Tag Archives: Counseling Connoisseur

Counseling Connoisseur: Revisiting the Spoon Theory

By Cheryl Fisher July 1, 2019

“If opening your eyes, or getting out of bed, or holding a spoon, or combing your hair is the daunting Mount Everest you climb today, that is okay.” – Carmen Ambrosio

 

Tara, 36, wakes up and rolls out of bed. Her pain factor is a five out of 10. She feels well rested after spending the past two days in bed–the result of working an 8-hour day and going to dinner with friends. Today she will try to finish her laundry and run errands. The lupus flare-up appears to have subsided–for now.

Kevin, 28, a graduate student, is not as fortunate. He struggles to keep up with the demands of a full-time job and graduate school. Kevin has weeks when he is able to manage both. However, today, he has become physically and emotionally paralyzed by his autoimmune disorder and struggles to bring even his thoughts together. He is contemplating taking an academic leave of absence until his health improves.

Carmen, 57, has been living with multiple sclerosis (MS) for over 20 years. Each day she wakes up and takes inventory of her physical and emotional well-being. Some days are better than others. However, the uncertainty of her health has prompted her to seize the moment and engage fully in her craft as an author.

For Tara, Kevin, Carmen, and thousands of others, the challenge of managing their chronic conditions while also meeting the demands of daily life can be daunting. To those around them, they look perfectly healthy. Smart and ambitious, they excel when they are feeling well. However, without warning they can be thrust into the throes of physical, emotional and cognitive dysfunction, rendering them unable to get out of bed, let alone handle professional, academic or personal responsibilities and obligations.

The Spoon Theory Revisited

In an attempt to help her dear friend understand what living with lupus feels like, writer and activist Christine Miserandino crafted The Spoon Theory to explain how energy is limited by chronic illness. Miserandino uses spoons as a metaphor for energy. According to the theory, a person has a certain number of spoons representing energy each day, and each activity depletes a portion of those spoons. In this way, individuals are encouraged to ration and pace their spoon/energy usage in order to accomplish their daily activities. This theory has become widely accepted, and some individuals have even coined the name “Spoonies” for those with conditions that restrict energy. However, the Spoon Theory relies on myths about chronic illness and energy.

Myth 1: There is a set number of spoons each day.

The amount of energy (spoons) needed to function is not prescribed in a daily dose. Clients may wake up and feel that they are armed with a picnic basket filled with spoons. Then a few hours later, they crash and burn and are entirely depleted of whatever resources they thought they had. It is as if the bottom fell out of the basket without warning.

As Jennie, a blogger for The Mighty, an online support community for people facing health challenges, describes in her post, “Why the spoon theory doesn’t fit my life,” what seems like a high energy day can suddenly turn into total depletion:

“Often I wake in a morning and think, ‘Yes! Today is a good day!’ Then, within hours, or even minutes, the tides have turned. Maybe my spoons are ninjas? Maybe the borrowers have been rifling through my stash? Whatever it is, I can go from having just enough energy to less than zero quicker than a scrambling fighter jet. Sometimes it’s due to a weather change; sometimes it’s stress. Often I have no clue whatsoever what happened.”

Myth 2: Spoons can be banked for another day

The Spoon Theory suggests that rest will help bank energy for the next day. This sounds like it makes sense, right? However, chronic illness doesn’t play fair. Resting for a day or two may result in feeling even more fatigued the following day. This makes it difficult to plan activities for the day, week or month. For example, my own daughter, who was recently diagnosed with lupus, confided that some days she wakes up feeling energized only to crash within hours and be wholly depleted the remainder of the day or even the next few days. It is frustrating to both the person who has the illness and those around them who may want to make plans. At times, life is only manageable in chunks of minutes versus days.

Myth 3: Activities require a specific number of spoons

One of the challenges of the Spoon Theory is that it is impossible to quantify (in spoons) the amount of energy it takes to accomplish any given activity. The amount of energy expended is influenced by other variables, including pain threshold. For example, getting dressed for the day may be as easy as slipping into an outfit one day, but feel like donning a suit of armor the next. So, although the activity for both days is identical, the depletion of energy is vastly different. Therefore, preparing for energy expenditure can feel like a futile effort.

 

How counselors can help

Living with the day-to-day uncertainties of a chronic illness can be isolating, alienating and frustrating. Making plans with friends and family must be spontaneous and depends on the illness effects du jour. Counselors can assist clients and families who are impacted by chronic illness by validating their experiences, providing psychoeducation, and stepping up to advocate on local, regional and national levels.

Validate

By nature, counselors are exceptional listeners who are able to hear and identify the concerns of the client. Additionally, we can validate the challenges experienced by the client. Clients may feel anger and resentment at how their condition may restrict activities. They may feel isolated and alone. Friends and family who were present at the initial diagnosis may have returned to their busy lives. This often may leave the client feeling abandoned and alienated. Validating the difficulties of navigating chronic illness allows the client to feel heard and understood.

Educate

While we are able to sit with the client and the emotional, cognitive and physical pain of chronic illness, we can also provide psychoeducation that may promote strategies for better self-care. For example, helping clients grieve the old lifestyle and create a new normal that is shame-free and includes strength-based coping skills that allow them to deploy greater flexibility in the face of those “not-so-great days.”

Counselors can also help clients locate resources in the community, such as support groups or career assistance. They can provide education to family and friends about the uncertainty of living with chronic conditions that tax energy. For example, helping significant others understand that staying in bed all day is not indicative of a character flaw or laziness but a real depletion of energy (those spoons again!).

Advocate

Counselors can contribute to efforts for institutional changes that will benefit clients by participating in legislation and signing petitions. We can attend hearings and provide testimony to the needs of our clients. Finally, counselors can use their voice and power to advocate for clients by participating in any number of activities to increase awareness or fund research.

Conclusion

The Spoon Theory attempts to explain the energy consumed by chronic illness. In reality, it oversimplifies the complexity of day-to-day functioning. Perhaps one of the gifts of counseling is to provide a relationship without conditions where the client is valued beyond the constraints of the illness and a place that welcomes vulnerability and recognizes the courage of showing up each day in spite of the challenges. Perhaps the act of counseling is — as Brené Brown suggests — joining the client in the “arena” and experiencing their pain and disappointment. Perhaps even in the complexity and uncertainty of living with chronic pain and illness, the counselor can help clients recognize that showing up each day if worth the challenges.

Finally, perhaps in the midst of the discomfort of the seeming betrayal of the body and mind, the best gift counselors offer to their clients is as author Hannah Brencher says in her book,  If You Find This Letter: My Journey to Find Purpose Through Hundreds of Letters to Strangers, “… the permission to feel safe in their own skin. To feel worthy. To feel like they are enough.”

 

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Related reading, from the Counseling Today archives:

The tangible effects of invisible illness

Assessing depression in those who are chronically ill

 

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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.

 

Counseling Connoisseur: The Gift of Community for Counselors — An Interview with Thelma Duffey

By Cheryl Fisher April 30, 2019

“Pull up a chair. Take a taste. Come join us. Life is so endlessly delicious ― Ruth Reichl

 

I sit down to write my last client note of the day and click away about the client’s presenting concerns. Smiling at the great progress she has made, I conclude with final comments and an action plan and then click save and submit where my therapy notes will be forever stored in a HIPAA-compliant digital safe. I slurp down my last sip of coffee–cold from the morning. Just a few more things to do then I can head home. I put away my files and lock the file cabinet. I pack up my bag and turn off the lights. I am the last to leave the office so I turn off the Keurig and store the teas and sweeteners. I look around at the empty suite. It is 8:30 p.m. I wonder if my colleagues were in today? I have seen clients back–to-back today with little time to socialize. I lock up the suite and head home.

I have found that while private practice affords many wonderful professional and personal benefits, it can be a very isolating experience. I see 20 to 25 clients a week, and I rarely schedule enough break time to visit with the other clinicians who practice in the suite. We each have our own schedule and do not rely on each other for our practices. Therefore, with the exception of my quarterly peer supervision breakfasts, weeks can go by without actually interacting with another therapist. This, I admit is not a good standard of practice, which becomes incredibly apparent when I leap toward my annual conferences with fervor. Conferences provide me with not only clinical, academic and business development, but professional community.

Professional community

As counselors we are held to a code of ethics that does not allow us to discuss the circumstances of our work day with others. Many years ago I was doing work with a prominent actress. While I would have never disclosed the circumstances of her therapy, I longed to tell my husband about meeting with her. Or the ex-girlfriend of a well-known musician. We work with celebrities, politicians and pillars of the community, in addition to marginalized individuals. The pain and suffering we hold for our clients is (at times) palpable. However, with the exception of supervision (and our personal journals which require de-identification), we don’t have a forum to process our work.

Community is essential. It is a place where others understand the magnitude of the work that we do and the weight it carries in our daily lives. It energizes, inspires and fortifies — allowing us to return to our work rejuvenated and renewed. Where do you find professional community? Do you participate in local counseling-affiliated organizations or make use of the extensive national opportunities that include the National Board of Certified Counselors (NBCC) and the American Counseling Association (ACA)?

Over the many years of my practice, I have affiliated with both local and national groups. However, I longed to find a forum that appreciates my research in nature therapy and my clinical interest in superhero narratives. I wanted to dialogue with others around the role of expressive arts and energy psychology in clinical practice. I wanted to collaborate with creative and innovative practitioners. I found my community in the Association for Creativity in Counseling (ACC), a division of the American Counseling Association (ACA).

I presented at ACC’s 2018 annual conference in beautiful Clearwater, Florida, where I was joined by dozens of others who genuinely uphold a creative lens to clinical practice. In addition to my nature-informed workshop and superhero presentation, topics included movement, art, expressive and animal-assisted therapies. Additionally, energy psychology was explored as a clinical modality. As I attached my Wonder Woman headpiece and armbands in preparation for my presentation I walked down the hallway of the conference and passed Snow White preparing for her session, I knew I had found my people.

 

Q+A

Thelma Duffey, ACA’s 64th president

Thelma Duffey, former ACA president and the founder of both the ACC and its accompanying Journal for Creativity in Counseling, participated in my nature therapy discussion and afterward allowed me to interview her about the conception and vision of ACC.

Cheryl:   What inspired you to found ACC?

Thelma: There were several factors that inspired my interest in creativity, and my hope to establish a division within ACA focusing on creativity in counseling. For one, I learned early on that as connected as we can be with our clients, and in spite of our sharing a trusting relationship, there are times in counseling when talk just isn’t enough. Most of us can identify with feeling stuck in a situation, thought, or feeling, and our clients are no different.  The good news is that people carry all sorts of resources within them, and there are all sorts of resources around us, which can serve as creative, innovative supports. When we tap into our clients’ creativity, and into our own, and share that creativity within a growth-fostering therapeutic relationship, we can create opportunities for change. This was particularly evident when I chaired a series of creativity conferences in the 1990-2000s in central Texas. The energy around them was incredible. These conferences became a place where practitioners, students, and counselor educators would come year after year with so much enthusiasm and shared energy.  It was that response, and my own experiences with clients, that generated the passion to establish ACC as a “home” for counselors with this interest.

 

Cheryl:  Over the past 14 years, what changes have you observed in ACC?

Thelma: One of the more exciting things I’ve seen over time is ACC’s growth into an international community of counselors who share a like-minded passion; counselors who are out there doing great things and making a difference. I’ve seen ACC evolve from a grass-roots effort into a well-established organization represented by members living across the country and throughout the world. That is amazing! I just returned from Clearwater, Florida where the ACC conference was held, and it was terrific being there with such great colleagues sharing such incredible ideas and interests.

 

Cheryl: What are your hopes/vision for ACC?

Thelma: My hope for ACC is that it will continue to thrive and that the membership will feel the comfort of “home” that we hoped it would. My vision for ACC is that as people connect with one another, they will discover new ways to support clients and communities, using creativity, connection, and the kind of compassion that can inspire change and promote healing.

 

Cheryl: What would you like counselors to know about ACC?

Thelma: ACC is a home base for students and counselors interested in exploring creative, diverse and relational counseling approaches. It was founded on the principles of relational-cultural theory and focuses on the interdependence of relationship and creativity. Creativity in Counseling as a new counseling approach has been included in a theories textbook, and it is exciting to see the many ways in which our creative thought processes, interventions, research, and resourcefulness can promote change. I feel so fortunate to be part of ACC!

 

 

Finding a community

I plan on attending and speaking at this year’s Association in Creativity’s annual conference, which will take place September 6-7 in Clearwater, Florida. I am ecstatic to have found a forum of like-minded clinicians who I can both share with and learn from in a professional forum.

The American Counseling Association has 18 divisions, four national regions, and 56 chartered branches in the United States, Europe and Latin America. Take the time to seek out a community that will ignite you and your clinical practice. It will not only inspire you– it will also benefit your clients.

 

Colleagues having fun at ACA’s 2019 Conference & Expo in New Orleans (Photo by by Paul Sakuma Photography).

 

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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.

The Counseling Connoisseur: Cultivating silence in a noisy world

By Cheryl Fisher March 11, 2019

Silence is about rediscovering, through pausing, the things that bring us joy –  Erling Kagge

In an attempt to reboot, my husband and I packed up our fur family and spent a week at the beach over the Christmas holiday. We got up each morning and trekked the shoreline immersing ourselves in the feel of the fresh salt air, the crash of the ocean waves and the caw of the seagulls flying overhead. We walked miles and miles each day — often in companionable silence with our cell phones off and tucked away in back pockets. Every now and then we would stop, plop down on the cool, damp sand and just be in silence.

Noise does not simply refer to sound, it includes the busyness of both internal and external environments. The constant need to “do” something and the aversion to boredom prevent the opportunity to relax the body and the mind. While technology has certainly contributed to the “skim, scan, scroll” processing of our world, it has also generated the technostress afforded by constant availability. Therefore, it is important to recognize the value of cultivating a practice of silence.

The Benefits of Silence

According to a study published in the March 2015 issue of the journal Brain Structure and Function, preliminary research on mice indicates that  as little as two hours of silence may promote brain cell growth by strengthening the hippocampus and improving memory. Additionally, some research has found that cultivating just moments of silence can lower blood pressure and heart rate, and improve relaxation and sleep even better than listening to soothing music.

Ways to Cultivate Silence

  1. Early morning moments: Invite intentional silence into your morning. Curl up in a blanket and sit in the dark allowing your eyes to focus slowly. Take a few moments to gaze at the sunrise, or inhale the fresh morning air. Ease into your day grounded and calm.
  2. Thankful mealtimes: Use the first few seconds prior to eating to close your eyes, take a deep breath and take a moment to appreciate your meal. Attending to your meal in this manner will not only provide you with a nice transition from your busy morning but welcome a more pleasant dining experience.
  3. Breathe: Throughout our busy days, we often forget about breath. We become complacent that the next breath will come without effort or thought. Take a moment to turn your attention to your breath. Are you taking full, deep cleansing breaths? Or do you inhale wisps of air? Take time to breathe.
  4. Meeting preludes: Begin your meetings at work with a five- minute practice of silence. This will allow the transition from work to the meeting agenda at hand. You and your co-workers will begin the meeting focused and ready to tackle the work.
  5. Media fast: Intentionally unplug for thirty minutes, an hour, a day. No cheating! No devices. A colleague of mine has initiated Unplugged Sundays, where she and her family members put away devices and spend time interacting as a family.
  6. Brisk walk in nature: Nature provides endless opportunities to soothe and refresh. Take a 15-minute walk around the block or on a nearby trail. When I work from home, I schedule a couple brief walks with my dogs to clear the clutter from my brain.
  7. Bedtime brain purge: Prior to bedtime, take a moment to purge all of the worries of the day. Lists of things left undone. Ruminations of concerns. Simply let them go long enough to prepare for slumber. You can use a journal to quickly write down your thoughts or just say them all out loud — quickly.
  8. Gratitude: I love to end my day with a gratitude list. I crawl into my comfy bed and immediately acknowledge the comforts of my home, my bed, my full tummy and the loving companions (my dogs and hubby) who share my life.
  9. Meditation practice: Consider beginning a meditation practice. A 20 minute practice morning, midday, or evening can promote calm focus to the day.
  10. Silent retreat: If you find that you crave longer jaunts with silence, consider participating in a silent retreat. Many retreat houses offer formal or informal retreats. Additionally, you may choose from group or individual silent retreats. I regularly schedule overnight escapes to the beach by myself to just reboot. I return ready to take on life’s challenges.

 

Modern-day living is accompanied by a cacophony of external noise and internal concerns. Our bodies and minds cannot sustain the ongoing level of stimulation without disease or disorder. Apparently, silence is golden, and it is imperative to make time for silence in our noisy lives. As counselors, we are trained to listen and sometimes we just need to unplug, retreat and refresh.

 

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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.

Counseling Connoisseur: Cannabidiol and mental health therapy

By Cheryl Fisher February 4, 2019

Carol presented with concerns related to continuous panic attacks that were jeopardizing her work as a medical professional. “I can’t think straight when they happen and I cannot be this debilitated when I see patients,” she explained. Carol had also been self-medicating with alcohol on the weekends to “ease the stress.” Throughout a year and half of intensive therapy, Carol’s panic disorder began to subside, but her general anxiety continued. One day during therapy Carol announced, “I have not been anxious for two weeks!” Thrilled for her, I asked what had caused such a significant change. She looked sheepishly at me and whispered, “cannabis.” I inquired whether she had shifted to smoking marijuana versus drinking alcohol (which she had recently begun cutting back on). She quickly responded, “Oh no! That would get me fired from my job. I am taking a cannabidiol tincture.”

 

Geraldine came to therapy having returned from a year deployment to a country that is without sunlight for months at a time and has very limited pharmaceutical access. She had been without her medication for anxiety and depression and was feeling overwhelmed. “I can’t function,” she lamented. She had contacted a psychiatrist, but the only available appointment was a month away. We identified some tools she could use to help ease her symptoms while she waited, but they only worked for short periods of time. As a result, she was constantly anxious and depressed. Three weeks into our work together, Geraldine announced that she was feeling much better and attributed it to the cannabidiol-infused honey that she was using in her morning oatmeal.

 

Tim presented with depression and insomnia related to chronic pain caused by lupus. He had been taking psychotropic medication for years, but it no longer brought him any relief. Despite taking sleep aids, he was unable to get a good night’s sleep. Tim worked hard in therapy and was able to ease some, but not all, of his symptoms through regular mindfulness meditation. To my surprise, Tim appeared one afternoon smiling in delight. “I slept all night this week!” he exclaimed. Again, the answer to his dilemma was cannabidiol, which he consumed in capsules.

 

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As a counselor, I strive to create the best evidence-based, holistic and individualized treatment plans through collaboration with my clients. In addition to traditional talk therapy, I use a variety of therapeutic approaches, including a wide range of expressive arts and animal and nature-assisted therapies. Recently multiple clients have reported symptom improvement through the use of an over-the-counter supplement that works with the body’s endocannabinoid system (ECS). Approved in the form of an oral solution (Epidiolex) in June 2018 by the U.S Food and Drug Administration (FDA) for the treatment of Lennox-Gastaut syndrome and Dravet syndrome — rare and severe forms of epilepsy — cannabidiol (CBD) has also drawn interest as a therapeutic agent for use on a variety of neuropsychiatric disorders.

 

What is cannabidiol?

CBD is a naturally derived, non-psychoactive hemp derivative. Proponents describe CBD as a food supplement that provides the therapeutic element of cannabis without tetrahydrocannabinol (THC), which is the component that produces a high. It can be found as a tincture, vapor, infused in honey or creams and is used in food products such as smoothies. Reported side effects include possible positive drug screening results, appetite changes and sleepiness.

How does it work?

CBD affects the ECS, which consists of endogenous cannabinoids, cannabinoid receptors and the enzymes that synthesize and degrade endocannabinoids. As noted in a 2018 article in the journal Frontiers in Molecular Neuroscience, research has found that the ECS plays a significant role modulating physiological functions such as mood, cognition, pain perception and “feeding behavior.” The ECS also interacts with the immune system and moderates inflammatory processes. Animal studies and anecdotal observations have shown that modulating the ECS can have beneficial effects on mood, but the authors note that numerous additional factors, such as the placebo effect, could be influencing these findings.

Research that focuses specifically on targeting the ECS with CBD has also been intriguing. In a 2015 article appearing in the journal Neurotherapeutics, a review of studies on animal and limited human populations concluded that acute doses of CBD can reduce anxiety. The authors call for research on chronic doses and note that because past human studies of CBD were conducted with healthy volunteers, future work should focus on clinical populations.

Overall, current research indicates that CBD has significant potential as a treatment for a number of mood disorders.

What does this mean for counselors?

As counselors, it is important to be informed about supplements clients are using to manage mental and physical disease. While we cannot prescribe medications and should refer clients to their doctors for medical advice around pharmacology and supplements, we do have a duty to provide our clients with psychoeducation and research.

 

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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.

 

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EDITOR’S NOTE: Counselors should be aware that according to a U.S. Food and Drug Administration (FDA) statement issued in December 2018, although hemp has been removed from the Controlled Substances Act, it is still illegal to add CBD to consumer food products or to market it as a dietary supplement.

Some jurisdictions, such as the cities of New York and Los Angeles, have begun ordering restaurants to stop selling food containing CBD. The FDA is not currently preventing the manufacture of CBD as a dietary supplement. However, counselors and clients should be aware that like all dietary supplements, those containing CBD are not subject to set standards regarding dose or strength.

 

Learn more about risk management issues related to client marijuana use (ACA members only): counseling.org/docs/default-source/risk-management/ct-risk-management-july-2018.pdf

 

FDA statement on CBD cannabis regulation: fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm628988.htm

 

FDA and marijuana Q+A: fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm#enforcement_action

 

 

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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.

 

 

Counseling Connoisseur: Children and grief

By Cheryl Fisher November 13, 2018

Nicolas was just under 3 years old when he attended his grandfather’s funeral. He wandered through the sea of adults, holding tight to his mommy and daddy’s hands as he made his way to the front of the line where his grandfather lay peacefully in the casket. His grandmother picked him up as he tried to climb into the casket. “Sleeping?” he asked his grandmother. “No, sweetheart. Your grandfather died.” Nicolas paused looking at the man in the box and back at his grandmother, “Sleeping?” he tried again. “No, he has died. He is not sleeping”, the grandmother replied softly. Nicolas looked around and attempted to contort his face — mimicking the adults around him. “They are sad, honey. When someone dies, we can feel sad,” his grandmother attempted to explain. Nicolas just watched, trying to imitate the adults around him as the man in the box continued to sleep.

 

According to William Worden, psychologist and grief expert, all children grieve regardless of age and stage of development. However, each stage provides a different understanding of death and loss. Grief can be experienced in a variety of ways. A child may experience a physical manifestation such as shock, or somatic ailments. They may feel anxious, angry, depressed or withdrawn. The children may act out behaviorally, resulting in biting or hitting. Additionally, there are critical periods where adverse experiences impact the neurological development of children in more critical ways. Having an understanding of how developmental stages affect the manifestation of grief can help counselors provide more effective support for children who have experienced a loss.

Infants and preschoolers: Infants and preschool age children experience life through their senses. Object permanence doesn’t become established until approximately 28 months. Therefore, children at this age may experience grief as the annihilation of existence: now you see me, now you don’t. Challenges resulting from loss at this age include a desire to connect to others but not knowing how, which may cause either clingy or standoffish behavior. A child may also exhibit a decrease in impulse control and tolerance, an increase in uninhibited behavior and poor emotional regulation, and possibly difficulty with toilet training. This is a critical period, neurologically. Neurons that fire together, wire together. Therefore, losses at this age have a higher chance of impacting children in significant ways.

School-age children: As children continue in their development, they are able to recognize attachment relationships, and they may experience loss as abandonment. School-age children may become preoccupied with death, which may become demonized during this stage, and children may experience anxiety related to the idea of mutilation. For example, children in this age group may talk of “blood and guts” and the Grim Reaper when referring to death. Children during this age are capable of conceptualizing loss as permanent and experience magical thinking. Grief may manifest as hyperactivity, emotional eating and/or somatic complaints. Children may withdraw or become argumentative and demanding. They may have difficulty concentrating and demonstrate a decrease in academic performance. Additionally, they may identify with the deceased by exhibiting similar behavior or experiencing symptoms of a loved one’s terminal illness. For example, Tony, an 8-year-old client came to me experiencing pain in his chest. A full pediatric work-up did not find a physiological etiology to his discomfort. However, in his intake, Tony stated that his grandfather had just died. When I asked his parents about Tony’s grandfather’s death, they indicated that he had died of lung cancer. Tony’s chest pain appeared to be a somatic manifestation connected to his grandfather, and after a few months in play therapy, Tony was able to work through his grief in a way that allowed him to find other ways to remember his grandfather.

Adolescents: Adolescents are capable of abstract thinking and struggle with the concepts of being versus non-being. While teens may feel immortal, they have increased awareness of the permanence of death. They may begin to think about death in terms of their own mortality. Teens may have experienced a variety of losses by now, and are better able to differentiate between types. The death of a distant elderly relative may feel different than the loss of a close friend.

Grief may manifest in a variety of ways including survivor’s guilt, a reduced sense of spontaneity, self-medicating (food, drugs, sex, etc.), social isolation and cyber mourning. Thanatechnology, or the use of media and technology to mourn, may be a way to seek comfort and connection through mourning sites, grief blogs and music playlists. However, it may also be a venue to glamorize loss in an unhealthy manner.

For example, I was working with a 16-year old girl who was devastated by the sudden death of her classmate by drug overdose. In addition to experiencing survivor’s guilt, she began engaging in high-risk behavior such as getting intoxicated at parties and offering sexual favors. This was a complicated situation as the client was not only grieving her classmate but also struggling with her own identity and self-worth. “Why should I live and she die?” We used an online memorial site to create a digital scrapbook of her friend’s favorite music, poems and pictures of special places they had gone together. I watched my client (and, with her permission, the memorial they had created) carefully. I started to get concerned as it remained a dark space for several months with little construction of hopeful meaning in sight. One day while the client was lamenting this loss, I asked, “Where would you have liked to go with your friend?” This led to a discussion about how the client and her friend had talked about hiking the Appalachian Trail when they graduated from high school. I grinned and said, “What a lovely tribute to your friendship to keep that promise.” By the next session, she had begun adding pictures and maps of the Appalachian Trail, marking the route she planned to take in a post-graduation trip to honor her friend.

 

Grief Work

It’s important to acknowledge that the deaths of family members or friends are not the only losses which can cause grief in children. For example, the death of a beloved pet, the divorce or separation of parents or a move to another school are all events that can evoke a significant sense of loss. It is vital to honor and understand these losses and ensure that children are allowed to express the accompanying grief.

Recognizing the varied symptoms of grief in children is essential as it may be masked in a variety of behaviors resulting in misdiagnosis and treatment. Even the most well-intentioned clinician or educator may misread and pathologize a child’s lack of concentration, fidgeting and restless behavior. This was the case for 5-year-old Andrew whose grandmother died suddenly from a heart attack. Andrew was very close to his grandmother, and even though his parents provided him with age-appropriate information around her death, Andrew began eliciting restless and inattentive behavior at school. Even though [his teacher was] aware of the death, notes were still sent home daily indicating that Andrew was disruptive in class. On the last day of the week, and the day before Andrew’s grandmother’s memorial service, the teacher’s note read, “Andrew is exhibiting signs of ADHD.” Andrew had not previously experienced difficulty in class. This is an example of a misdiagnosis. Andrew did not need medication or treatment for attention deficit hyperactive disorder (ADHD), but support during his grieving process.

After all, the goal of grief work, according to Worden, is to emotionally relocate the deceased loved one in a way that allows the child to move forward. In this way, children discover ways to remember the loved one in a healthy way. This involves helping children create connection to self, to others and to the sacred.

 

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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.