly so her mother will not know. She hides the wrappers in her book bag and throws them away later. Nila then uses self-induced vomiting, a technique she learned from watching YouTube videos, to try to “get rid of the calories.” She begs Asha not to tell her mother because she does not want her mother to become even more controlling of her food intake.

Asha isn’t sure of the next best step to take because Nila is in a normal weight range and seems to be healthy overall. Asha decides not to inform Nila’s parents and keeps working with Nila individually because she wants to respect Nila’s privacy.

Implications for counseling practice:

In resolving the issue of whether Nila’s parents need to know about her binge/purge behaviors, Asha has to balance the parents’ legal right to know what is disclosed in sessions, Nila’s ethical right to privacy and autonomy, and the counselor’s duty to provide effective treatment and protect Nila from future harm. In making this decision, Asha recognizes that Nila does have an ethical right to privacy and could possibly be harmed if her mother becomes even more controlling over her food intake.

However, Asha should also be very concerned about Nila’s emerging diet/binge/purge cycle because this is a potentially high-risk behavior. While the binge/purge behaviors are not currently life-threatening, Asha needs to consider the serious and potentially lethal nature of eating disorders, the chronic and compulsive nature of the diet/binge/purge cycle, and the medical and psychological consequences of any emerging eating disorder. Because Nila is an adolescent, her health could deteriorate quickly due to weight loss and purging behaviors.

American Academy of Child and Adolescent Psychiatry practice guidelines call for a comprehensive medical examination, working with a treatment team, and family involvement in the treatment of eating disorders. For any of these treatment aspects to occur, the parents would need to be informed of Nila’s disordered eating behaviors; Nila can’t arrange for them herself. In this case, therefore, Nila’s parents would need to be informed, even if this goes against Nila’s wishes.

In order to respect Nila’s right to privacy and minimal disclosure, however, Nila should be involved as much as possible when her parents are informed. If feasible, the information should be shared in a family session. If Nila can be in the session when information is disclosed, she is less likely to feel betrayed by Asha. If Asha can establish an alliance with the parents while also maintaining trust with Nila, Asha can start to work with the family system to create better communication. The parents need assistance in allowing for increased, developmentally appropriate autonomy and privacy for Nila. At the same time, Nila will have to accept her parents’ assistance in helping her manage her disordered eating symptoms.

The entire family would benefit from education about the harms of dieting, particularly for children and adolescents, and how food restriction is directly linked to binge eating and
is often the trigger for binge/purge cycles. With Asha’s help, the family can start to focus more on overall health and communication and far less on control over Nila’s eating, weight and body shape.

Scenario 3: Jamie’s diet advice

Jamie is a female counselor who works for a community counseling agency. Jamie’s client Dan reports frequent binge eating that causes him a great deal of distress, guilt and shame. Dan is a 45-year-old man who is in a higher-weight body. Jamie assumes that Dan needs to eat less and lose weight to feel better about himself because of his larger body size. She does not assess for an eating disorder but rather persuades him to pursue weight loss as his treatment goal.

In contrast with what she deems as Dan’s “weaknesses,” Jamie is highly invested in maintaining her own weight, daily exercise routine and “clean eating.” She feels a certain pride in her own self-discipline and thinks that Dan’s problems result from a lack of willpower and effort on his part. She is quite uncomfortable with Dan’s body size and tells him he would be better off in his career and relationships if he were to lose weight.

Dan reluctantly agrees to restrict his calories and to exercise more, even though he has tried “hundreds of diets” over the years. As time progresses, he feels discouraged and even worse than he did prior to treatment with Jamie because he can neither adhere to the weight loss plan nor stop his binge eating. He drops out of treatment, believing he is a failure.

Implications for counseling practice:

Even though binge eating disorder is by far the most common eating disorder (occurring in 3.5% of women and 2% of men), it was overlooked by Jamie in this example because her client is male and has a larger body size. In addition to neglecting assessment for binge eating disorder, Jamie seems to lack awareness of effective treatment for binge eating.

American Psychiatric Association practice guidelines for the treatment of binge eating disorder state that dietary restriction is actually contraindicated; in fact, dieting is known to trigger and sustain binge eating. There are biological and psychological reasons for this relationship. When Dan (or anyone on a diet) restricts food, he begins to deprive himself of the energy needed to maintain his current weight. As a result, the brain sends out warning signals telling his body to slow down because it thinks it is entering a time of famine. It also tells Dan to take in more fuel to prevent what it perceives as starvation. In an effort to preserve energy and fight against weight loss, his body’s metabolism will decrease, he will have more thoughts about food, and he will become increasingly hungry.

Second, the more Dan imposes restriction and deprivation on his life, the more he will experience psychological reactance — an internal battle that ensues anytime we perceive that our personal freedoms are being restricted. He will start to think about, crave and, eventually, overeat the very foods that he has ruled “off-limits.” He will likely eat more, not less, because of dietary rules. And for Dan, who has a long history of binge eating, his hunger, deprivation and dietary rules will most likely serve as triggers for continued binge eating. This will lead to a cycle of guilt/shame, dieting, broken rules, binges and more guilt/shame.

In addition to pushing a potentially harmful treatment plan, Jamie seems to be having difficulty managing her countertransference reactions. Like so many people in today’s culture (including many mental health and medical professionals), Jamie appears to have a bias against people in larger bodies. Because she believes that losing weight is the “answer” to Dan’s problems, she imposes this value on him even though he is seeking treatment not for weight loss but for reducing his symptoms of binge eating. Jamie’s discomfort with her client’s body is a form of weight-based discrimination that can cause Dan to feel judged and further marginalized.

Research indicates that weight stigma actually demotivates, rather than encourages, health behavior change. In response to weight stigma, people tend to eat an increased amount of food and are less likely to adhere to a diet plan. To avoid further stigmatization, they tend to avoid exercise, fearing additional judgment from others. They also tend to delay medical care to avoid stigmatization from medical professionals who may further criticize, blame or shame them for their weight. Jamie’s personal values in this case are causing her to display a lack of respect for Dan’s dignity and welfare. In sum, her biases and lack of knowledge of effective treatment for binge eating disorder are actually causing her client harm.

Key takeaways

The following list is a summary of considerations for counselors when they encounter clients who experience problems with eating, weight and body image:

  • Remember that anyone can develop an eating disorder. Do not assume that only underweight white women have eating disorders. For example, binge eating disorder is the most common eating disorder, and it occurs in people of all sizes and cuts across both gender and race/ethnicity.
  • During the intake process, ask questions about the client’s attitudes and behaviors toward eating, weight and body image. Remain aware that initial symptoms can potentially progress to full-syndrome, complex eating disorders.
  • Regardless of your treatment setting, be aware of resources, and be prepared to make proper referrals so that clients can receive specialized care when needed.
  • Effective eating disorders treatment involves a multidisciplinary approach.
  • Counselors, like all people, can have strong biases in the areas of eating, weight, body image and the importance of appearance. We have to be careful about imposing these values on our clients.
  • Weight stigma is a form of discrimination that serves to marginalize and shame people. It is not a value supported by the counseling profession.

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Recommended resources:

  • “Ethical Issues in the Treatment of Eating Disorders” by Laura H. Choate (in The Cambridge Handbook of Applied Psychological Ethics, edited by Mark M. Leach and Elizabeth Reynolds Welfel, Cambridge University Press, 2018)
  • “Assessment and diagnosis of eating disorders” by Kelly C. Berg and Carol B. Peterson (in Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment, edited by Laura H. Choate, American Counseling Association, 2013)
  • American Psychiatric Association practice guideline for the treatment of patients with eating disorders (2010): tinyurl.com/APAEatingDisorders
  • “Practice parameter for the assessment and treatment of children and adolescents with eating disorders” by James Lock, Maria C. La Via and the American Academy of Child and Adolescent Psychiatry Committee on Quality Issues, Journal of the American Academy of Child and Adolescent Psychiatry, 2015
  • National Eating Disorders Association: nationaleatingdisorders.org
  • Academy of Eating Disorders: aedweb.org/home

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Laura H. Choate is the Jo Ellen Levy Yates endowed professor of counselor education at Louisiana State University in Baton Rouge. She is the author of five books, the most recent of which is Depression in Girls and Women Across the Lifespan: Treatment Essentials for Mental Health (2020). She has 40 publications in journals and books, most of which have been related to girls’ and women’s mental health. She is a member of the ACA Ethics Committee. Contact her at lchoate@lsu.edu.

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

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

I don’t care what my body looks like on the beach, bro!

By Andrew M. Watley July 25, 2019

Many guys and girls alike trained hard during the frigid winter months under a common belief: Summer bodies are made in the winter. Traditionally, getting “beach body ready” was associated with women. But that idea is so 20th century. Now, through the influence of social media and many other factors, guys are just as likely as women to stress about their appearance during these warm summer months.

Let’s take Instagram, for example. I don’t know about everybody else, but my page is filled with diet tips, workout routines, and guys who have the body type that I desire. The posts from these extremely “ripped” gentlemen are a double-edged sword.

One side is inspirational. These people put in a lot of time, dedication and patience to mold their bodies, like art, into the creation they see fit when they look in the mirror. Guys like me who strive to be in better shape look up to these men, hoping that the same level of fitness is obtainable for us.

The other side of the sword can bring about despair because of society’s decision that these model bodies — a body type that is not like mine — is what is considered favorable. Take a walk in history through People magazine’s “Sexiest Man Alive” covers. Most, if not all, of the men who have won these “competitions” have had favorable bodies. What an honor it must be to be considered the sexiest man to walk the Earth at a given time.

The idea that men don’t worry about their bodies is simply not true. Like the male peacock, we like to “strut our stuff” to gain the attention of those we might find attractive or for the man we see staring back at us in the mirror. He seems to be the hardest critic to impress.

Of course, negative consequences can be associated with the sometimes obsessive desire to be “Instagram worthy.” The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) specifies muscle dysmorphic disorder (MDD) as a subdisorder of body dysmorphic disorder (BDD). Muscle dysmorphia is defined as a preoccupation with the idea that one’s body build is too small or not muscular enough.

MDD occurs almost exclusively in men. This diagnosis can lead individuals down a path of obsessive behavior such as extreme exercise programs and long hours of weightlifting to gain muscle mass. These men may work out to the point of injury and often ignore said injury to continue their muscle growth. These individuals typically engage in unhealthy diet habits such as mass consumption of protein-rich foods to increase weight. In extreme cases, men may resort to the use of steroids or other addictive performance-enhancing drugs.

I conducted a doctoral research project in 2017 that studied men who considered themselves members of the fitness culture. The study conducted interviews of seven men and observed their gym habits. I paid close attention to how these habits and thoughts about their routines and physiques affected their mental health. According to these men, a muscular or fit physique brings not only desired attention but also validation of a man’s masculinity.

Society has equated a muscular or physically fit man with being more masculine than those men who are smaller in stature and weight. Obtaining this physique has become a social norm for the masculine guy. Maintaining a muscular physique is yet another gender norm that men are expected to adhere to in North American culture.

One gender norm that is changing is the notion that men do not talk about their feelings. It is not as far-fetched today to have men lying on the counseling couch as it was previously. It is possible that some of the men who end up in your office may experience symptoms related to a negative body image.

Unfortunately, counselors do not have a magic wand to use to “bibbidi-bobbidi-boo” our clients into the most muscular men at the ball. Nor do we have a single can of spinach that we can give our clients to instantly make them ripped like Popeye. But what we do have is research stating that when treating clients with dysmorphic disorders, cognitive behavioral techniques work best.

One of the first steps in cognitive behavior therapy is gaining an understanding of the problem. BDD/MDD may be the result of an underlying issue or concern. As with most eating disorders, muscle dysmorphia is likely caused by biological, psychological and social factors.

For some, it could be a traumatic event that was caused by unhealthy choices. One of the gentlemen I interviewed during my doctoral research recalled a moment when he had to run after a bus and, because he was overweight at the time, he couldn’t catch up to it in time. He equated his health and the laughter of the bystanders with his image. This moment pushed him into a lifestyle that would eventually lead to body dysmorphic disorder.

Another interviewee who identified as a member of the LGBTQ+ community discussed his desire to be viewed as attractive. He explained that some members of the community could be superficial, and in order to fit in with certain crowds, he needed to look a certain way. These represent just brief examples of how discovering the root of a client’s BDD or MDD may open the door to a helpful discussion about the person’s obsession with obtaining the “perfect” body.

As counselors, we need to help these clients first identify their automatic thoughts. As a theories class refresher, an automatic thought is one that is triggered by a particular stimulus that leads to an emotional response. Individuals maintain certain beliefs about themselves, others and the world. It is safe to assume that our male clients with BDD/MDD have similar negative views of themselves as it pertains to what is beautiful and accepted and what is not. These automatic thoughts can lead to cognitive distortions or faulty ways of thinking. As long as a client’s negative view of himself does not match his positive automatic thoughts about the world, he will feel as if he can’t comfortably be happy with himself as he currently is.

As trained professional counselors, we are no strangers to working with clients with anxiety. Anxiety is a big part of dysmorphia. Clients may experience anxiety when thinking about how others may perceive them. That faulty perception can then be reflected on themselves.

Helping clients to overcome anxiety is key. Anxiety is a fear of the “what ifs” in our lives, and 99% of the time, these events never take place. A person who struggles with BDD/MDD may be preoccupied with the thoughts of “What if I gain/lose weight?” “What if I don’t look like him/her?” Or, more common these days, “What if I don’t get enough likes?”

By helping clients confront the negative thoughts that plague their minds, we can potentially eliminate the harmful and, most times, irrational thoughts that haunt them.

Perhaps the most beneficial thing we can do as counselors is help our clients learn the importance of both acceptance and change. The DSM says that most men who struggle with MDD usually appear to be in pretty good shape already. Although it may be challenging, we must try to help these clients see their muscles as “half full” rather than “half empty.” Introducing them to the habit of positive self-talk may help them remember that it is OK to have a cheat meal or to miss a day at the gym.

If our clients are unhappy with the way they look, it can be beneficial to help them find healthy ways to change. Pointing them in the direction of a nutritionist or a personal trainer may be a healthy alternative for those who take extreme measures to alter their bodies.

Be proud to strut whatever you have at the beach this season, fellas. Remember that maintaining a muscular body takes time, effort and patience. If you aren’t where you want to be this year, set the goal to be there by next beach season. Be proud of the way that you look, and be sure to wear your shades and sunblock so that the rays of the haters can’t touch you.

 

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Andrew M. Watley is a licensed professional counselor and an adjunct professor in New Orleans. His practice specializes in children, adolescents, men’s issues, and struggles that may arise for members of the LGBTQ+ community. Learn more about him and his practice at drandrewwatley.com.

 

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

Talking about menopause

By Laurie Meyers January 7, 2019

Sleepless nights. Sudden temperature spikes and night sweats. Fluctuating moods. Brain fog. Sudden hair loss (head). Sudden hair growth (face). Dry skin, leaky bladder, pain during intercourse.

This litany of symptoms may sound like the signs of a mysterious and slightly terrifying disease, but they’re actually all possible side effects of a normal, natural life transition: menopause.

Menopause is an inevitable part of life for women — or, more precisely, people with ovaries — but chances are, many clients who show up to counseling know little about it. “The Change,” as it is sometimes called, isn’t taught in sex education classes and is rarely brought up by doctors. Even friends don’t always tell other friends about it. Unprepared for this disruption that usually coincides with a life stage already known as a major time of transition, clients may turn to counselors for help navigating this natural biological process.

Understanding the process

Therein lies the first lesson: Menopause is part of a process. Menopause refers to a specific point 12 months after a person’s last menstrual cycle. Perimenopause, which can begin up to 10 years before menopause, is the transitional time during which most menopausal symptoms occur. Perimenopause usually begins in a person’s 40s but can start as early as a person’s mid- to late 30s.

“During these years, most women will notice early menopausal symptoms such as hot flushes, night sweats, sleep disturbance, heart palpitations, poor memory and concentration, vaginal dryness and … depression,” says American Counseling Association member Laura Choate, a licensed professional counselor (LPC) who has written extensively about issues that affect women and girls.

According to the National Institutes of Health, other perimenopausal symptoms include irregular menstrual periods, incontinence, general moodiness and loss of sex drive. Some people also experience aches and pains and weight gain, particularly in the abdominal area, although experts are unsure whether these effects are tied directly to perimenopause or are instead caused by aging.

LPC Stacey Greer, whose practice specialties include assisting clients with issues related to perimenopause/menopause, says that many clients show up to her office because they’ve been feeling “off” or “not like themselves.” Some of these clients may even have received a perimenopause diagnosis, but most still are unaware of the symptoms and don’t understand the process, she says.

Both Greer and Choate believe that knowing what to expect in perimenopause can in itself ease some of the discomfort of the transition. Choate notes that for those who are unaware of the signs of perimenopause, many of the symptoms can be alarming. Some clients’ symptoms may be mild, but for others, they are severe and can significantly interfere with clients’ functioning and quality of life, Choate says. She adds that symptoms usually peak about a year before the last menstrual period and begin to ease significantly in the second year of postmenopause.

Is it hot in here?

Knowing what to expect from perimenopause is all well and good, but in this case, forewarned doesn’t mean forearmed. Clients still have to live through the symptoms.

Counselors can help with that. Greer says that charting is an excellent tool. She gives clients a chart listing perimenopausal symptoms and asks them to note all the ones that they experience over the course of a month. This allows her to identify and focus on a client’s specific problems.

Hot flashes, night sweats and trouble sleeping are some of the most common complaints. Choate says research has shown that cognitive behavior therapy (CBT) can help with hot flashes and night sweats. She recommends the techniques contained in Managing Hot Flushes With Group Cognitive Behavioral Therapy: An Evidence-Based Treatment Manual for Health Professionals by Myra Hunter and Melanie Smith. The book highlights the importance of identifying and reframing thoughts that occur during a hot flash.

When hit with a hot flash, instead of thinking, “Not other one!” or “I am going to pass out” or “This will never end,” clients can tell themselves, “It will pass” or “Menopause is a normal part of life” or “The flashes will gradually go away over time,” Choate explains.

“In addition to changing self-talk, it is helpful to have an attitude of calm acceptance, mindfully accepting the hot flash instead of trying to push it away or become upset by it,” she says. “There is evidence that mindful acceptance and allowing the flash to ‘fall over you’ helps women cope more effectively. Also, using paced breathing to elicit the relaxation response helps women cope as they focus on their slowed breathing instead of the discomfort that accompanies a hot flash.”

Many people also experience problems sleeping during perimenopause. According to the National Sleep Foundation (NSF), this is not only because of nighttime hot flashes but because of decreasing levels of progesterone, which promotes sleep. The NSF recommends the following for menopause-related sleep problems:

  • Stay cool. Keep a bowl of ice water and a washcloth near the bed for quick cool-offs when awakened by a hot flash. Also maintain a cool, comfortable bedroom temperature (ideally between 60 and 67 degrees), and keep the room well ventilated.
  • Choose the right bedding. Skip thick, heavy comforters and fleece sheets and go for bedding made from lighter materials, such as breathable and fast-drying cotton. This prevents overheating.
  • Eat soy. Eating soy products such as tofu, soy milk and soybeans may help combat dropping estrogen levels. Soy products contain phytoestrogens, which have weak, estrogen-like effects that may ease hot flashes.
  • Consider a natural remedy. Natural hot-flash helpers include botanicals such as evening primrose and black cohosh. Make sure that clients consult a physician before taking these or any other supplements because they are not regulated and may interfere with other medications.
  • Try acupuncture. This ancient Chinese remedy uses tiny needles to unblock energy points in the body and may help balance hormone levels to ease hot flashes and trigger the release of more endorphins to offset mood swings.
  • Balance hormones. Clients should consult a physician for sleep problems that last for more than a few weeks. A physician might recommend hormone replacement therapy (HRT), which helps stabilize decreasing hormone levels and lessen the severity of hot flashes. Other medication options such as low-dose antidepressants and even some blood pressure drugs have also been shown to alleviate menopausal symptoms.

Good sleep hygiene habits are also important. The NSF recommends the following:

  • Get earplugs or a sound conditioner to maintain a quiet environment. Extraneous noise in the bedroom can disrupt sleep.
  • Keep overhead lights and lamps in the home dim (or turn off as many as possible) in the 30 to 60 minutes before going to bed.
  • Position the alarm clock so that it’s difficult to see from bed. Watching the seconds and minutes of a clock tick on and on while trying to fall asleep can increase stress levels, making it harder to get back to sleep when awakened.
  • Keep a consistent sleep schedule. Going to bed and waking up at the same time every day — even on the weekends — reinforces the natural sleep-wake cycle in the body.
  • Develop a bedtime routine. Running through the same set of habits at night helps the body recognize that it is time to unwind.
  • Stay away from stimulants such as nicotine and caffeine at night. Avoid drinking tea or coffee, eating chocolate or using anything containing tobacco or nicotine for four to six hours before bedtime. Alcohol can also disrupt sleep, so avoid more than a single glass of liquor, beer or wine in the evening.
  • Get regular exercise, but not too close to bedtime.

Greer also recommends relaxation techniques. She works with clients to help them focus on the things they can control and let go of the things they cannot control.

Many people find significant relief from hot flashes, sleep problems and mood disturbances by taking HRT or antidepressants, but clients often need help sorting through their options, Greer says. It’s not uncommon for clients to come to counseling with a whole sheaf of information from their OB-GYN, much of which can be difficult to understand. Greer helps clients navigate the material and identify any follow-up questions they have for their physicians. “This can help them feel more empowered and have a voice in their treatment,” she says.

“Speaking to a trusted medical and mental health professional is important at this time,” says Joanna Ford, an LPC whose practice specialties include assisting clients with issues related to menopause and perimenopause. If her clients don’t already have a physician, she suggests that they ask family members and friends or even consult social media for recommendations. In fact, some of Ford’s clients have created circles on social media that offer recommendations on physicians and treating menstrual issues.

Depression risk

Choate, who is currently writing a book on depression in women across the life span, says that depression is a common perimenopausal symptom. “There is an increase in depressive symptoms, first-time episodes of major depressive disorder (MDD) and … risk of recurrence of MDD in women who have a history of MDD,” she says. “Symptoms of depression occur at a 40 percent greater rate [among perimenopausal women] than in the general population, and the prevalence of depression increases 2-14 times in women during perimenopause versus the premenopausal years.”

Interestingly, perimenopausal depression presents slightly differently than depression as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. In perimenopausal depression, clients are more likely to be irritable or hostile, have mood lability or anhedonia, and have a less depressed mood than is commonly seen in MDD, Choate explains. “Therefore, without a predominantly depressed mood, depression during the transition can be overlooked or misdiagnosed,” she says.

“Counselors can help women focus on self-compassion and self-care during this time, as studies show that there is an increase in negative life events for midlife women compared to other times in their lives,” Choate continues. “This could include children leaving home, caring for aging parents, the death of parents, personal illness, divorce or separation, [and] loss of social or financial support. With the increase in stressful life events, paired with the biological changes of perimenopause, women are more likely to experience distress.”

But all hope is not lost, Choate says. “I think it is helpful to be aware of studies that indicate that while women do experience a decrease in their mental health during these years, recent longitudinal studies show that depressive symptoms decrease as women age out of the perimenopausal years and enter their late 50s, 60s and 70s,” she says. “It is helpful to view this time as a window of vulnerability that does dissipate as women age and as they learn to view mid- to later life as a time of renewal and vitality.”

Sense of self and sexuality

It is not uncommon to feel grief about the menopausal transition. Greer says that some of her clients describe feeling “old” and struggle with their identity as women. “I try to help them work through the grieving process and work toward an acceptance of what is happening to their body,” she says. “It [the transition] does not change who they are, just how they see themselves.”

It isn’t difficult to understand why perimenopausal women feel old. As Choate notes, in Western cultures, youth is viewed as highly desirable, particularly for women, who continually receive the message that signs of aging should be avoided and obscured as much — and as long — as possible.

“The anti-aging industry is designed to perpetuate the myth of eternal beauty — that women can and should maintain a youthful, thin appearance regardless of their age,” Choate says. “The myth implies that women should exert the energy needed to conceal signs of aging, and if they don’t, then they are to blame.”

Women are socialized to prevent or repair skin changes such as wrinkling, sagging and age spots, all of which are natural signs of the aging process. Thinning and graying hair and weight gain are other results of aging that are considered undesirable, Choate notes.

Women “are taught that as they lose their youth, they will also lose their physical beauty, their sexual appeal, their fertility and their overall use to society,” she says. “In contrast, in cultures in which older age is revered, women report fewer symptoms during the menopausal transition. Cross-cultural studies show us that when older women are valued for their wisdom and contributions, they have more positive expectations about aging and menopause, and they also experience few menopausal symptoms. The message from these cross-cultural studies is that when women welcome aging as a natural process, not a disease, and accept naturally occurring changes to their weight, shape and appearance, they are less likely to experience negative symptoms associated with menopause.”

Women may know all of this intellectually, but the societal message is hard to ignore: Youth = beauty = power. Even women who habitually kept these weapons sheathed may feel the shift as they enter the perimenopausal transition.

“Body issues are important to address during this transition time,” emphasizes Ford, a member of ACA. “Aging is part of every life. The culture that we are surrounded by may impact our image of ourselves and our self-value. If we can increase our awareness about how we speak to ourselves about our bodies, it is possible we can accept the changes instead of fighting them.

“People may feel invisible before entering perimenopause, and it can increase feelings of depression and isolation. It is imperative to find a support system that encourages an individual’s values based on a variety of things, such as personal interests, skills, spiritual or religious beliefs, occupation, artistic or creative pursuits or any topic people can connect through.”

Body image issues can become part and parcel of the sexual changes that accompany perimenopause. “Menopause is reached upon the cessation of a woman’s menstrual cycles for 12 consecutive months. This means that menopause culminates in the loss of fertility,” Choate says. “For many women, this is a difficult role transition, particularly if they have based their identity upon a youthful appearance, which is often associated with fertility. For other women, the end of the childbearing years is a welcome change, as they become free from monthly menstrual cycles and also gain freedom from the need for birth control and other pregnancy concerns. They may experience negative biological sexual changes but may be more motivated to seek treatment for these changes as they begin to explore their sexuality apart from its association with childbearing.”

“Women often report a decrease in libido during this time,” Choate continues. “Some of this is due to physical factors — pain during intercourse, vaginal dryness — and some is due to psychological factors, including poor body image, beliefs and expectations about aging and sexuality, stress, fatigue from night sweats, and sleep disruption.”

Estrogen replacement therapies can help with many of the physical factors, but addressing the psychological factors is equally important.

“CBT is also helpful in examining a woman’s expectations for menopause, aging and her sexuality now that her sexuality is no longer linked to fertility and youth,” Choate says. “She might need to change her beliefs about women and aging, viewing menopause as a natural process that occurs to all women but does not indicate a disease, nor does it necessitate a view of herself as an aging, asexual woman. She might benefit from discussing her concerns with her partner to clear up any miscommunication about her partner’s expectations or attitudes toward the changes that are occurring in her body.”

It is essential — but sometimes difficult — to talk about those negative biological sexual changes, Ford notes. “Testosterone and estrogen levels are decreasing at this time and can lead to a change in libido or discomfort during intercourse,” she explains. “I do think people have to ‘re-envision’ their sexuality because hormonal changes are always happening.”

Of course, sex does not mean just intercourse, Ford continues. Embracing different ways of sexual expression can be helpful if intercourse becomes painful. People for whom intercourse is painful may also want to consult their physicians about lubrication or hormonal therapies, she says, adding that she recommends clients read The V Book: A Doctor’s Guide to Complete Vulvovaginal Health by Elizabeth G. Stewart and Paula Spencer.

Ultimately, counselors can help clients see not just the losses associated with menopause but also the opportunities.

“Now that you are entering a new life stage, what new opportunities do you want to seek out for yourself?” Choate asks. “What can you explore and enjoy during this next life phase? Research shows that while women do experience increased unhappiness during their early 50s, longitudinal studies show that they are happier than ever in their mid-50s and into their 70s and benefit from decreased caregiving and work responsibilities in their later years.”

Greer reassures clients that even though the menopausal process may sometimes seem as if it will go on forever, the stage is temporary. “There is life after menopause,” she emphasizes.

 

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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.

 

When bias turns into bullying

By Lindsey Phillips June 29, 2018

We all have our biases — but just because bias is a universal part of the human experience doesn’t mean it is something we should ever dismiss offhandedly, either in ourselves or others. That’s because bias has serious consequences, and when left unchecked, it can turn into bullying. A 2012 study of California middle and high school students published in the American Journal of Public Health found that 75 percent of all bullying originated from some type of bias against a person’s race, sexual orientation, religion, disability or other personal characteristic.

People often talk about bullying in general terms. But as Anneliese Singh, a professor of counseling and associate dean for the Office of Diversity, Equity and Inclusion at the University of Georgia, points out, “If you look more closely at ‘general bullying,’ what you’ll see is a lot of bias-based bullying.”

SeriaShia Chatters-Smith, an assistant professor of counselor education and coordinator of the clinical mental health counseling in schools and communities program at the Pennsylvania State University, defines bias-based bullying as bullying that is specifically based on an individual’s identifying characteristics, such as race/ethnicity, gender, sexual orientation or weight. For example, adolescents might create Snapchat stories that attack someone on the basis of their race, weight or sexual orientation, and parents or teachers might treat children differently on the basis of their skin color, notes Chatters-Smith, an ACA member who presented on “Bullying Among Diverse Populations” at the ACA 2017 Conference & Expo in San Francisco. Research indicates that individuals of color, particularly black and Hispanic men, are more likely to be identified as being aggressive, she adds.

In her research on transgender people, Singh, who co-founded the Georgia Safe Schools Coalition and founded the Trans Resilience Project, has found that bias-based bullying can be based on appearance, gender expression or gender identity, and it can range from name-calling to physical and sexual harassment and assault.

A four-letter word

When people start talking about someone having a bias, those four letters typically trigger a negative reaction and shut down conversation, which isn’t productive. Thus, Chatters-Smith argues that helping people understand that everyone has biases is crucial to addressing bias-based bullying.

However, this task can be difficult because people often resist closely exploring their own prejudices. Counselors should help clients realize that just because everyone has biases doesn’t mean they are excused from recognizing and addressing their own, Chatters-Smith argues.

Because bias is often an emotionally charged topic, Chatters-Smith finds it helpful to start with a nonthreatening example. After pointing out bias, she asks clients when they first identified something as their favorite color. Most people can’t remember when this color preference started because they were young, Chatters-Smith says. She explains how after someone establishes a color preference, the brain starts to sort things by that color.

“When you see something that is your favorite color, you are more likely to gravitate toward it. You have more positive feelings toward cars that are your favorite color. … And sometimes a car may not be the best-looking car, but because it’s our favorite color, we gravitate toward it. That is bias,” Chatters-Smith explains.

Bias is a kind of sorting process that our brain goes through, she continues. “The experiences that we have with individuals can then cause us to have specific attitudes toward someone, and when we see them, we prejudge that they are going to act or be a certain way because of those experiences. … We do an automatic sort.”

Counselors are not immune to bias either. For example, a counselor might assume that a black male client who is unemployed did something to cause his unemployment, Chatters-Smith says. If this happens, the counselor needs to take a step back and ask why he or she is entertaining that assumption, she continues.

These internalized biases can also have a direct effect on students. For example, Singh says, LGBTQ students will not feel safe reporting bias-based bullying by their peers when they hear educators or school counselors expressing anti-queer or anti-trans views. Educators can also hold bias against students in special education, which may limit the opportunities those students have to learn, she adds.

Singh, an American Counseling Association member and licensed professional clinical counselor in Georgia, finds cognitive behavior therapy (CBT) helpful because challenging irrational thoughts is at the heart of addressing bias-based bullying. Thus, counselors need to ask clients and themselves some CBT-related questions: Where did you learn this thought? What research supports this idea?

Counselors “have to become strong advocates in order to interrupt those beliefs systems because the person enacting them — whether or not they’re conscious [of it] — isn’t going to stop until there’s an advocacy intervention,” Singh says.

After making clients (or educators) aware of bias, counselors can work with them to figure out times that they might have sorted a person into a category before getting to know that person and then brainstorm ways to manage that differently in the future.

Counselors can also benefit from bias-based bullying training. In working with Stand for State, a bystander intervention program at Penn State, Chatters-Smith found that certain questions or situations related to bias would cause the counselors participating in the bias-based education to pause or stumble. “A person who is not educated to know [how to respond] can get really thrown off guard,” she says.

Chatters-Smith knows from experience. Once in a workshop, she mentioned how saying that all Jewish people are good with money is an example of a racially charged joke. One of the participants responded, “But all Jewish people are good with money.”

Chatters-Smith questioned this statement by asking, “Really? All Jewish people? Where does this stereotype come from? Is this a racially based stereotype that is meant in a negative way?”

“One of the most damaging things that can happen in [a] workshop is if a bias educator is perpetuating bias,” Chatters-Smith contends. This experience helped her realize that the trainers themselves needed training to be effective at bias and discrimination education. She is currently developing workshops and a workbook that will allow counselors to practice answering questions and go through specific scenarios related to bias-based bullying to help them gain confidence and knowledge in handling these challenging situations.

Uncovering bias

A counselor’s role is to interrupt the systems of bias-based bullying, Singh argues. This process starts with the intake assessment, which should clearly define what bias-based bullying is and provide examples, she continues.

Counselors need to ask upfront questions about bias and harassment in counseling to let clients know that these issues exist and that they affect mental health, Chatters-Smith says. The best way to know if it is happening is to ask, she adds.

Of course, when assessing clients, counselors can also be alert to signs that bias-based bullying may be occurring. Anxiety or fear of being bullied may cause younger children to wet their beds at certain times of the year (right before school starts, for example) or to avoid public bathrooms, Chatters-Smith notes. She advises school counselors to pay close attention to the dynamics between students in the cafeteria. “A child can be sitting at a table full of kids because they don’t want to sit alone, but no one is interacting with them. No one is talking to them. They’re purposely being excluded,” she says.

Singh and Chatters-Smith also urge counselors to watch for signs of depression or anxiety, client withdrawal, client complaints that are not tied to anything specific, chronic tardiness, or changes in client behavior such as nervousness, avoiding school or sessions, or missing certain classes.

Counselors should exercise the same level of vigilance with young adult and adult clients. Chatters-Smith finds that counselors often fail to factor in the isolation, feeling of being ostracized and lack of belonging that some minority college students experience at predominantly white institutions. Counselors “know all of [these factors] impact mental health from [the] K-12 research of bullying but seem to forget about it when people graduate from high school,” she argues.

In addition, counselors often “do not factor in the cultural pieces of experiencing bias-based bullying at work. It manifests itself differently,” Chatters-Smith says. For example, individuals may go on short-term or long-term disability, or bullying may result in harassment claims or absenteeism from work. In certain instances, clients may not be able to put a finger on the core issue causing them not to enjoy the workplace, or they find that for some unknown reason, they can’t please a co-worker or employer, she says.

Sometimes, clients don’t even recognize that bias-based bullying could be an issue until the counselor brings it up, Chatters-Smith adds. Thus, she advises counselors to ask questions such as “Have you experienced any prejudice or discrimination at work?” or “Do you have increased anxiety around yearly evaluations for work?”

“In any organization that has built-in hierarchies, bullying [is likely] to occur,” Chatters-Smith says. For example, in the military, transgender individuals still face discrimination, and often discrimination is based on race or socioeconomic status, such as enlisted individuals versus officers who require a college education and receive more money and leadership positions, she explains.

Avoiding assumptions

When people are introduced to the concept of bias-based bullying, they often assume that it involves someone from a dominant group bullying someone from an oppressed group. “When you think about bias-based bullying, typically people are going to gravitate toward majority [versus] minority … but at the same time, it can happen within group,” points out Cassandra Storlie, an assistant professor of counselor education and supervision at Kent State University. She cautions counselors not to overlook the possibility of intracultural bullying because it does happen. For example, a Latino child may bully another Latino child because that child doesn’t speak Spanish, or an individual may bully someone else of the same ethnicity because that person’s skin color is judged to be “too dark” or “too light.”

Just because someone is oppressed does not mean that they can’t be oppressing others, Chatters-Smith emphasizes. “For centuries … African Americans have bullied each other based on darker complexion versus lighter complexion, and the same thing happens in Latino and Hispanic groups as well,” she says. “What makes it identity based and bias based is because there are biases that come along with the perspectives of individuals who are of darker skin. Even though it’s within a specific racial category, the bias is still there, and then the individual still has the psychological impact because they’re being bullied just for who they are.”

In addition, although people of color have a higher likelihood of being bullied in predominantly white settings, bias-based bullying can still occur when they are in settings with higher diversity, Chatters-Smith notes. The bias may just take another form and be based on characteristics other than race, such as sexual orientation, she explains.

Within transgender communities, someone who is more binary identified and operates with certain gender stereotypes may discriminate against another transgender person for not looking enough like a woman or a man, says Singh, a past president of both the Southern Association for Counselor Education and Supervision and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling. Within-group bullying is particularly painful to the individuals who experience it because the group is supposed to be their source of support and belonging, she says. 

Singh also points out that bias-based bullying can be targeted at anyone based on how he or she is perceived. “If they’re perceived to step out of a gender or sexual orientation box, even if they don’t have that identity, they may experience [bias-based bullying].” In fact, Singh says, a substantial amount of anti-queer and anti-trans bullying is actually experienced by cisgender and straight people.

Creating a positive, safe environment

“Ethnic identities are strong protective factors,” says Storlie, president-elect of the North Central Association for Counselor Education and Supervision. She encourages counselors to find ways to celebrate cultures and differences. If counselors are practicing in a school district or community that isn’t taking preventative measures against bias-based bullying and being inclusive and advocating for all students, then they need to take initiative and educate those communities, Storlie says.

One approach that Storlie, an ACA member and a licensed professional counselor with supervisory designation in Ohio, suggests is to mention how diverse populations are increasing. In fact, according to the National Center for Education Statistics, the percentage of white students enrolled in public elementary and secondary schools decreased to less than 50 percent in 2014, while minority students (black, Hispanic, Asian, Pacific Islander, American Indian/Alaska Native and those of two or more races) made up at least 75 percent of the total enrollment in approximately 30 percent of these schools.

Storlie works with a school district that has Ohio’s second-highest number of students who speak English as a second language. Roughly 50 percent of the student body is Latino — up from approximately 2 percent only two decades ago.

When Storlie first walked into the school district, she couldn’t find any Spanish on the walls of the schools or in school materials, but since she started working with the educators and teachers, all of the school district’s documents are translated. “If you’re handing this information out to students … you’ve got to make sure it’s in the right language,” she argues.

Schools are in transition now because of increased diversity, Storlie notes. “It’s happening across the country where teachers don’t look like the kids that they’re teaching anymore, and they have stereotypes that can be pervasive,” she observes. Thus, counselors need to work with educators and communities to ensure that they are being inclusive.

Storlie advises counselors to facilitate events such as English classes for parents whose first language is not English to improve communication between teachers and parents, and workshops to educate parents, school personnel and the community on bias-based bullying. Counselors might also provide workshops for school personnel on multicultural competency, she says.

The Human Rights Campaign Foundation’s Welcoming Schools program is one helpful resource, Chatters-Smith says. The program provides training and resources such as recommended books, lesson plans and videos to school educators to help them create inclusive, supportive school environments and aid them in preventing bias-based bullying.

Building strong relationships

Storlie has found that teachers and school personnel who instill hope in their students — regardless of any identifying characteristic — have the best outcomes. These students often have higher levels of school engagement, demonstrate greater resilience and enjoy more academic success.

The therapeutic relationship can play a central role in instilling hope and achieving these positive outcomes, Storlie argues. For that reason, she adds, counselors shouldn’t become so focused on theories and techniques that they forget what it means to foster a good relationship with their clients. Among individuals who have been oppressed or marginalized, there is often an “us versus them” attitude, so the challenge for counselors is finding a way to reconnect and develop the relationship, Storlie says.

Trust is one key component of building a strong relationship with clients. However, Chatters-Smith has found that adults don’t always trust children’s reports of bias and discrimination. In her private practice, Chatters-Smith often works with children of color who report that no one believes them when they complain about bias-based bullying. Over time, this disbelief can result in their silence. Thus, she emphasizes, it is crucial that counselors believe children when they report having experienced bias-based bullying and discrimination.

In addition, Storlie stresses the importance of taking a team approach to bias-based bullying. “You can’t do it solo. … You really have to have the team approach because that’s how change happens,” she says. This is especially true for school counselors confronted with high student-to-counselor ratios, she adds.

When school counselors notice bias-based bullying in their schools, they should connect with other leaders in the school district and position themselves as a part of the leadership team, Storlie advises. Then, in this leadership position, counselors can educate school personnel on warning signs and interventions for bias-based bullying, thereby creating a team approach to intervening, she explains.

School counselors should also strive to work with families to address bias-based bullying. Because family members’ work schedules may not coincide with school system hours, counselors might have to get creative to find ways to reach families, Storlie continues. “School counselors who stay in their offices are not going to be able to reach families the same way that … [counselors] doing outreach with families would,” she adds.

In Storlie’s work with undocumented Latino youth, she found that the school counselors who were present, who made a point of getting out of their offices and who were visible to parents — for example, showing up at basketball games after school hours — enjoyed the most effective relationships with families and students. Their students were also more receptive to looking ahead and thinking about their future careers, she adds.

Bystander intervention

“What hurts [children] typically is not specifically the bullying itself. What hurts them is the other children around who stand and watch it happen,” Chatters-Smith asserts. The inaction and silence of bystanders causes people who are bullied to feel depressed and isolated, and it feeds into dysfunctional thinking that they are not good enough and no one cares about them, she adds.

In workshops, Chatters-Smith uses an active witnessing program to train people how to respond to discrimination and bias. Because bias-based bullying is often verbal, onlookers can state that they disagree with what is being said and question the validity of the biased comment, she elaborates. Bystanders can also support the person being bullied by telling them they are not alone or calling for help, she says.

Bystanders can also help people who commit the offense to self-reflect by asking them to repeat what they said and letting them know that it was hurtful, Chatters-Smith continues. If a bystander doesn’t feel safe to intervene at the time of the incident, they can later call a manager (if the bullying incident happened in an establishment or organization) or notify someone about what they witnessed, she advises.

Chatters-Smith has also used ABC’s What Would You Do? — a hidden-camera TV program that acts out scenes of conflict to see if bystanders intervene — in her workshops. She plays the scenarios from the show but not the bystanders’ reactions. Instead, she has workshop participants use the skills they have learned in the workshop to see how they would respond.

The more aware counselors become of bias, prejudice and discrimination in their day-to-day lives, the more it will affect them in their work with clients, Chatters-Smith says. “Practice is what helps us move forward as individuals,” she explains. “When you are at the store, when you are eating in a restaurant, when you are in the mall, when you see these things happening, if you feel [like you] know what to do, you’ll become more aware of what it is and you’ll feel more confident at not only being able to intervene and be empowered in your everyday life but also being able to talk to your clients about their experiences.”

Storlie and Singh both tout training student leaders as an effective approach to preventing bias-based bullying. Often, students — not counselors — are the ones who hear about or witness these instances of bullying. So, counselors can work with these student leader groups to teach them how to intervene, Storlie says.

Another way to create a team approach to bias-based bullying intervention is through the use of popular opinion leaders, Singh says. With this approach, school counselors and teachers nominate student leaders who represent different groups in the school (à la The Breakfast Club). With the counselor’s guidance, these students discuss bias-based bullying, what they’ve noticed and how they might be able to change it. Then, after learning bias-based bullying interventions, the popular opinion leaders try them out and report on which ones worked and which ones didn’t, Singh explains.

An ongoing issue 

Singh warns of the danger of minimalizing bias-based bullying — such as saying that people “don’t mean it” — because it sends a message that it is OK to have bias. Comments that dismiss bias-based bullying “can really add up over time in the form of microaggressions for transgender people,” she argues. “But, more importantly, [these comments create] a hostile environment in society, and that hostile environment in society can set transgender people up for experiencing violence.”

“When children grow up in an environment where they are taught implicit and explicit messages about whose identities matter and whose don’t, and then there’s power attached to that, then you’re going to see those negative health outcomes,” Singh argues. “And they’re not just negative health outcomes and disparities. They’re verbal, physical and sexual harassment that play out across people’s bodies and communities. Those microaggressions add up to macroaggressions on a larger scale.”

Apologizing isn’t the answer either. Often, people who bully, commit a microaggression or say something prejudiced will apologize by saying that they didn’t intend it that way, Chatters-Smith says. “It’s not intent that matters. It’s impact. … Whether or not you intended it, it doesn’t matter. It hurt the person.”

One possible solution is to start bias education at a young age so that over the life span, people are more aware of bias-based bullying and discrimination, Singh says. Counselors can challenge the internalized stereotypes that people learn in society about themselves and others and counter those biased messages with real-life experiences and compassion, she adds.

Education and awareness are key because bias-based bullying is an ongoing issue. “[Bias] is not going to go away. … People are going to find a way to treat each other differently. I think that what will change is more and more people not accepting it,” Chatters-Smith says.

This past spring, social media revealed another case of discrimination when two black men who were waiting for a friend were arrested at a Starbucks in Philadelphia on suspicion of trespassing. The incident might have received little notice except that a white woman posted a video of the arrest on Twitter and challenged the injustice, which prompted protests. Starbucks responded by apologizing and announcing that it would close thousands of stores for an afternoon to conduct racial bias training in May.

Even though this injustice never should have occurred, the public outcry sent a message that these two men were not alone and that bias is not acceptable, Chatters-Smith says. “The intervention is what’s going to change [things],” she says. “If we have more eyes on it, hopefully we can reduce the impact and reduce the duration and the longevity of the impact of these instances.”

Chatters-Smith, Singh and Storlie all agree that counselors have an important role to play in educating people about bias and building strong partnerships between educators, parents, students and communities. “[Counselors] are in the business of helping people challenge inaccurate, internalized thoughts,” Singh points out. “Counselors have to challenge those thoughts and help rebuild beliefs systems that include the value of a wide variety of social identities.”

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

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.

Food for thought

By Laurie Meyers January 25, 2018

With January now behind us, the annual barrage of diet and fitness commercials has started to fade. Many people who made New Year’s resolutions to lose weight or “get fit” have already labeled themselves failures for indulging on leftover holiday chocolate and not making it to the gym more than twice per week. Other determined warriors in the fight to attain the perfect size and shape may stick to their resolutions and lose the desired amount of weight, only to find that they’ve gained it all back (and then some) within six months. This cycle of dieting and weight loss, followed by weight gain, is a process that many Americans go through over and over again, often in search of an unattainable or unsustainable ideal.

“The primary message we get from popular culture is that our worth is based on our appearance and the ability to achieve a thin and beautiful cultural ideal,” says Laura H. Choate, editor of the book Eating Disorders and Obesity: A Counselor´s Guide to Treatment and Prevention, published by the American Counseling Association. “When individuals internalize this message — that they are only worthwhile or acceptable if they are able to achieve this ideal — they develop a negative body image, which can lead to dieting and disordered eating behaviors.”

According to the National Eating Disorders Association, in the United States, approximately 20 million women and 10 million men will struggle with a clinically significant eating disorder at some point in their lives. Experts say that many millions more will engage in disordered eating — patterns of behavior that resemble those of eating disorders but which do not meet clinical criteria. Symptoms of disordered eating may include chronic dieting, frequent weight fluctuations, extremely rigid and unhealthy food and exercise regimens, emotional eating and a preoccupation with food, body and weight issues that causes distress.

Ashamed to eat?

Licensed mental health counselor Tamara Duarte, a private practitioner in the Vancouver, Washington, area who specializes in treating women with eating disorders and body and food issues, says that we live in a culture that has normalized chronic dieting. She refers to this phenomenon as the “dieting roller coaster.”

Women come to Duarte, an ACA member, having spent years pingponging back and forth between restrictive diets and binge eating. After attempting to limit their consumption only to “good” food, these clients have typically fallen off of their diet wagon and ended up in a binge cycle, during which they eat all of the foods they consider “bad,” Duarte explains. Feeling guilty, the women go back to dieting and start the cycle all over again.

Duarte also sees clients who have gained weight as they have aged and want to get their former bodies back — even if it is through unhealthy means. “People come in and tell me that they used to have a restrictive eating disorder and wish they could go back to that time so that they could be thin,” Duarte says.

What all of these clients have in common is a sense of shame about food and their bodies, Duarte says. Fear of being or becoming fat is so prevalent in our society that this shame has become normalized, she says. The irony is that much of the research has found that dieting ultimately leads to weight gain, Duarte notes. Chronic dieting (even at a subclinical level) may even be harmful to the body, and Duarte and other eating disorder experts say that the benefit of weight loss through dieting is unclear.

Like many who study or treat disordered eating and eating disorders, Duarte wants to remove the stigma attached to different-sized bodies. “Fat is just an adjective,” she says.

Part of breaking free of disordered eating — and eating disorders — is learning body acceptance, Duarte says. “Helping a person to accept their body as is can be a very slow, complex process,” she admits.

“I read something posted on Instagram once that said, ‘You cannot obtain recovery while actively trying to change the size and shape of your body,’” Duarte continues. “I really liked that, and I introduce that very early on in the counseling process. Throughout counseling, we look at the beliefs the client has about their body and where those stem from. Typically, thoughts like ‘I’m ugly and unlovable in this body’ stem from society or family members. It’s interesting because none of my clients so far have thought others are unlovable because of their body size, so I question what makes them different. We also look at how screwed up society is for picking one body size as being beautiful and acceptable. With a recovering mind, they are able to recognize how erroneous these thoughts are.”

Duarte also asks clients to get rid of their scales. “Not relying on an arbitrary number to tell them whether they are ‘good’ or ‘bad’ frees them up to connect in with themselves to figure out how they are feeling,” she explains.

Intuitive eating and Health at Every Size

Duarte has personal experience both with eating disorders and the power of that “arbitrary number.” She had been in recovery for more than 10 years when she happened to gain about 45 pounds because of some medication she was taking. Uncomfortable in her new body size, Duarte was ready to put herself on a diet and workout regimen. But then she attended some seminars on intuitive eating, an approach created by dietitian Evelyn Tribole and nutrition therapist Elyse Resch, both of whom specialize in eating disorders. Intuitive eating rejects dieting. Instead, it advocates listening to the body’s signals of hunger and fullness and getting rid of the idea of “good” and “bad” foods, among other principles.

Duarte also learned about Health at Every Size (HAES), a program and social movement inspired by the book written by Linda Bacon, a nutrition professor and researcher. HAES advocates the acceptance of bodies of all sizes, rejects dieting and calls for addressing health concerns directly with healthy behaviors. Both intuitive eating and HAES also encourage physical activity in whatever form a person naturally enjoys.

“I immediately recognized the power of teaching IE [intuitive eating] and HAES to clients,” Duarte says. “Both HAES and IE teach that when you listen to your body and feed it what it wants, when it wants, how much it wants, your body will naturally go to its set point range — the weight range where it works optimally. HAES tells me that I am OK no matter what my body looks like and that I can love and accept it right now.”

After learning about intuitive eating and HAES, Duarte started following the principles found in each approach. “At that point, I had a laundry list of good foods and bad foods, so I did the work to incorporate my ‘bad’ foods back into my diet,” she says. “An incredible thing happened: As I allowed myself to want and have these foods, the power they used to hold went away. Pizza was pizza. In the past, I would not allow myself pizza, and if I did decide to allow it, I would eat like five pieces because it tasted so good and I was telling myself I wouldn’t have it again. When pizza became accessible, I realized I only wanted one or two slices, and then I was able to step away because I knew that the next time I wanted pizza — in 10 minutes or 10 days — I would be able to eat it.”

Duarte also realized that although she enjoyed going to the gym, the activity she loved best was going on walks with her dog. So, instead of carving out time to devote to workouts, she started spending more time walking her dog.

“I really enjoy my walks when I go on them, and I am kind to myself when life gets busy and I can’t or don’t want to fit them in,” she says. “I no longer berate myself because the walks are for self-care, not to manipulate the size and shape of my body. I enjoy the array of foods I eat. I love opening a menu and deciding based on what I want instead of what I ‘should have.’ I never thought I would have this kind of relationship with food or my body.”

For those who might wonder whether Duarte lost weight, she responds that it doesn’t matter because her body shape and size have no bearing on her happiness or success.

Combating body hatred

Knowing from personal experience that intuitive eating and HAES can be very effective, Duarte now incorporates the approaches into her counseling work. “Every single client that calls my office for a free consultation ends up telling me that what they want most from counseling is freedom,” she says. “Freedom from the eating disorder, the never-ending thoughts about weight and food, freedom from self-hatred. I know that HAES and IE [are huge pieces] of the puzzle when it comes to freedom.”

“I don’t have to tell my clients about my experience with HAES and IE,” she continues. “I just have it with me when I am helping to guide them through it. It influences the way I feel and think about my clients’ bodies as well. I do not hold judgments about people’s bodies because of what I have learned in my journey, and my clients know I don’t judge them. When I tell my clients that their body is acceptable no matter what it looks like, I mean it, and they know it.”

Duarte discusses how HAES and intuitive eating helped guide her treatment of a teenage client she calls “Sara,” who was restricting her food intake and using exercise and vomiting to purge. “Sara believed that her body was wrong and ugly because it didn’t look like her family members, who were taller and built leaner than she was,” Duarte says. “One of the first things I had Sara do was put her scale away in a place that she wouldn’t have easy access to.”

Duarte introduced Sara to intuitive eating and its philosophy that foods should neither be demonized nor celebrated. Sara was particularly resistant to this concept, but Duarte successfully encouraged Sara to slowly add “forbidden foods” back into her diet.

Duarte also used mindfulness to help Sara with her purging behavior. “We worked on mindfulness, so she was able to identify when the urge to purge was coming on,” Duarte says. “She would write down for me everything that she was thinking — why she wanted to purge and why she didn’t.”

The urges would usually pass, and over time, Sara was able to get through them by using tools she had learned in session. Duarte teaches all of her clients distraction and self-soothing skills drawn from dialectical behavior therapy. Examples of distraction activities include dancing to a favorite song, writing or drawing, calling or texting a friend and going for a walk or a drive. Self-soothing might involve clients taking a shower, painting their fingernails (an activity that Duarte says is great for people with bulimia because they can’t induce vomiting with wet nails) or giving themselves a foot massage.

With time — and the help of the tools she had learned — Sara no longer experienced urges to purge. It took awhile for Sara to grow comfortable with her body, but she began to enjoy the increasing sense of physical strength that came from no longer restricting her food intake, Duarte says. Over time, that physical feeling of strength also became psychological.

“She struggles from time to time with not liking how she looks, but she’s able to identify what’s really going on at those times,” Duarte says. “Typically, Sara is stressed or scared, and instead of feeling [that], she focuses on her body and her need to change it. [But now] she uses the tools we have worked on in session, and she feels her feelings effectively, and most often, the body hatred goes away too.”

Alternatives to emotional eating

Licensed professional counselor Rachael Parkins is a practitioner at the Bucks Eating Support Collaborative in Bucks County, Pennsylvania, where she currently runs a support and therapy group for emotional eating. The group meets weekly and serves as a place for women to share their challenges, support one another and get professional guidance from Parkins. Group members may be struggling with a variety of concerns, but food is their common method of coping with emotions and issues such as stress, insecurity, self-esteem and body image, Parkins explains. Most of the women are working with a dietitian, and group members also have access to an intuitive eating coach.

The goal of the group is to learn how to handle emotions in a healthy way by working on methods such as distress tolerance. Group participants identify distressing emotions, such as loneliness, and Parkins helps them identify alternative ways to cope with what they’re feeling. Sometimes, this can be as simple as group members going out of their way to be kind to themselves and practice self-care, such as putting on lotion or taking a bubble bath. Other methods are more concrete, such as journaling or completing a decatastrophizing worksheet. In that case, participants write down their worst thoughts, evaluate the worst-case scenario and the likelihood of it happening, and identify other possible outcomes.

Parkins also encourages group members to acknowledge the small victories they experience in pursuit of their personal goals by recording them in a log. For example, a group member might state a goal of practicing better self-care. For this particular group member, an action such as getting out of bed and taking a shower might represent a small victory. Another participant might want to stop procrastinating. Calling to set up a doctor’s visit could be a small victory, even if the group member doesn’t keep the appointment.

Parkins also helps group members break free of comparisons, both with other people and themselves. She explains that participants regularly hold themselves and how they look up not only to the perceived “successes” of others in their lives, but also to their own past selves. Parkins says it is not uncommon for group members to express a desire to go back in time to when they were thinner, even if it was a miserable point in their lives.

“They have this idea in their head that if they get to this size or number on the scale, that’s going to bring happiness,” she says. “Losing weight might be desirable, but as an emotional focus, it’s never enough. I’m helping people accept that losing weight is not the answer.”

Signs of a problem

Although not every client who diets is engaging in disordered eating, counselors should regularly assess for eating and body issues, says Choate, a professor of counselor education at Louisiana State University.

“We know that a large proportion of the population experiences problems related to eating and negative body image, so it is reasonable for counselors to assess for these issues with all of their clients,” she says. “Because clients with eating-related problems might come to counseling with other issues — depression, anxiety, relational problems — asking questions specifically related to eating patterns and body image is a good way to explore to see if these problems are contributing in any way to the client’s presenting issues.”

Choate suggests asking the following questions:

  • Is the disordered eating pattern causing problems in the person’s life?
  • Does the disordered eating pattern interfere with the person’s relationships with others? With the enjoyment of life activities? With completing daily routines?
  • Does the client’s weight, shape or appearance unduly influence self-esteem?
  • Does the client believe that she or he is less acceptable if weighing a few pounds more than in the past or, conversely, that she or he is more acceptable if weighing a few pounds less?

When assessing clients for signs of an eating disorder, Duarte says, it is essential that counselors not be misled by the stereotypical presentation of extreme thinness. The stigma attached to larger bodies often can obscure the reality that eating disorders may occur in people of all sizes, she says. In part because our society generally expects that people who do not fit into an idealized size range want and need to lose weight, counselors may be less likely scrutinize dieting behavior and weight loss in larger clients. Like Choate, Duarte believes that counselors should assess all clients for signs of disordered eating.

Choate also offers one final caution for counselors. “While there are some eating-related problems that might respond well to counseling alone, it is important to be aware that eating disorders are chronic, and anorexia in particular has the highest mortality rate of any psychiatric disorder. Treatment of these disorders requires specialized knowledge and training, and because eating disorders all involve a medical component, the involvement of a multidisciplinary treatment team is required. This would include, at minimum, a physician or medical professional, a dietitian and the counselor.”

 

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Defining eating disorders: Changes in diagnosis

Laura H. Choate notes that in the past, most individuals with eating disorders fell into the diagnostic criteria of eating disorders not otherwise specified (EDNOS), which led to changes in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

The criteria for anorexia nervosa and bulimia nervosa were expanded to include more people. Binge eating disorder was added as a stand-alone disorder (rather than remaining as previously listed as a subcategory under EDNOS). EDNOS was renamed “other specified feeding or eating disorder” and includes issues such as:

  • Atypical anorexia nervosa: All criteria for anorexia nervosa are met; despite significant weight loss, the individual’s weight is within or above the normal range.
  • Bulimia nervosa of low frequency or limited duration
  • Binge eating disorder of low frequency or limited duration
  • Purging disorder
  • Night eating syndrome

 

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Multicultural considerations

Although often perceived as a “white” problem, eating disorders and disordered eating do occur among women and men of color, says Regine Talleyrand, an American Counseling Association member whose research focuses on eating disorders among women of color.

“Counselors should be aware that women of color do experience concerns regarding beauty and body esteem,” she says. “[However], the traditional methods of evaluating these factors — weight, body parts, preoccupation with thin body ideals — may not capture the real body appearance concerns of all women of color.” Talleyrand, an associate professor and coordinator of the counseling and development program at George Mason University in Virginia, says that characteristics such as hair, skin color and facial features may be more relevant when evaluating body image in women of color.

In addition, high rates of obesity and binge eating among Latina and African American women highlight the need to look beyond “traditional” eating disorders such as anorexia and bulimia when working with women of color who struggle with eating, weight or body issues, Talleyrand says. Because African American and Latina women are even more likely than white women to display eating disorder symptoms at any size, counselors who are evaluating clients of color for disordered eating should also look beyond the stereotypical underweight image, she emphasizes.

Of course, the factors influencing the risk of eating disorders in all populations go beyond appearance. These factors are often culturally specific. In particular, racism and oppression may play a significant part in eating disorder risk among Latina and African American women, Talleyrand says. In fact, the development of eating disorder symptoms — particularly binge eating — has been linked to racism and oppression experienced by African American women, she adds.

 

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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)

  • Eating Disorders and Obesity: A Counselor´s Guide to Treatment and Prevention, edited by Laura H. Choate

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Anorexia Nervosa” by Shannon L. Karl

Journal articles (counseling.org/publications/counseling-journals)

  • “Special Section: Assessment, Prevention and Treatment of Eating Disorders: The Role of Professional Counselors,” Journal of Counseling & Development, July 2012

 

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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.