Tag Archives: Counseling Connoisseur

Counseling Connoisseur: Brain science, courage and chronic pain

By Cheryl Fisher January 19, 2023

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

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

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

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

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

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

Chronic pain

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

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

Neuroscience advancements

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

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

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

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

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

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

Implications for counselors

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

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

Courage

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

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

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.

Counseling Connoisseur: Fostering female mentorship in counseling

By Cheryl Fisher August 31, 2022

My cell phone lights up with a text from my 15-year-old client. He is mad at his parents who are constantly arguing and often use him as a pawn, and he has skipped school to make a point. He took his bike and rode to a local convenience store. His text says, “I will show them!”

In the process of calling my client, I get another call: It is his father. The call goes to voicemail, and he leaves a message saying that he is worried because his son left a note that he is running away. He has called the police and wonders if I have heard from his son.

I am torn. I want to maintain the trust of my client, but I also recognize that he is a minor and could be putting himself in harm’s way. His parents are extremely dysfunctional and are no doubt blaming each other for their son’s disappearance.

I take a deep breath and then pull up the phone numbers of three women who have served as my professors, clinical supervisors and now dear friends. I text, “I need a consult now. Are you available?” Within seconds my phone lights up again. When I answer, I hear the calm voice of one of my mentors. I summarize the situation and my concerns. She reiterates that my client is a minor and regardless of how dysfunctional the estranged parents are, they need to know the location of their son. After processing with her, I decide to call the father and provide him with the son’s location. I also point out for the 100th time that he and his ex-wife need to seek counseling to better navigate co-parenting because the current situation is too stressful for their son. The father thanks me and hangs up.

I immediately call my client to let him know that his father is on his way to find him and to give the client space to diffuse from the morning’s event. I apologize for the breach of his confidence and remind him that as a minor he could be in harm’s way by running off. I validate his frustration. And I ask for his forgiveness. He pauses a moment and then says, “Yeah, I figured you’d have to tell my parents. I am mad … but not at you. We’re good!” Then he sees his dad’s car pull into the parking lot and says, “I guess I’ll see you in session.”

I let out the breath that I felt like I had had been holding since my client’s initial text and call my mentor to thank her for the consultation and support.

The benefits of mentorship

Mentorship is when a more experienced person provides guidance to a less experienced person. The relationship may be formal (e.g., programs for emerging leaders) or informal (e.g., naturally occurring relationships that may develop between student and faculty). In a 2011 article published in Counselor Education and Supervision, L. DiAnne Borders and colleagues found informal mentoring relationships to be more “visible, meaningful, comfortable, individualized, effective, and long-lasting.”

Stephanie Maccombs and Christine Bhat, in 2020 article published in the Journal of Counselor Leadership and Advocacy, identified two areas where mentorship relationships can be most impactful: career development and psychosocial development. In addition to providing a way for the mentee to make connections in the industry, research consistently finds that engaging in a mentoring relationship is associated with positive outcomes for both mentor and mentee. For example, people who receive mentoring are more likely to experience career satisfaction and advancement. Additionally, students in mentoring relationships are more likely to complete dissertations and take advantage of professional leadership and research opportunities. This is especially true for female students.

Women in counselor education

Currently, there is not much data on women’s leadership in higher education. Ashley Gray, a senior analyst for the American Council on Education (ACE), studies leadership patterns in higher education and recommends that a deeper dive into the intersectionality of identities and experiences are needed to inform policy and practice of higher education (see Gray’s article in the 2021 edition of ACE’s International Briefs for Higher Education Leaders).

Although there are more women enrolled in higher education and appointed to junior faculty roles, too few female leaders exist in counselor education. Female leadership styles have historically been found to emphasize collaboration and teamwork which tend to promote innovation, and we need more innovative and transformative leadership to help navigate the existing challenges resulting from the COVID-19 pandemic.

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Systemic barriers

Women in higher education must often navigate competing efforts. These include balancing family and work responsibilities, navigating pregnancy and childbirth with the tenure time frame, and establishing relational networks that may be diminished by a patriarchal social structure. The pandemic further highlighted and exacerbated gender inequities: The increase in virtual learning brought the classroom into the home and caused women in higher education to navigate remote work and child care.

In their article “Only second-class tickets for women in the COVID-19 race. A study on manuscript submissions and reviews” (published in PLoS ONE in 2021), Flaminio Squazzoni and colleagues used the term “she-cession” to describe the disproportionate gender disadvantages created by the pandemic. Women submitted fewer manuscripts, participated in less research and applied for fewer research grants during the pandemic. However, there appeared to be an opposite impact on men in higher education, with more men publishing academic works during the pandemic.

Challon Casto and colleagues noted in their 2005 article published in the Journal of Counseling & Development that female counselor educators often lack the inside knowledge of internal structures and politics across department and university structures. This places women at a disadvantage in traditional “good old boy” systems that thrive on strong networks. The authors recommended creating a formal and informal system that connects female graduate students and marginalized students with mentors to help navigate the unspoken rules of graduate school and advancement.

Women’s Inclusion Mentorship Framework

Maccombs and Bhat created the Women’s Inclusion Mentorship Framework (WIMF), a model of mentorship specifically for women in counselor education programs. The WIMF provides mentorship opportunities and leadership development to any interested female student or faculty member. Based on their extensive review of research of higher education and mentorship in counselor education, Maccombs and Bhat identified four areas emphasized in the WIMF approach: (a) a relational-cultural focus, (b) quality mentors and mentor-mentee matches, (c) vision and plan development and (d) mentoring interventions specific to counseling and women.

A relational-cultural focus

Research consistently finds that mentorship relationships in counselor education contribute to psychosocial and clinical growth and, as noted by Maccombs and Bhat, to “a sense of empowerment, increased insight, increased self-efficacy” that results in mutual respect and empathy. Therefore, Maccombs and Bhat recommend that mentorship relationships are fostered between mentor and mentees who self-identify as women. Women mentors emphasize nurturing the relationship and encourage interconnectedness and the sharing of empowerment and authenticity. Interventions in line with this approach include self-reflection, self-care, connection to groups (such as in group writing) and recognition of the collective accomplishments of other women in the academic community.

Quality mentors and mentor-mentee matches

Quality mentorship can be challenging. Faculty are inundated with responsibilities and even the most well-intended mentor may fall short if they do not have the time to commit to the relationship. Additionally, incompatible pairing can be frustrating to both mentor and mentee. Mentors need ongoing training and support to be effective and sustainable. Maccombs and Bhat suggest that female mentors actively recruit other women in counselor education programs to a meet-and-greet event at the beginning of the academic year. This approach allows for an informal connection to occur organically between mentor and mentee, as mentors and mentees exchange information regarding research interests and academic and leadership experiences. And it also reduces the chances of incompatible pairing.

Vision and plan development

Maccombs and Bhat also recommend that that counselors outline the expectations of the mentorship relationship. Research indicates that clear expectations are associated with a more effective and satisfying mentorship experience. Additionally, mentees are encouraged to identify clear indicators of their academic and career vision. These could include increasing industry networking or scholarships such as publications or conference presentations. In addition to performance indicators, leader attributes and behaviors can be explored in a more measurable approach by using Chi Sigma Iota’s Principles and Practices of Leadership Excellence or the Dynamic Leadership in Counseling Scale — Self- Report (developed by W. Bradley McKibben and colleagues).

Mentoring interventions specific to counseling and women

Maccombs and Bhat encourage counselor education departments to consider allowing two to four hours of dedicated mentoring time a month. A flexible meeting schedule that works best for the mentor and mentee will be more successful. Additionally, a family-friendly approach that allows for child-care options or virtual meetings will be supportive of female mentees and mentors who may be caregivers. Service, research and teaching success include learning how to navigate these demands and other obligations. During pre-enrollment interviews, I encourage student applicants to approach their graduate degree as a “family degree” by recruiting the support of their partners, friends and family members in a variety of ways, including outsourcing some tasks and setting healthy boundaries. For example, family members can help with setting timers for lunch breaks on the weekend when the graduate student is immersed in research and writing papers.

According to Maccombs and Bhat, additional strategies around research and service include “being persistent, … avoiding personalizing the barriers, staying true to one’s personal plan or vision, and engaging in self-care.” It also helps if you are surrounded by a support system who can cheer you on during challenging times, such as dissertation editing.

Focusing on service activities that align with your areas of expertise or personal interests can create an extension of your personal worldview. My research interest in nature therapy, for example, has led me to be more engaged in sustainable ways and serve as the Green Office Ambassador for my counseling program. In this role, I helped the department identify ways to be more responsible with resources and sustainable in practices.

Finally, creating an environment of collaboration will aid in accessing the resources and knowledge to be successful in scholarship, teaching and service. Recently, I identified an area for growth at my university around research support for online faculty, who are mostly women in my department. I met with executive leadership and discussed my observations and suggestions. This resulted in plans to form a student and faculty clearinghouse for resources (e.g., research projects, grant opportunities) and a forum for trainings and mentorship on research development, implementation and publication.

Conclusion

Research indicates that mentorship relationships promote growth and satisfaction, professionally and personally. Women are often disadvantaged by historical academic and professional structures. But the WIMF provides one approach to capitalize on the mentorship relationship between women.

I have been fortunate in my career because I have always been surrounded by wise and empowered women. Women who dared to offer their secrets of success and wisdom in mentorship. They have shaped me professionally, informed me clinically and ultimately transformed me personally.

Whether it was providing me with feedback to hone my clinical skills, observing and ever so gently illuminating countertransference observed in a session, or simply bearing witness to my struggles of navigating work, family and graduate school, these women crafted a web of support as well as strategy that continues to sustain me as a clinician, counselor educator and administrator of a counselor education program.

I am forever grateful to the wise women who not only taught me how to be a strong clinical counselor but also guided me into my role as a counselor educator so that I may also mentor women entering the field of counseling.

In appreciation to my mentors, Sharon Cheston, Gerry Fialkowski and Rev. Anne Stewart.

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

Counseling Connoisseur: Nature therapy and brain science in children

By Cheryl Fisher April 20, 2022

Alfred Adler purported that all behaviors have a purpose. Behaviors are often the way the body responds to life’s stressors, especially for children. Yet, many therapeutic treatments for children focus on the modification, remediation and even elimination of a behavior without addressing the underlying cause. This approach suggests that once a behavior is corrected, the child will experience general wellness.

Brain science, however, indicates that the physiological state of children must be attended to before one addresses behavioral change. In Beyond Behaviors: Using Brain Science and Comparison to Understand and Solve Children’s Behavioral Challenges, Mona Delahooke, a licensed clinical psychologist, argues, “When we see a behavior that is problematic or confusing, the first question we should ask isn’t ‘How do we get rid of it?’ but rather ‘What is this telling us about the child?’”

Therefore, behavior is adaptive and a response to the internal and external experience of the child.

Autonomic response refresher

The human body responds to perception of threats to safety by creating a biochemical and physiological state prepared to move the body to fight, flight or freeze. In this state, the body increases the production of adrenaline, norepinephrine and cortisol. The amygdala and the limbic system become activated and temporarily lead brain functioning over the prefrontal cortex, which is responsible for higher order thinking and executive functions. The child is now functioning in survival mode, and the child’s behaviors may manifest in a variety of ways, including distraction, withdrawal, irritability or fidgeting, fearfulness, regression, and aggression.

Rather than blindly rewarding or punishing the child’s behaviors, neuroscience suggests that we seek out the cause of the behaviors before addressing them. It begs us to answer the questions, “Why is the child acting this way? Is the child perceiving a threat to safety?”

As I have addressed in my book Mindfulness and Nature-Based Therapeutic Techniques for Children, counselors must consider if the child is functioning from an underdeveloped kinesthetic system (our sense of our body in space) or vestibular system (associated with the inner ear and balance) resulting from lack of free-form movement. So much of children’s time is spent sitting at their desks or in front of devices, or in structured activities. They lack nondirected, unstructured play and movement. What is the underlying cause? How is the behavior serving to protect the child? Most important, how can we, as counselors, help the child resume a sense of safety and balance and experience a calm and alert state?

Brain science

Several models have emerged over the past few years that emphasize the role of the physiological state of children when treating their behaviors. All these models assume that the behaviors are an attempt to cope with internal or external stressors.

Stephen Porges, the founder of polyvagal theory, proposes that mammals have two neural pathways. The first, the social engagement state, is accessible when the child feels safe and can trust the environment, promoting a calm state accompanied by prosocial behavior. The second pathway is engaged when the child feels unsafe.

Porges introduced the term neuroception to describe the body’s way of scanning the environment for threats to safety. At times, the body miscalculates the risk of safety. According to Porges, the symptoms of faulty neuroception are translated to psychiatric labels and disorders. In other words, a child who has experienced trauma may have a vulnerable nervous system that detects threats that do not exist. Resulting behaviors may include hypervigilance, insomnia, paranoia, bedwetting or a host of other regressive or safety-seeking responses. On the other end of the spectrum, the child may ignore actual risks in the environment, resulting in greater threat to self and psyche.

Therefore, based on neuroscience, Porges recommends providing children with individualized cues of safety that allow social engagement behaviors to emerge spontaneously. According to Porges, three situations must be present to feel safe. First, the autonomic system must not be in a defensive state (fight, flight or freeze). Second, the social engagement system must be activated, which results in the downregulation of the sympathetic nervous system and promotes prosocial behavior. Finally, there must be cues for safety (vocalizations, gestures and positive facial expressions) detected via neuroception. The assumption is that cues for safety can only be exhibited and detected in human-human interaction. However, research continues to support that human and more-than-human interactions also afford meaningful connection.

Brain science and nature

Engaging in the natural world has long been known to have a calming effect on the body. A biochemical exchange occurs in the natural world that results in by-products that, when inhaled or absorbed by the human body, produce a calm and alert state. The earth’s core is like a battery that emits negative ions. Blue spaces (oceans and waterways) offer ionic by-products. Additionally, green spaces (forests and parks) produce phytoncides and terpenes.

Fifteen to twenty minutes of being in a natural setting affects the body by decreasing cortisol, norepinephrine and adrenaline (hormones released when the body perceives threat); increasing serotonin; and reducing blood pressure and respiratory rate. The body responds to the natural space by engaging the relaxation response. Additionally, the immune system is enhanced by both an increase in number and activity of natural killer cells. These effects are sustained for up to a week following single exposure to forests and as long as a month following two days of engagement in green space.

David Clode/Unsplash.com

The earth communicates through the production of these chemicals, and the human body responds to many of the messages (safety cues) by reducing the body’s defensive state, activating the social engagement system and promoting homeostasis (i.e., a calm and alert state).

Research is conclusive that children who engage in natural settings experience greater well-being, are calmer and demonstrate more prosocial behavior. For example:

In their article “The role of urban neighbourhood green space in children’s emotional and behavioural resilience,” Eirini Flour and colleagues found that children impacted by poverty and living in urban settings experience improved emotional well-being when exposed to neighborhood green space.
Diana Younan and colleagues noted in their article “Environmental determinants of aggression in adolescents: Role of urban neighborhood greenspace” that exposure to greenspace within 1,000 meters surrounding residences is associated with reduced aggressive behaviors in youth.
Andrea Faber Taylor and Frances Kuo discovered that, in general, children who play regularly in green play settings are calmer and more alert than children who play in concrete outdoor and indoor settings. Their study, “Children with attention deficits concentrate better after walk in the park,” also found that children with attention deficit/hyperactivity disorder who play in green open areas versus areas with trees and green grass show milder symptoms.

Although it is becoming increasingly important to integrate outdoor activities into clinical practice, routine access to green and blue spaces may be hindered by many factors. In this case, we turn to indoor alternatives.

Nature therapy indoors

Ecotherapists are capitalizing on the research by integrating nature-informed practices and activities into their work. My own research examines the use of nature-informed sensory “time-out/time-away” stations in the emotional and behavioral regulation of school-age children. Historically, time-out has been used to remediate unwanted behaviors in children. This often involves using a corner of a room without windows or distractions. Once the child has calmed down, they may return to the group setting.

However, if (as Adler suggests) all behaviors have a purpose, then the child has learned only that the presenting behavior is unacceptable and to suppress their natural response to whatever triggered it. They have not learned to self-regulate and address the underlying emotional or physical state.

A nature-based sensory time-away station, however, is imbued with items such as plants and herbs that emit terpenes. The station may have a tabletop sand garden that provides tactile exposure and promotes mindfulness. Additionally, nature soundtracks may play in a headset to allow the brain to register these soothing frequencies.

The preliminary data continue to demonstrate that children are able to use this time-away station as a self-regulating tool to allow for the relaxation response, calming of the amygdala and engagement of the prefrontal cortex. Children engage with the natural material, feel more grounded and (depending on developmental stage) are better able to articulate their underlying state verbally or through expressive arts. They return to their previous activity feeling calm and alert.

Here’s some advice on how to create and introduce a nature-based sensory time-away station:

Create the station. A nature-based sensory station may be created indoors or outdoors. It includes physical elements that engage the senses. Items may include edible plants and herbs to promote exposure to terpenes. Cotton balls soaked in essential oils also can provide exposure to terpenes through smell. Small containers of rocks, sea glass, pinecones, feathers and shells can provide the child with different tactile experiences. A small tabletop sand garden with miniature rakes can be purchased or created for a tactile and mindful activity. A betta fish or small fish tank may also add biodiversity to the space. Nature sounds can be streamed through headphones. Additionally, paper and tools to write, color or paint may aid in the communication of triggers once the child begins to enter a calmer state. And items can be rotated to capture seasonal changes to your nature-based sensory station.
Introduce the station. Because this is a novelty, everyone in a group setting such as a classroom will want to play at the station. It is important to allow each child a chance to explore the space. Using a timer, have children take turns engaging in the station. When the time is up, they may return to the classroom activity. If introduced as a tool, children will soon learn that this space can be accessed to help regulate emotions and behavior in a productive manner. In essence, the children will learn that they feel better after spending time interacting with the space.

In the home setting, the child can help create the space and be taught that it is a place to go to reboot. Show the child how to engage with the multisensory space and then leave them to their own processes.

In addition to the many ecotherapeutic homework assignments and interventions available, counselors utilizing this space as a co-therapist in the field can introduce the benefits of nature-based multisensory engagement and help their clients learn to self-regulate outside of the therapy session.

In conclusion, behavior is a response to interpretation of internal and external stimuli. A child who feels unsafe may experience physiological arousal and respond in a defensive manner. As counselors, we can help educators and parents learn to address a child’s physiological state by creating safety cues for the child. By introducing a nature-based multisensory space, children can learn ways to reduce defensive states, increase homeostasis and activate their social engagement system.

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

Counseling Connoisseur: Reconnection — Healing the embodied self

By Cheryl Fisher January 6, 2022

“Everything we know, everything we do, and everything we are is mediated by the body.”

– Joan C. Chrisler and Ingrid Johnston-Robledo, Woman’s Embodied Self: Feminist Perspectives on Identity and Image

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Embodiment is a concept originating with the French philosopher Maurice Merleau-Ponty, who noted that we experience our humanity through and with our bodies. This is not an isolated experience but one that is impacted by interactions with others. The embodied self is a psychospiritual concept that hosts existential questions of “Who am I? What am I? Where does my value lay?”

In addition, we experience our bodies in a cultural context. Body parts and experiences may be objectified (e.g., breasts, buttocks) or medicalized (e.g., pregnancy). Furthermore, there appears to be social sanction around when a body or body part is acceptable and when it is not, and the resolve is a lifelong relationship of self-projects and self-loathing. For example, Marilyn Yalom, a feminist author and cultural historian, described the psychosocial and political history of the breast in her book A History of the Breast. As stated in the book’s blurb:

Through the centuries, the breast has been laden with hugely powerful and contradictory meanings. There is the “good breast” of reverence and life, the breast that nourishes infants and entire communities, as depicted in ancient idols, fifteenth-century Italian Madonnas, and representations of equality in the French Revolution. Then there is the “bad breast” of Ezekiel’s wanton harlots, Shakespeare’s Lady Macbeth, and the torpedo-breasted dominatrix, symbolizing enticement and aggression.

Therefore, there are sociocultural prescriptions to the body, including that of gender. In their 1987 article “Doing Gender,” Candace West and Don Zimmerman argue that gender is a performance that people “do” that is based on social norms. A person may choose to perform gender in a normative way (cisgender), with their preferred gender that may differ from the one assigned at birth (transgender) or in a way that feels more genuine.

Our relationship with our bodies is complex. It is informed by society’s view of our bodies. The size, shape, skin color and hair texture inform our experiences, along with the gender we perform. Additionally, illness and injury to the body affects our image of self in the context of society’s understanding of ableness. An attempt to “fit in” to normative standards may result in efforts to alter our physical appearance or disregard and disconnect from our embodied self.

Disconnection

Our relationship with our bodies can be fraught with neglect and dissociation as we learn to ignore the many messages it sends to us. We ignore the hunger and push through lunch. We hold our bladder until we are dizzy with urge. We shiver or sweat, ignoring the clear signals. We pull all-nighters when our body is begging for rest. We discount and dismiss the value of our physicality and dissociate from our embodied self.

The embodied self can be experienced in a positive or negative manner, and it is strongly related to self-esteem, self-image, and one’s satisfaction with personal and sexual intimacy. A positive sense of an embodied self is associated with autonomy, functionality, joy and fulfillment. However, chronic illness, disability and accidents, and negative social sanctions can result in a sense of disembodiment. For example, a former track athlete loses his legs during combat, the neurological impact of a stroke leaves a brilliant novelist unable to write a sentence, or a 17-year-old African American girl asks her parents for plastic surgery to “make her nose more normal” (i.e., conform to an unrealistic, Western beauty standard).

In my own research, I encountered a 35-year-old woman who had been diagnosed with metastatic breast cancer, and she described her body after a complete double mastectomy and oophorectomy in the following way:

I felt like a freak. I had lost my hair from the chemotherapy. What was left from my 34C cups were scars and lopsided breasts with tattooed nipples. I didn’t recognize the body in the mirror.

After someone experiences a sense of disembodiment, the sociocultural context of healthism (e.g., I have cancer.), medicalism (e.g., my body is subject to scans and treatments making it a medical object), sexism (e.g., I am a female but now I do not have breasts and reproductive organs), ageism (e.g., I am only 35 but my treatments caused me to have early menopause) and ableism (e.g., I cannot do the things other 35-year-old women can do) further challenges their ability to reconnect with their body.

Reconnection to self

Researchers Niva Piran and Tanya Teall describe positive embodiment in their article “The developmental theory of embodiment” as one with “agency, self-care, and joyfulness.” Therefore, healthy connection, reconnection and adaptation to the body requires the experience of physical and mental liberation and social empowerment. This has implications when working with marginalized populations. For example, the 17-year-old African American girl who wanted to change her appearance due to negative social constructs must cultivate an appreciation and a liberation of her embodied self.

Learning to adapt to the alterations of the body is greatly impacted by the previous connection to body. If a person’s self-worth was associated to the objectification of body as beautiful, then a disfigurement may attack one’s self-worth — “I am not ‘pretty’ therefore I am no longer valuable.” However, befriending the body in a way that affords compassion can be empowering. For example, the metastatic breast cancer survivor previously mentioned said during counseling,

I don’t want lopsided breasts and tattooed nipples. I am a seventh-degree black belt in karate. I want to remove these false pretenses and replace them with a tattoo of a warrior’s breast plate. This is how I see my body now. This is empowering!

Counselors can encourage clients to engage in physical approaches such as yoga, breathwork, martial arts or free-form dancing (e.g., Nia — a holistic fitness practice that combines dance, martial arts and mindfulness) to help them reconnect to their physicality. And because being in nature is a multisensory approach to engaging the body, counselors can recommend clients to spend time in the natural world either in green spaces (e.g., forests, parks) or blue spaces (e.g., oceans, lakes, rivers).

Reconnection to others

A chronic diagnosis or injury can alter not only one’s physicality but also their social connections. The new diagnosis and treatment often test previous social supports and challenge friendships. For example, the combat vet who returned with a double amputation of his legs noticed his priorities were different from his civilian friends. “I was struggling to learn how to walk,” he recalled, “and they [his friends] were complaining about gas prices. We just didn’t have anything in common any longer.”

Clients can reconnect with their embodied self by finding others who share similar experiences and bodily appearances. I connected the combat vet with other soldiers with amputations who also identified as athletes and trained regularly. The physical connection to his body in an empowering way was part of his healing.

In addition to social supports, it is important to become reacquainted to intimate partners. This can be a difficult task because few clinicians or providers invite discussion around sexual and personal intimacy in the recovery process. However, it is important to begin this exploration to discover new and creative ways to experience the new body in a sensual and sexually satisfying way. Counselors can begin the dialogue by normalizing and validating that when we are disconnected from our bodies we are often disconnected from others and this lack of intimacy crosses into our personal and sexual intimacy behavior. Counselors can also provide insight into this connection and refer to sex therapists and sexologists when needed.

Reconnection to sacredness

Counselors can help clients learn to experience their bodies in the present moment by bringing their attention to their physicality in the here and now. When we fully embrace and experience this physicality of our bodies, we allow for opportunities of awe and wonder. The first snowflake melting on our tongue. The smell of homemade gingerbread. Crossing the finish line of that first 5K race. Reaching the highest peak of a hike and overlooking the terrain below. Pausing a moment after a strong paddle to the middle of a lake. The pain and pleasure of birth and then skin-to-skin contact that warms this precious body.

Our bodies are beautifully made, and our embodied experiences can be transcendent. Rediscovering the body in this way is not only empowering but also sacred.

Role of mental health providers

As mental health providers, we have the privilege of entering this vulnerable world of recovery and rediscovery. We can validate and normalize the incredible losses (both visible and invisible). We can create a space for the tasks of grief.

In addition to addressing the grief and loss, we can cultivate a bottom-up approach to recovery. Rather than emphasize the cognitive reprisal of the experience and the resulting new body, we can create a multisensory therapeutic space that emphasizes the physical self, the embodied self.

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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.

Counseling Connoisseur: Trauma-informed return from COVID-19

By Cheryl Fisher July 6, 2021

“What lies behind us, and what lies before us, are tiny matters compared to what lies within us.”

— Henry Stanley Haskins

Jo Panuwat D/Shutterstock.com

[NOTE: This is this third piece in a COVID-19 recovery series. See the first and second installments.]

The sun shining in my windows rouses me before my alarm clock goes off, and I roll out of bed. After navigating around Elsa, my 3-year-old poodle, who is now sprawled across both sides of the bed (neither designated as hers), I make it to my dresser and pull out my workout clothes. I am a creature of habit and my workout routine is consistent. During the height of the COVID-19 pandemic, I constructed a home gym and participated in Zoom and YouTube classes. Body Pump on Mondays and Fridays. Step on Wednesdays and Saturdays. Yoga in between. The only class I did not do from home was cycle which was replaced with outdoor cycling during good weather. It was not perfect, but it kept my body moving and my mind clear. Following the Center for Disease Control and Prevention (CDC)’s recommended two-week wait after my last COVID-19 vaccination, I resumed my gym workouts, now masked and physically distanced.

That was until this week. I entered the gym, swiped my membership fob, and grabbed a towel. However, I noticed that the people behind the desk were smiling. SMILING! I realized that no one (except me) was wearing a mask. I looked up sheepishly and asked, “Are we clear to take off the mask?” The smiles and head nods continued. The CDC’s latest recommendations indicate that fully vaccinated people can meet both indoors and outdoors without masks. In twenty-four hours, my gym responded by lifting all capacity and mask restrictions. I took off my mask and walked to my class, where the taped Xs on the floor to promote physical distancing had already been removed. I set up my equipment in my usual location and waited as others trickled into class, each with a smile — and reservation. “I feel naughty not wearing my mask,” one person stated. “Is it weird that I still feel I need to stand 6 feet away from you?” another inquired. Even the instructor acted a bit disoriented around the new mandate. I watched as everyone navigated the change — such an abrupt turnabout from a year of fear, spent masking, distancing and washing to protect ourselves from a virus that changed our lives as we knew them.

Trauma-informed re-entry

The past year has been one of unprecedented circumstances. We have navigated lockdowns, a toilet paper shortage, remote work and virtual school. We have experienced loss—disconnection from family and friends, total disruption of routine and the loss of loved ones (see “Counseling Connoisseur: Navigating the losses of COVID-19”). Holidays and vacations were replaced with Zoom gatherings and staycations. The politicizing of the pandemic amplified confusion and fear.

There appeared to be some reprieve with the lifting of restrictions afforded by the distribution of the vaccine (see “Counseling Connoisseur: Hope in action and mental health“). However, we are far from being “back to normal.” Vaccination distribution continues with simultaneous bipartisan banter. Mask mandates have been relaxed, and we are left feeling both relieved and vulnerable. School and work are returning to brick-and-mortar spaces but with jubilation, but also reservation. As we return to some semblance of pre-COVID-19 life and routines, we are left with the fallout from the chaos of not only the pandemic but also the heated struggle against racial injustice and the violent insurrection on January 6.

As trauma therapists, we recognize that we cannot be expected to resume pre-COVID activities at full capacity. It will take time and work to re-integrate to the increase in sensory demand, schedule capacity and social engagement. We can help our clients and one another understand the changes and aid in a trauma informed re-entry. Here are a few tips:

Prepare for sensory demand: I was astonished at how even a drive on a major highway seemed daunting after a year in which my commute consisted of walking down the hallway to my makeshift office and an occasional outing to the park. I had basically stayed in a one-mile radius: grocery, gas station, home. Now I was traversing several lanes of traffic at high speeds and getting re-acquainted with reading road signs along the way. Allow the time and space to re-acclimate to the sensory demand.
Pace schedule capacity: A common conversation topic of late has been how the pandemic allowed us to rethink our schedules. Limited were the board meetings, book clubs and sports events. Optional activities were removed from our often-overbooked planners. Many people have commented on how the pandemic reinforced the importance of downtime that allowed people to spend time with their household members, take leisurely hikes in nature or simply reboot at home. With the excitement of re-entry comes the anticipation of the return to overloaded schedules. Now is the time to rethink those commitments. Set boundaries. Say no and give someone else an opportunity to make that bake sale cake or lead that community project. It is OK to step back from or choose not to re-enter the climate of busyness.
Plan for social re-engagement: I am currently writing this on my first airplane flight in a year and a half. I am heading to see my daughter, son-in-law and grandson. Fully vaccinated (yet still masked for travel), I cannot wait to hug my kids and enjoy just being with them. Yet, I know there will be momentary awkwardness as we remove our masks and re-engage. Oh, it will only be for a nanosecond, then I will kiss their whole faces — but that nanosecond is real! Except for virtual gatherings and get-togethers with our small bubble of family and friends, most of us have not witnessed real smiles and received real hugs in over a year. It may take time to adjust to social engagement. If you are returning to your workplace and encountering clients or co-workers, prepare to take time to just re-connect. Smiles, greetings, small talk. Allow for mask-wearing as you and others feel the need (or are still mandated). The art of connection is the counselor’s bailiwick. However, even we may need to allow additional “warm-up” time as we resume face-to-face sessions. Consider continuing to offer telehealth/virtual gatherings as you can allow for a safe return.

It has been a challenging time. While we are moving in a direction of healing, we are not there yet. There is still so much more to be cognizant of and prepare for as we return to our work, school and social lives. We are resilient and as counselors, we can help our family, friends and clients better acclimate in a trauma-informed way by helping them to prepare for sensory demand, pace schedule capacity and plan for social re-engagement.

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.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.