Tag Archives: body image

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.

Girls feeling pressure to be ‘sexy, famous and perfect’

By Laurie Meyers April 5, 2016

In our culture, women receive many messages that can eat away at their self-esteem. For example, self-worth equals youth and beauty. Perfection in all areas of life — professional and personal — is not only achievable, but expected. Women begin to learn these “lessons” as girls, say counseling experts.

American Counseling Association member Laura Hensley Choate says girls are taught that their value is connected solely to what she calls the “three A’s” — appearance, attention and Vgu1RUfKT3WN1ZYxSWaR_14672519443_13d8873062_kaccomplishments. The expectation they take away is that not only must they look their best, but they must also be noticed and popular, all while achieving high grades and earning recognition and awards in sports or other extracurricular activities, Choate explains. In addition, these messages are trickling down to girls at younger and younger ages, so that now even the youngest girls feel the pressure to be, as Choate puts it, “sexy, famous and perfect.”

This pressure has harmful effects on girls’ social and academic development, says Michelle Bruno, a counseling professor at Indiana University of Pennsylvania whose research interests include trauma and resiliency in adolescent girls. Bruno had the opportunity to work with girls on these issues through her involvement in an empowerment program designed by the nonprofit organization Ruling Our eXperiences (ROX), which began as a research study by counselor educator Lisa Hinkelman at Ohio State University.

ROX programs are designed for elementary, middle and high school girls. The programs target areas such as confidence, self-esteem and body image, healthy relationships, effective communication, social media, cyberbullying, sexual violence prevention, stress and coping, academic and career development, and leadership. Bruno, an ACA member, helped bring ROX to several schools in western Pennsylvania, coordinating with school counselors and serving as one of the onsite supervisors.

“Girls [as young as 9] are navigating peer relationships and beginning to be able to choose more independently their participation in classes and activities in school,” she says. “How they perceive and feel about themselves plays an important role in such tasks. Younger children often display higher levels of confidence than what we see in adolescents. We see younger children believing they can do anything, believing that they are the best at whatever fun activity they are trying out. During the preteen and teen years, many girls experience comprised levels of optimism and decreased healthy risk taking. They value acceptance by others and work hard to achieve it among their peer groups. Girls may not want to try new things for fear of failure or standing out.”

Bruno, like Choate, decries the tremendous pressure placed on girls regarding appearance. “The prominent messages about female beauty depict unrealistic and even unhealthy images,” Bruno explains. “Body image struggles are exacerbated by the sexualization of girls in the media, which teaches girls that their value stems from sexual appeal, to the exclusion of other traits. Young girls may end up engaging in self-objectification to achieve attention from others. How one looks becomes a significant focus for young girls, who of course are also in the midst of physical changes.”

Girls are also constrained by what they learn about “acceptable” female behavior, Bruno continues.

“Girls may be oversocialized with regard to expectations around relationships, with a need to please others being paramount over other behaviors,” she says. “This may lead to a perceived need to regulate emotions such as anger, which can result in relational aggression. This is often a result of when girls experience anger or other difficult emotions but mask it because of negative consequences seen as ‘unladylike.’ This creates incongruence and the message that being authentic is not always OK. Taken together, girls in their preteen years are forming all of these ideas around self-worth, how to define it and how to be worthy.”

ROX is a 20-week program that aims to help girls “unlearn” — or not learn in the first place — these “lessons,” Bruno notes. During the course, school counselors or other facilitators work with small groups of girls in what Bruno describes as “interactive psychoeducation” that focuses on building skills such as communication through practice and role-play. The girls also receive homework to work on in between sessions.

Bruno’s involvement with ROX was brief — her role was simply to help introduce the program into Pennsylvania schools — but she remains a big proponent.

“I saw the ROX program as unique and empowering because it is built upon a framework that examines the interrelatedness of all of these factors [appearance, appropriate behavior, etc.] and creates a safe space for girls to examine these topics while building concrete skills,” she says. “The program is highly successful because it addresses the very issues that many women can continue to struggle with throughout their adult lives. Learning these skills at 11 or 12 years old provides opportunities to support girls in defining themselves by internal standards, to help them exercise the ability to communicate feelings in an appropriate manner and to recognize the impact that outside factors can have on them.”

One of the predominant outside factors influencing today’s girls is social media, and Choate is very concerned about its effect. Although she does not view social media as the root of all negative messaging, she is concerned about certain aspects of it.

“Social media is … a new and constant pressure for girls as they feel they must be ‘on’ and perform at all times in order to get noticed and not to miss out on anything,” says Choate, whose book on cultural influences and young girls, Swimming Upstream: Parenting Girls for Resilience in a Toxic Culture, was recently published by Oxford University Press. “They tend to measure their worth on their numbers — their number of friends, followers and likes for each picture. This leads to the development of an inauthentic self that is focused on pleasing others instead of what is authentic to her.”

“We have not yet seen the long-term effects of these pressures on girls because they are so new,” she continues. “It will be interesting to see today’s young girls, who have grown up on social media and who experience a lack of face-to-face communication, in terms of their mental health. What we do know is that rates of depression, anxiety, substance use problems, eating disorders and self-injury are all on the rise for adolescent girls and young women. So I am concerned about these trends and how they will affect girls’ future development and mental health.”

Because of these concerns, Choate, a professor of counselor education at Louisiana State University, also wrote a book for mental health professionals, Adolescent Girls in Distress: A Guide for Mental Health Treatment and Prevention, in 2013. In it, she recommends that counselors focus on the following areas when helping adolescent girls navigate cultural pressures:

  • Parenting: Working with parents to improve communication and family support.
  • Authenticity and self-awareness: Encouraging girls to take time for self-reflection to gain a strong understanding of who they are and what they value. Possessing this level of self-awareness can encourage adolescent girls to stand up for who they are and what they believe in rather than giving in to the pressure of meeting cultural expectations.
  • Wellness, spirituality and gratitude: Encouraging girls to maintain balance in all life dimensions, not just the ones valued by culture (such as the physical). In addition, recognizing meaning and purpose in their lives and being grateful for what they have rather than focusing on what they do not have.
  • Problem-solving and decision-making skills: Promoting problem solving versus ruminating about problems and learning to have the confidence that they can take action to solve their own problems.
  • Coping skills for emotional resolution: Teaching girls how to manage intense emotions without harming themselves or others.
  • Social skills for communication, assertiveness and conflict resolution: Teaching girls how to develop healthy relationships first with peers and then with romantic partners.
  • Cognitive skills for cognitive restructuring and self-regulation: Helping adolescent girls learn to delay gratification and think through the consequences of actions.
  • Body acceptance and positive physical self-concept: Teaching girls to love the changes in their developing bodies and to appreciate their bodies for what they can do, not just for how they look.
  • Media literacy skills: Teaching girls how to critique the cultural messages they receive through the media and to recognize and resist the intent of the messages.
  • Goal-setting skills and perseverance: Encouraging girls to develop goals and a positive outlook for the future.

 

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Related reading: For more on women, body issues and societal pressure, see “Falling short of perfect” in the April issue of Counseling Today

 

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Laurie Meyers is senior writer at Counseling Today. Contact her at LMeyers@counseling.org

Falling short of perfect

By Laurie Meyers March 28, 2016

This past December, a major pop culture event occurred for which millions of people had been waiting longer than three decades: Star Wars: Episode VII was released. Finally, the story from 1983’s Return of the Jedi was continuing. Many fans reserved tickets two months in advance, while others camped out in line overnight to be part of the audience for the first of the film’s showings. Individuals active on social media reasoned that it was essential to see this latest installment of the Star Wars series as soon as possible to avoid tripping over spoilers.

As with any work of art, people held widely divergent views of the film. In print and online — particularly on social media — passionate discussions were held on virtually every facet of the new movie, but one of the most frequently broached topics involved actress Carrie Fisher. People weren’t usually talking about how Fisher’s character, Princess Leia, was now a general or how great it was to see one of the original characters in the newest film or even the quality of Fisher’s performance though. Instead, the comments most frequently referred to her graying hair and extra weight. The overall sentiment was that Fisher was not aging “well.”

At the same time, no significant accompanying discussion took place about Harrison Ford’s (Han Solo’s) graying hair or Mark Hamill’s (Luke Skywalker’s) prodigiously grizzly beard. Instead, the refrain heard throughout social media was: What happened to the princess in the gold bikini?! (For those who have somehow managed to resist the force of the original Star Wars trilogy, Fisher — as Princess Leia — had two scenes in Return of the Jedi in which she was held prisoner while dressed in a gold-colored leather and metal bikini. The image of Fisher in the costume has become iconic.)

As Fisher herself said in a 2011 blog post discussing her decision to become a spokesperson for the weight loss company Jenny Craig: “You know, I swear when I was shooting those films, I never realized I was signing an invisible contract to stay looking the exact same way for the rest of my existence.”

Fisher’s “invisible contract” is representative of the expectations that women face in American society today: to remain young and beautiful forever, to work harder to be considered equal to men (and yet be paid less) and to be a perfect daughter, mother and wife or partner — all while doing the majority of the housework, child rearing and caregiving. Despite the significant strides women continue to make toward equality, societal expectations still lead many women to think that they can (and should) “have it all.” But that picture is acutely unrealistic, say counselors.

“Having it all means being able to fulfill multiple expectations simultaneously — the perfect appearance, perfect relationships, perfect mother and perfect career,” says Laura Hensley Choate, a licensed professional counselor (LPC) who has written extensively about women’s and girls’ issues. “It means being perfect according to societal standards for each of these roles, but even if this were possible, it also means achieving them all simultaneously.”

The problem, counselors say, is that these standards are perniciously presented to women not just as goals that can be achieved but as expectations that must be met. And when women fall short of these standards, they often view their unsuccessful attempts as personal failures rather than as an understandable inability to meet unreasonable expectations. This perspective can cause feelings of frustration, inadequacy and shame and, in some cases, lead to more serious problems.

“These expectations are so unreasonable and unattainable, and much of it is out of an individual’s control,” comments Vanessa McLean, an LPC from Richmond, Virginia, whose specialties include women’s issues. “It is easy to see how women become plagued with anxiety, self-doubt and negative cognitions that can easily spiral into anxiety disorders or depression.”

By identifying and countering these harmful societal influences, counselors want to help women separate self-image from societal expectations — and perhaps even start changing and setting the expectations themselves.

Chasing eternal youth and beauty 

Throughout much of history, women were valued only for their beauty and fertility, says Choate, a member of the American Counseling Association. Although these qualities are no longer the sole sources of a woman’s worth, youth and beauty are still the most valued, she continues, and once a woman ages and those qualities are diminished, she loses value. In contrast, Choate says, research has shown that the characteristics most prized in men — wealth, power and status — increase with age, meaning that men generally gain value as they age. This disparity is evident in popular culture, particularly in films, which frequently pair young women with much older men, but not vice versa, she notes.

In society at large, this translates into an internalized mandate for women to fight against aging by any means necessary: products, diets, surgery and so on, says Choate, a professor of counseling education at Louisiana State University. Although we live in a youth-obsessed society, the pressure Branding-Images_Falling-Shortis mostly one-sided, she notes. “Men do not feel this same pressure. Certainly not to the same extent that women do,” Choate says.

The youthful ideal that women are supposed to maintain is in itself unrealistic, McLean says. “It isn’t just attractiveness that is the ideal but an obsession with physical perfection,” she explains. “Perfect hair, perfect skin, perfect body, perfect teeth. … And the message is not only geared to young single women but to all women.”

“Women now have equal rights and opportunities to pursue education and careers,” McLean continues, “but if you consider the message that mainstream media send, both overtly and covertly, the message is still that women’s primary value is sex, [which equals] physical attractiveness.”

Working more for less

Women have largely seized the opportunity to pursue advanced education and careers, but on a societal level, their contributions in the workplace are not as highly valued as those of men — not just symbolically but also literally, experts contend.

According to a 2014 study by the U.S. Census Bureau, the median annual salary for women is 79 percent that of the median annual salary for men. That’s 79 cents for every dollar a man makes. A 2015 comparison by the U.S. Department of Labor measuring weekly salaries found that women make 81 cents for every dollar that men make. “Women often feel more pressure in the workplace to perform, simply to get equitable recognition and pay,” McLean says.

Many women’s wages are affected by factors such as maternity leave and child care, as are their career trajectories, which are often linked to making better wages, says Nadine Hartig, an associate professor and chair of the Department of Counselor Education at Radford University in Virginia. Beyond the physical demands of pregnancy, giving birth and raising children, women are often confronted with choices related to balancing their work and life roles. These are choices that men generally do not have to make, Hartig points out. Even if a woman’s husband or partner assumes some of the child-rearing and household responsibilities, the bulk of those responsibilities will typically still fall on the woman, says Hartig, a member of ACA.

Hartig notes that she made a career choice herself because of the demands of motherhood. “I chose not to go into a tenure track right away mostly because I thought it would kill me to do that at the same time as raising children,” she says.

Many women wrestle with the challenge of how or if to try balancing motherhood and work, knowing that the decisions they make could mean delaying or even derailing a career. Women are sometimes judged negatively for taking time away from work, even for maternity leave, but they are also susceptible to being judged for returning to work as quickly as possible and continuing to pursue their careers, note Hartig and Choate.

When a woman who is a mother seeks a promotion, her dedication to her children may be questioned, along with her ability to get the work done, says Hartig, an LPC who also maintains a small private practice. “This can be done in really insidious ways, with comments such as, ‘I’m concerned you won’t have enough time for your family [if given the promotion].’ Generally, men do not face this same kind of judgment. No one questions a man’s commitment as a father if he takes a promotion.”

McLean says that when parenting and household duties are factored in, research has shown that women perform 50 percent more daily work than men.

“The reality is that working mothers still tend to serve as ‘managers’ of the home,” agrees Choate. “They are the ones who keep up with the schedules, the tasks that keep the household running, the doctor’s appointments, the school needs. And while research shows that fathers do help out, it is the mothers who tend to assign the tasks to keep everything on schedule.”

“So, the mothers have to manage the home tasks — which of course take a great deal of mental energy for planning and can lead to worrying — while fathers tend not to carry this burden with them,” Choate continues. “And the societal expectation is that a good mother will keep the family’s schedule flowing seamlessly. If things don’t run well in the home, the expectation is that the mother is not doing her part well. And for single mothers, this pressure is even greater because they are not only the managers of the home, but they also have to carry out all of the tasks with very little help or support.”

Sadly, for many women, the harshest critics they face are themselves, Choate says. They try to have it all and then feel like failures when they can’t achieve the impossible. In essence, she says, “having it all” boils down to “figuring out a way to look young, thin and beautiful, be home with the kids as much as possible, be a superstar at work, have lots of successful friendships, have a blissful romantic relationship, have a perfectly decorated, always clean home [and] cook fresh, organic meals daily.”

Breaking free of the mold 

Choate says counselors can help their female clients uncover the unrealistic expectations they are operating under. “What are the actual standards they hold up for themselves in order to feel they are a success? Actually putting these expectations into words is the first step in helping to change them,” she says. “Where did they learn these expectations? How did they come to internalize these expectations? Did they learn them from parents? Teachers? Coaches? Popular media? Whose approval are they seeking?”

Once a client realizes she is responding to outside forces rather than considering options that might be right for her, the counselor can help her identify ways of creating a healthy balance that fits her life, Choate says. The counselor should have the client ask herself what makes sense for her given her personal strengths and resources.

“This will look different for everyone,” Choate says. “What are realistic and meaningful goals that respect self-care and balance versus living up to a never-ending treadmill of others’ expectations? Helping our clients separate the difference between societal ‘shoulds’ versus what each client actually wants for herself will be very freeing for her.”

In Choate’s book Girls’ and Women’s Wellness: Contemporary Counseling Issues and Interventions, published by ACA, she talks about strategies couples can use to strike a balance in household duties. Rather than trying to decide how to divide tasks exactly 50-50, she suggests that couples talk about particular duties that each partner prefers. For instance, one might prefer folding laundry to vacuuming, or washing dishes rather than taking the trash out. Couples should also talk about who will keep track of items such as bill paying, appointments and other deadlines. The most important goal is for both partners to be satisfied with the division of labor, Choate says. It is also important for partners to be flexible enough to temporarily take on more or less responsibility when needed, she adds, such as one partner tackling extra household tasks when the other partner has a project that requires extra hours.

Hartig also helps her clients re-examine the stereotypes they have been taught, particularly as they relate to body image. “I believe the first step is assessing where clients’ narratives about their bodies began,” she explains. “For example, was the client told she was fat by a parent, or did the client gain a significant amount of weight and feel differently about his or her body? Identifying the struggles a client has about his or her body is important to begin working toward self-acceptance. Often, a negative body image is indicative of feelings of inadequacy and shame. Working on these feelings can lead clients to finding peace with their bodies.”

“Some of the ways that we work with clients on self-acceptance is to explore the negative self-talk they experience and where this self-talk originated,” Hartig continues. “Coaches, parents, teachers and friends all can have an immense impact on self-talk. Counteracting this self-talk with CBT [cognitive behavior therapy] can be very helpful. Creating a new narrative about the client’s self and body is also helpful. For example, a client who can say ‘My body is strong and my body helped me escape some pretty hard situations’ is on the road to appreciating her body.”

Hartig also notes the importance of counselors being aware that negative societal messages about appearance and body image are even greater for women who are not white or heterosexual. “Women of color face even greater assaults on a positive body image [because] our culture has an ideal that is rarely inclusive of all women — or people,” she says. “Women who identify as lesbian or bisexual are also often marginalized and misunderstood with regard to body image.”

“Internalized self-loathing is a natural consequence of media and other outlets that do not embrace the beauty of diversity and realness of people,” Hartig says. “Understanding these issues specific to different cultural groups is key to helping clients with body image issues.”

McLean uses brain-based psychoeducation to help women understand why they feel they need to meet society’s unrealistic expectations. For instance, she explains that humans are hard-wired to seek social approval, so it is normal for people to want to conform. McLean then helps clients to understand their own expectations and fears and to recognize and reframe cognitive distortion. She encourages women to explore how to balance their lives around their personal values rather than around social expectations.

Hartig likes to use narrative therapy to examine her clients’ struggles with the expectations they feel they need to meet. As she listens to clients’ stories, she finds it particularly important to note losses — for example, dreams or plans a woman may have had to let go of in one part of her life, such as her career, to attend to an aspect in another domain, such as family.

For instance, Hartig had a client who had decided not to have a second baby because she wanted to pursue tenure. However, after achieving tenure, she didn’t find it particularly satisfying and felt that she had given up the chance to have another child for nothing. It was important for the woman to grieve this loss, Hartig says.

Hartig encourages clients to grieve such losses by helping them develop rituals for letting go. This might involve a client writing a letter to herself and then burning or shredding it, releasing balloons, journaling or even holding a “funeral” for what was lost. The funeral ritual might include gathering pictures or symbols of what the woman lost, putting them in a box and burying them.

Once the client is ready, Hartig helps her to “reimagine and recreate,” building a narrative around what she wants her life to be going forward and how she can make that happen.

“For some, writing this plan down makes sense and is helpful,” Hartig says. “This can take the form of a ‘letter from your future self’ or free writing/journaling about hopes for the future. This process can also be done in the therapy session, as some clients do not respond well to written homework. I think the crucial element is to gently invite the client to envision a life that looks different than what … she originally planned, once the grief has dissipated.”

Until society rejects the picture of perfection that is “having it all,” counselors can play an important role in helping women strike a balance that allows them to have what they need.

 

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To contact the individuals interviewed for this article, email:

 

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Related reading:

See Laurie Meyers’ companion article to this piece, “Girls feeling pressure to be ‘sexy, famous and perfect’,” for more on how counselors can help young girls defy societal stereotypes and pressures.

 

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

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