Tag Archives: family counseling

Exploring the ties that bind

By Bethany Bray April 24, 2020

Family therapy pioneer Virginia Satir famously said, “If we can heal the family, we can heal the world.”

Satir believed the family to be the “factory” where all people are made. She was among the first to champion an idea now commonly acknowledged among counselors: A person’s family of origin and family relationships influence that individual’s health, personality and life patterns — and, when explored in therapy, provide a fuller picture from which to help the client. That understanding can be expanded even further when the individual consents to involving family members in counseling sessions.

When considering whether it is appropriate to involve a client’s family in counseling sessions, “I look at what the primary focus of our work will be,” says Esther Benoit, a licensed professional counselor (LPC) with a private practice in Newport News, Virginia. “If the primary focus is on relational [issues], I want to bring in as many people as can possibly show up to sessions.”

Regardless of whether professional clinical counselors work with family groups, couples or individuals, an exploration of family issues can provide a more holistic picture of clients and what is contributing to their presenting issues.

Heather Ehinger, a licensed marriage and family therapist in Connecticut, urges practitioners to ask questions that dig into the traditions, boundaries and roles in the family systems in which clients operate. For example, perhaps clients perceive their role within their family to be that of the troublemaker or the placater. How did they arrive at that role? Is it a role that they desire
to inhabit?

“Using a family systems lens to treat anyone is very important,” Ehinger says. “Even if all you do is treat individuals … [using] a holistic lens, a family systems lens, in their assessment … will enrich any counseling that did not include that already.”

Trauma and transitions

Although discussing a client’s family background or involving family members in counseling sessions can enhance work with clients regardless of what brought them to counseling, there are a number of issues for which family work can be particularly helpful. The counselors interviewed for this article report that issues related to trauma and transitions — such as blending two families after a second marriage — come up repeatedly in their work with families.

Trauma, including past sexual, physical or emotional abuse, can often lead to problems with attachment in families, notes James Robert Bitter, a counselor educator who supervises graduate students at East Tennessee State University’s (ETSU’s) on-campus community counseling clinic. There is also the trauma of separation. Bitter says several students he supervises are counseling young clients who are in foster care or being raised by grandparents because their parents are incarcerated or struggling with addiction.

“[In] family therapy these days, in our area, we’re not working so much with children and families because they are structurally misaligned or have difficulty with psychiatric disorders. We are much more working with trauma and working with families to be more effective in how they raise children,” says Bitter, a professor of counseling and human services who specializes in family counseling and the Adlerian method. “When there’s been a rupture in attachment issues, helping clients [relearn attachment] in a compassionate way is hard. The people who have been traumatized are way outside the natural bond.”

Kristy A. Brumfield, an LPC at a group practice in Philadelphia, finds that working with families in groups can often help those who are struggling with transitions such as the arrival of a new baby, a move, or the particulars of co-parenting after a divorce.

Transition challenges can also crop up naturally as families grow and age, Benoit adds. For example, families may find that formerly established patterns that used to work well around the areas of discipline and boundaries begin to cause friction as children turn into teenagers. Professional counselors can serve as valuable sources of support and guidance as families take a step back and examine the patterns within their systems, says Benoit, who specializes in relational work with individuals, couples and families across the life span.

“Working through developmental things is huge [with families], as well as attachment and focusing on relationship patterns,” Benoit says. “Also transition points. Anytime there’s an expansion or contraction of a family system, that’s when people often seek help. It can be a birth, a death, a divorce or a blending of a family. Sometimes, what was working before is no longer working.”

Getting together

The term “family counseling” may invoke thoughts of the traditional nuclear family, with juvenile children and parents sitting together and talking with a clinician. This arrangement can and does happen, but family counseling also encompasses groupings beyond the immediate or traditional family unit. It can involve any constellation of family members willing to participate who are relevant to or involved in the family’s presenting issue and who could benefit from work on communication patterns and relationship issues.

When involving multiple people in counseling sessions, counselors must first identify who the client is and what that entails, including privacy issues. In some cases, the individual who first sought counseling will be the client; in others, a couple or the entire family group will be the client. (Find out more about this essential conversation in the 2014 ACA Code of Ethics, including Standards A.8. and B.4.b., at counseling.org/knowledge-center/ethics/code-of-ethics-resources.)

Benoit says she always begins counseling with family groups by fully explaining and defining the therapy relationship and letting the family decide if they would be comfortable with a group format. “I like to put the ball in the client’s court and give them a chance to decide if this modality feels right and will address what they want it to in counseling,” says Benoit, a member of the American Counseling Association.

Recently, Benoit received a call from a couple seeking counseling for their twin teenagers struggling with stress related to being in high school. The twins were both gifted and very bright. Benoit first met with the parents, without the twins, to learn more about the situation and to explore the family dynamics. She quickly saw that the family’s relationship was strong and healthy, which meant that wasn’t the issue of concern. Instead, the twins needed space to process some complicated emotions — feeling close and supportive of each other and yet sometimes simultaneously competitive with each other in academics, sports and extracurricular activities.

When Benoit had her first session with the twins, she talked over several options with them: individual work with different counselors, seeing her together for sessions, or having the entire family involved in counseling. Benoit stressed that if the twins decided to come to her together for therapy, they would need to stay together for sessions. She gave the twins time between their first and second sessions to think it over.

“Because of the uniqueness [of their situation] and how connected they were to each other, they felt it was most appropriate to be seen together,” Benoit recalls. “Ultimately, they decided that this felt like the best option [for them].”

Benoit emphasizes that this process will look different for each client and must be tailored to fit each client’s needs and presenting issues. For example, she has another set of juvenile siblings on her caseload who see her separately as individual clients. Their presenting issues are very different, and their counseling work does not overlap, so individual sessions work best for them, she explains.

The symptom carrier

Ehinger owns a group family counseling practice with two locations in Connecticut. Her staff of therapists is able to collaborate and co-treat family groupings and individuals within families who need counseling on separate issues simultaneously.

Frequently, in families, there is one identified person who is symptomatic and causes the family to seek counseling, such as a teenager with an eating disorder or a child with attention-deficit/hyperactivity disorder. Even so, the problem often runs deeper and affects the entire family. “The idea is that one person is holding the symptoms, but it’s not the only problem within the family system,” says Ehinger, an ACA member with a doctorate in counseling education and supervision.

This is especially common when couples have an unhealthy relationship or are going through a divorce, she says. Their child may be the one who is symptomatic, but the issue is rooted in the parents. “The child may be afraid to go to elementary school and has a lot of anxiety. The parents have talked with the school and find that it’s not anything academic, and the child is not being bullied,” Ehinger says. “Then we might find out from the parents that the father moved out two months ago, there’s a lot of fighting and there are lawyers involved. They may say, ‘We’re not fighting in front of the kids.’ [But] whether they’re fighting in front of the kids or not, this child is absorbing the energy and knows there’s something going on.”

Ehinger and a colleague at her practice co-treated a family in which a teenage son was identified as symptomatic. The parents initially sought counseling for the 16-year-old because they said he was grumpy and defiant, staying out past curfew, skipping classes and experimenting with substance use.

The teenage son started individual counseling with a male clinician at Ehinger’s practice. Because the practice specializes in family systems issues, the clinician viewed the teen’s troubles from a systems perspective and soon uncovered a larger challenge. The answers the teen gave to questions about his family life indicated there was tension in the home and that his parents were having trouble.

The family also had a daughter who was a freshman in college. When she came home for holiday break, she refused to return to school and started displaying defiant behavior and some of the other symptoms her brother had shown. As these challenges unfolded, Ehinger began working with the parents, while her colleague worked with their children. Sometimes they would all convene for sessions together, with four family members and two clinicians in the same room.

Ehinger’s conversations with the parents in counseling revealed that the couple had experienced an issue with infertility and that both of their children were adopted. The couple hadn’t resolved their grief over their infertility, and that contributed to them struggling with their adopted children gaining their independence and beginning to “launch” from home, Ehinger says.

Within a few months, the symptomatic teenager was no longer “the problem” — the couple’s marriage was, Ehinger says. The son’s symptoms dissipated as counseling helped him find autonomy, and he subsequently stopped acting out as often.

This family’s presenting issue was due to problems with attachment, Ehinger explains. “The parents hadn’t really grieved the loss of having the ability to have their own children. They were extremely sensitive to being ‘perfect’ parents. They felt they would be failures if they weren’t perfect parents to these adopted kids and were pointing fingers at each other out of frustration.”

The issue was exacerbated, Ehinger recalls, because the parents had large extended families with lots of children, so they felt inadequate and insufficient compared with their relatives.

Ehinger worked with the mother to boost her self-esteem and process her infertility grief in individual sessions. With the couple, Ehinger also focused on grief processing, as well as finding safety within their relationship. They talked about “how to be intentional with each other, how to relate to each other, what their idea of marriage is, and how they [could] be more intentional to get to that,” she says. She also provided psychoeducation on why transitions, including child development during the teenage years, are so hard for families.

Ehinger often uses narrative therapy with families, and in this case, it was particularly helpful. In this family, the narrative was that the husband and wife felt like “bad parents,” the son was the “troublemaker,” and the daughter had always been the “good one,” although she later struggled when she came home from college.

“We worked to change that story: The parents were not bad but hypervigilant. We taught them about attachment, normal teenage rebellion and helped them recreate the narrative of their family,” Ehinger says. “We talked about roles: How did [the son] get the role of the troublemaker? Did he want to keep it? Did he ask for it? Who would resist him shedding that role? What other role could he [and other family members] become?”

Uncovering patterns

Benoit finds structural family therapy and experiential family therapy helpful in her work with family clients. Both modalities focus on interaction patterns within family groups.

“A family’s whole systemic interaction pattern can be shifted by changing small behaviors. That’s why it’s so important to identify those patterns,” says Benoit, a full-time faculty member teaching online at Southern New Hampshire University.

One way counselors can encourage families to shift long-held and unhealthy patterns is to raise family members’ awareness of the roles they play within the system. “For example, sometimes one member will be the family’s harmonizer, smoothing over all conflict,” Benoit says. “Those roles often dictate how members interact in day-to-day interactions, but also during conflicts and transitions. Understanding the roles that are played and how those influence interactions can help challenge family members to explore alternatives and to try on new roles as their family systems grow and change over time.”

Benoit’s focus on patterns involves careful listening and close observation of the ways that family members talk and interact, both verbally and nonverbally, in sessions. This includes body language as well as the tone and subtext of what is said verbally. “I’m taking it all in,” she says.

Perhaps the family members always sit in the same order for each session, for example, or one child always sits with one parent and distances themselves from the other, or the children always look at their mother before saying anything. Often, families don’t even realize that these patterns are happening or that there might be deeper meaning behind them, Benoit says.

Her method is to gently point these patterns out to the family, framed by curiosity. Her approach doesn’t paint the behaviors necessarily as being bad, but rather just as something to ask about and gather more information on.

“With family counseling, families are coming to us to get information and feedback, so pointing out patterns can help,” Benoit says. “Over time, I might point [a pattern] out to the family and say, ‘This is what I’m seeing. Help me understand where this comes from, and how it helps in your relationship. … Tell me about what this behavior means to your family.’”

For example, a child may always sit between his mother and stepfather in session. What might this symbolize? Is it a physical representation of the bridge-building role the child plays in the family? Benoit would bring up this observation, framing it as a question or a “tell me more” prompt.

“It’s something to explore. It doesn’t always mean something, but it’s worth asking,” she says. “And I get it wrong all the time. Sometimes the family will say, ‘Gosh, no!’ and then it just helps me to learn more information” about the family system.

Behavior patterns within families can also be rooted in culture or context, Benoit adds. For example, a young child who always defers to his or her parents or waits to speak in counseling sessions can be exhibiting a sign of respect taught within the family or culture.

Uncovering patterns and the meanings behind them demands that practitioners be present and focused on each moment in session. It also requires keeping a curious mindset, Benoit says. “One of the reasons I love relationship counseling so much is that instead of working with one person, you’re working with multiple people. But more importantly, you’re working on the space between people,” she says. “It’s really dynamic and powerful work.”

Processing trauma

Bitter counsels clients with the internship and practicum students he supervises at ETSU’s on-campus counseling clinic, which offers free services to members of the community, many of whom have minimal or no health insurance coverage. Bitter says he starts thinking about other family members who could be involved in counseling work within the first session with a client. From his perspective, all issues that bring clients to counseling are family issues in one way or another.

“Everything is a family issue,” says Bitter, who will be publishing a third edition of his book, Theory and Practice of Couples and Family Counseling, with ACA this fall. “Instead of family or couples [counseling], a broader term might be relational counseling. From the moment we are born, we are in a relationship. We can’t survive without them.”

Bitter recalls one client whom he has counseled for multiple years (beginning when the client was 14), with various counseling interns also being involved in one-semester intervals. Initially, the client’s aunt contacted ETSU’s counseling center to request help for her nephew.

The client’s mother struggled with addiction and had been married four times, in addition to having multiple other relationships, all of which had been immersed in drug culture. The youth — the second of his mother’s five sons — had seen “a constant stream in his young life of drug dealers and men with whom his mother was having relationships,” Bitter says. By the time the boy was 5 or 6, he had taken on the role of unofficial parent and caretaker for his younger brothers. He would get them up and dressed in the mornings and make sure they had food to eat, and he would clean the house.

When he was 9, the boy and his older brother went to live with their father, who had alcoholism. There, the client also took on caretaking tasks for his brother and, to an extent, his father. Bitter notes that the boy would have to ask his father repeatedly for money to buy food for the household.

At one point, the youth called his aunt and asked if he could stay with her. The aunt took him in and called the ETSU counseling center for help. Initially, Bitter saw the teen as an individual client (at the teen’s request). But in sessions, the youth would claim that he was “fine” and never bring up anything to talk about.

“The trauma and neglect in this boy’s life led him to be depressed but also led him to be very secretive. He had a very, very hard time telling me what was going on in his life,” recalls Bitter, an ACA member. “When you grow up being a little boy who has to take care of everyone else, you have to present a really good face to the rest of the world and learn to act as if everything is fine, until it is not.”

Eventually, Bitter worked with the youth to involve his aunt and grandmother — the most supportive family members in the client’s life — in counseling sessions. In their work together, Bitter focused on ways to rebuild the teen’s broken family while removing the caretaking role he had shouldered for so many years. “I asked the adults to be a family, and the aunt and grandmother were willing to do that,” Bitter says.

A year and a half later, counseling began to include a focus on the teenager transitioning from living with his aunt to moving back in with his father, who had worked to get sober and secured a job as a landscaper. “The counseling center helped with that transition and rekindled relationship and also reversed the pattern of trauma [in the family],” Bitter says. “We helped him to live as a child again and rely on the adults in his life. Now he has an aunt, grandmother and father who are functionally caring for him.”

The teen will soon turn 17. He’s doing well but is “still careful and cautious in relationships,” Bitter says. “He has two good friends and can’t really handle more than that.”

The teen and family’s recovery came “after two years of [counselors] constantly seeing this family, encouraging them and literally teaching them how to talk to each other, helping them with how to respond to each other,” Bitter says.

Effective parenting

In addition to working through unresolved trauma, much of what Bitter focuses on with families in counseling is changing unhealthy parenting patterns. Parents often come to the counseling clinic at their wits’ end because of behavior problems with their children.

The world has changed dramatically over the past century, but parenting styles, on the whole, have not, Bitter contends. With what counselors know about attachment and the benefits of using boundaries rather than punishment with children, practitioners are well-equipped to offer psychoeducation to parents who are struggling, he says.

“The majority of people parenting today, when we’re at our best, we sometimes parent better than our parents did, but when we’re at our worst, we all parent at about the same level our parents did — and we have to assume they did the same thing,” Bitter says. “Most of parenting is teaching [clients] how to form really good bonds with children and help them grow and develop.”

Bitter says a counselor’s role is to offer guidance rather than explicit instructions or commands to parents. “I wait for the client to say what they did and then ask, ‘Did that work for you? How did it go?’ If you had to spank your child [multiple] times per week, then it’s not working. Let’s talk about what might work [instead].”

Counseling can also normalize parents’ challenges, sending the message that they aren’t alone in their struggles. “They get to see that they’re like every other family — if you have children, you’re going to make a mistake every day,” Bitter says. “Often, parents are doing a pretty good job but just need [extra] help. But those who are dealing with trauma, or dealing with a bond between a child and parent that has to be reconnected, that takes some time and patience.”

Bitter draws on a number of methods to help parents, including Jane Nelsen’s positive discipline approach, Michael Popkin’s active parenting system, the Systematic Training for Effective Parenting (STEP) program, and James Lehman’s Total Transformation trainings for parents. However, Bitter emphasizes the “natural consequences” concept when it comes to child discipline.

As a child, Bitter says he hated Brussels sprouts, but his father loved them, so the pungent vegetable often appeared on the family dinner table. This circumstance frequently escalated into verbal battles, with his father insisting that Bitter was going to eat Brussels sprouts and Bitter insisting otherwise. Use of the natural consequences philosophy can circumvent such parent-child power struggles.

“Now we know that if parents serve a variety of things and a balanced diet, over time a child will make good choices,” Bitter says. “If you make [healthy] food available, a child will eat it. I recommend that parents model good eating habits but not get into fights over what the child is or isn’t eating. [When a child refuses to eat something], say ‘OK, don’t eat that.’ The natural consequence is that the child will get hungry. If they say, ‘I’m not eating breakfast’ [with the rest of the family], a parent should say, ‘OK.’ The child will come back at 10 a.m. and say, ‘I’m hungry.’ The parent can respond [by saying], ‘OK, lunch is served at noon, and you’ll make it until then.’”

If these types of patterns are repeated often enough, children will learn from their experiences and realize the natural consequences of their choices, Bitter points out.

He gives another example: Perhaps a mother who is struggling with a defiant adolescent finds that the child pushes back on her instructions to come out of the mall to be picked up at 3 p.m., despite having been dropped off for shopping with friends hours earlier. Bitter says he would ask the client, “What would happen if at 3 p.m. [when the child isn’t there], you just pressed on the gas in your car and drove away?” When the child calls to ask why Mom isn’t there to pick him or her up, she can calmly explain that she was there at 3 p.m. but the child wasn’t. Now, Mom has other things to do but will return to get the child when she can, Bitter says.

The crux of this method is for parents to learn to control themselves, Bitter says. Once they learn and find control, their child (or children) will follow.

“This is not difficult stuff. It’s hard to put into practice but easy to understand. Part of this is just helping couples and families get there,” Bitter says. “It takes patience on the part of the parent. The parents we are seeing are extremely frustrated because what they’re doing isn’t working. … If you put these [concepts] into practice, [parents] will have a more harmonious life with their children. It’s just a question of getting started.”

Playing together

Brumfield is a registered play therapy supervisor and has used play therapy not only with children, but with adults and families, for 18 years. While play therapy with children is mostly unguided, Brumfield provides prompts and gentle guidance for the adults and families on her caseload, often in the form of games and activities. This can include asking a family to create a puppet show or to play out a story using puppets in session. Among the many benefits of this approach, Brumfield says, is helping adults “reconnect to the playful parts of themselves.”

Brumfield, a member of ACA, also uses music and art in her work with families. For instance, she might ask family members to draw their answer to a counseling prompt. Or she’ll pass out rhythm instruments and have the young children beat a pattern, while the parents are encouraged to add to it or to repeat it back to the children on their own instruments.

Observing how the family interacts during these activities tells Brumfield a lot about the relationships, patterns and roles within the family. For example, is one person dominant and leading the entire plan for the family puppet show? Or does everyone work on drawing on their own, almost as if no one else were in the room? “While watching them interact, I see the gaps and places where the family might grow,” explains Brumfield, who is also a counselor educator at Immaculata University in Pennsylvania.

In addition to in-session activities, Brumfield encourages families to make time for activities together at home. These can run the gamut from a game of hide-and-seek or a family bike ride to board games and puzzles. She recommends games that encourage conversation and that are cooperative rather than competitive. One of her personal favorites is the Ungame, a board game that directs players to answer various questions to encourage conversation but has no winner. Similarly, families can use a conversational card deck — a number of which are available online — to spark healthy discussion at mealtimes.

When it comes to “assigning” families activities to do outside of session, Brumfield likes to have each family member think of three things they would like to do together. “Children often have ideas readily, and the children are really the ones teaching the parents. I ask the parents to think of their own childhood and what they enjoyed or things they wished they were able to do when they were a child,” Brumfield says. “The primary goal is connection and helping them be more cohesive and work together.”

Boosting family connection typically involves taking a break from technology, Brumfield adds. She often requests that clients try to unplug during family activities. An exception is when technology prompts bonding, such as when a teenager invites his or her parent to play a nonviolent video game together.

Playful activity — inside and outside of counseling sessions — helps families to be less guarded with one another, Brumfield notes. It also boosts communication, joy and vulnerability. Parents might feel silly at first, and that’s a good thing, Brumfield asserts. She reassures parents that letting their guard down to play does not lessen their authority or diminish boundaries.

“When family members are more vulnerable, they’re more able to be seen. It can increase [the family’s] understanding of one another,” Brumfield says. “The children can see their parents differently — as more human. The parents are able to feel reconnected and able to have fun with their children, which can help balance more challenging times for families. … For younger children, mastery can be learned. It can be a confidence boost to be able to participate and learn to be a part of their family. For parents, they’re able to see the things that their children are capable of. Parents often want to do everything for a child, [and play] helps them discover what they can do for themselves.”

Brumfield encourages counselor practitioners to remember the power of play, regardless of whether they specialize in play therapy. “We all — counselors and clients alike — need to be connected with the playful parts of ourselves,” she says. “Remember the importance of humor in our work. It can even be a form of self-care. Think of play as a way to release, stay centered and help in other facets of life.”

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Families and technology

Heather Ehinger, a licensed marriage and family therapist in Connecticut, says conflict over technology use comes up over and over again in her work with families.

This includes fighting between parents and children (and among couples) about which technology is being used and how often. In addition, a couple may have differing views over the age at which their children should have access to technology (such as their own cellphone) or whether they should be allowed to have a computer or video game system in their bedroom.

The conflict that arises over one or more family members’ use — or abuse — of technology can be a flashpoint or an indicator of deeper issues. Technology isn’t necessarily what brings a family in to counseling, Ehinger says, but it’s often a contributor to their presenting issue.

“Technology is not the problem exactly, but it is part of the problem. It feeds into authority issues and discipline,” Ehinger says. “Technology is like a thorn in the family’s side, but it actually turns into the lens through which we see whether the family is functioning or not.”

Ehinger worked with one family who had a son in fourth grade. He was acting out at home, having tantrums and pushing back against boundaries with his mother, who was a stay-at-home mom. He wanted to play Fortnite all the time and would sneak his mother’s cell phone away from her to do so. She would find her son upstairs, still in his pajamas, playing the online video game when it was time to leave for school in the mornings.

This was partly a problem of overstimulation and obsession on the son’s part, but there was also a disconnect on the part of the mother, Ehinger says. Sometimes, disagreements over technology use are generational. In this case, the mother didn’t realize that her son was using the game as a way to socialize and communicate with peers. Adding to her frustration was the fact that she had previously worked in a corporate environment and was used to people listening to her, Ehinger observes. Now, as a stay-at-home mom, she was locked in a battle of wits with her young son.

When it comes to addressing issues of technology use, Ehinger says that psychoeducation about family roles and setting boundaries can be particularly helpful for families in counseling. She often talks with parents about setting limits, taking televisions out of children’s bedrooms, and establishing regular “no tech” nights, when the home’s Wi-Fi is switched off for the evening, to spend time together as a family.

Ehinger also moderates conversations with couples in counseling to get them on the same page regarding their family’s technology use.

“Often, it turns out to be a couple’s problem,” Ehinger says. “They need to define roles when it comes to discipline and boundary-setting — which is all affected by their family of origin. They have to create an ‘our way’ [instead of ‘my way’] and stop bickering and fighting with each other.”

 

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Contact the counselors interviewed for this article:

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Find out more about family counseling from the International Association of Marriage and Family Counselors, a division of ACA, at iamfconline.org.

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Stepping up to the challenge

By Lindsey Phillips May 29, 2019

Stepfamilies are complex and feature unique differences, yet on the surface, there may be little to distinguish them from “traditional” families. In fact, as Joshua Gold, a professor in the counseling education program at the University of South Carolina, points out, some counselors don’t necessarily think to ask if they are working with a stepfamily or blended family.

But perhaps they should. According to a 2010 Pew Research Center report, more than 40% of American adults have at least one step relative — a stepparent, a step- or half-sibling or a stepchild — in their family. Gold points out that of the eight most recent U.S. presidents, four (Obama, Clinton, Reagan and Ford) were part of stepfamilies.

“Often for counselors, it gets overwhelming to think about working with stepfamilies because it does look like so many moving parts,” says Jayna Haney, a licensed professional counselor (LPC) in private practice at the Wellness Collective and at Red Dun Ranch in Texas. “But what is also true is that stepfamilies [tend to] have similar problems.”

According to Institute for Stepfamily Education Director Patricia Papernow in her 2017 Family Process article “Clinical Guidelines for Working With Stepfamilies,” stepfamilies face five
major challenges:

1) Insider/outsider positions

2) Children struggling with losses, loyalty binds and change

3) Parenting issues and discipline

4) Building a new family culture while navigating previously established family cultures

5) Dealing with ex-spouses and other parents outside the household

Normalizing stepfamily dynamics

Stepfamilies often assume that something is wrong with them if the family isn’t working well, so counselors should reassure these clients that crisis and change are normal in stepfamily life, says Haney, the founder of the Bridge Across for Single Parents and Stepfamilies. She will often tell clients, “It’s not you. It’s your situation.”

One tool that Haney uses to educate clients about the challenges of stepfamily dynamics is called the stepfamily triangle. She draws a triangle, and at the top she writes in the name of the biological parent. She adds the name of the stepparent in the bottom right corner of the triangle and the name of the biological children in the bottom left corner. Then she explains how the biological parent and biological children have three bonds — emotional, biological and legal — and each bond is as old as the children are. Haney draws three lines to represent these bonds on the side of the triangle that connects the biological parent and biological children. The biological parent and stepparent have an emotional bond and a legal bond (if they are married), so Haney adds the lines connecting them. The stepparent and stepchildren have only an emotional bond (one that is only as old as their relationship) connecting them, which Haney illustrates with one line at the bottom of the triangle.

“So, when stepfamily couples are confused or frustrated because it feels like the family dynamics aren’t squaring up, it’s because they’re not,” says Haney, a member of the American Counseling Association. To illustrate her point, she’ll often put her hands together in the shape of a triangle and tip it over to the left because all of the weight is with the biological parent and child. She has found this visual helps families understand the dynamics and challenges that stepfamilies often face. 

Gold, author of Stepping In, Stepping Out: Creating Stepfamily Rhythm and editor of the newly released book Intervening for Stepfamily Success: One Case, Multiple Perspectives (both published by ACA), also uses education as a means of normalizing stepfamilies’ experiences. Rather than directly asking stepfamilies whether a specific issue affects them, he provides general information about challenges that stepfamilies often face to see if anything resonates with them. He often starts counseling sessions by drawing two large circles — one for the clients’ lived experiences and the other for common stepfamily issues based on his professional knowledge. For example, in his circle, Gold may write that some stepfamilies deal with gendered expectations, such as assuming the stepmother will automatically be nurturing with the children or expecting the stepfather to be the disciplinarian. If the clients say they have experienced that issue, Gold will add it to their circle. 

Both Gold and Pat Skinner, an LPC in private practice in Denver, agree that the schools offer one effective avenue for easily reaching stepfamilies and helping normalize their experiences. Gold recommends that school counselors hold stepfamily groups. These groups can be promoted in the school handbook given to parents at the beginning of the year.

Skinner, an ACA member who specializes in working with stepfamilies, thinks that holding stepfamily groups or classes at schools helps address some of the time and financial obstacles that these families might otherwise face in getting assistance. She also says that groups allow stepfamilies to hear stories similar to their own, helping them realize that they are not alone in their experiences.

Integrating multiple perspectives 

Working with stepfamilies means having multiple voices and perspectives in each counseling session, which can further complicate the process. “The more complex the situation, the more flexible you need to be,” says Gold, a member of ACA and the International Association of Marriage and Family Counselors (IAMFC), a division of ACA. “If I’m dealing with one client, I’m trying to meet one client’s expectations. If I’m dealing with five, I now have five sets of expectations.”

“It takes more skill and more orientation as a clinician to figure out how to integrate all these different voices,” he continues. “Most conflict is founded in the notion that it’s an either/or situation. Either you’re right or I’m right.”

Gold, a contributing editorial board member of IAMFC’s The Family Journal, advises counselors to help stepfamilies switch to a both/and mindset so that situations won’t become win-or-lose propositions. For example, rather than focusing on how the kids from one family ate yogurt and cereal for breakfast and the other family ate eggs, the new stepfamily could include both breakfast options.

Haney, who specializes in high-conflict situations, parental alienation and stepfamilies, has developed an integrated family protocol in which she spends three to four family sessions discussing how to convert high-conflict tendencies into something productive. High conflict involves rigid thinking, unmanaged emotions, extreme behaviors and blaming others. She advises stepfamilies to do the opposite: engage in flexible thinking, manage their emotions, moderate their behaviors and own their actions.

In the first session, Haney always discusses flexible thinking. She puts eight or nine items with various textures (such as slime, play dough, Kinetic Sand, putty and therapy dough) on trays and passes them around. Each family member plays with the items and discusses how the items feel. Haney then asks what all the materials have in common. Someone typically responds that all the items can be mushed or smashed. Haney points out that no matter what the family members do to the items, the materials remain flexible. To emphasize this point, she asks the stepfamily to consider what would happen if they punched slime versus punching a wooden box. The answer: Only the wooden box would break.

Haney connects this exercise to the importance of being flexible in one’s thinking and explains that all people and situations have some good and some not so good features. With this new perspective, she asks each family member to tell her one thing that they like about their other family members.

Next, they take turns telling Haney one thing that drives them a little crazy about their family. For example, a family member may say that they don’t like it when everyone is yelling or how one of the parents is constantly asking the children how they are doing. Haney purposely uses the phrase “drives you a little crazy” because she finds it helps clients think of small problems, not big ones. She also advises counselors against asking clients what they wish were different because that is often counterproductive, she says.

When a stepfamily walks into Darrick Tovar-Murray’s office, he observes where each family member sits and how they communicate with each other. Take for example a session with Jim (the custodial parent), Jeff (the stepparent) and James (the child). Tovar-Murray will call attention to the way the family is arranged in the room: “James, why did you sit closer to Jim than to Jeff? Help me to understand what you make of the way … the family is sitting in the room right now.”

Tovar-Murray, an associate professor of counseling at DePaul University, also points out subtle verbal and nonverbal communication: “Jim, when you said James is not doing well in school, your voice went up, and at that moment, James turned his back to you. Can you tell me what James may be feeling right now?” Teaching stepfamilies effective communication skills helps them to understand one another’s experiences and emotions, says Tovar-Murray, a member of ACA.

Haney encourages clients to explore the narratives they are telling themselves about certain situations while simultaneously accepting that everyone has their own perspective on those situations. For example, if a stepmother says that her husband is always looking at his phone and waiting for his ex-wife to call, the counselor can say, “I understand that bothers you. What’s the story you are telling yourself?”

The stepmother might say she feels like the ex-wife is still more important to her husband than she is. The husband says he’s simply concerned that he’ll miss a phone call from his children. To which the stepmother responds, “I don’t want you to miss a phone call from your children. I just feel like you’re always looking at your phone when we’re out at dinner.” The couple can then make an agreement for the husband to either put his phone away for an hour or call his children before going out to dinner.

Recently, Haney had a stepmother come in by herself because her 25-year-old stepdaughter was constantly fighting with or upset with her and her husband. Haney worked with the stepmother to help her understand that she could not control the adult child’s behavior — but she could control how she reframed the situation and responded to the stepdaughter. With Haney’s guidance, the stepmother changed her perspective and learned new skills so she would no longer get surprised, upset or disappointed when the stepdaughter turned argumentative.

“The hardest part in relationships is to realize the amount of power you have or don’t have to make change,” Gold says. “You have endless power to make change in self. You have less power to make change in others. And, sometimes, part of being in a relationship means you accept things you don’t really like.”

Establishing stepfamily structure

Haney often begins counseling with the stepcouple first because she believes the partnering piece needs to be in place before other issues can be addressed effectively. “If the stepfamily couple can create the structure within their relationship and they can get on the same page with some of these issues, the kids fall into line,” she says.

Stepcouples often face challenges with establishing and maintaining clear parenting roles. In fact, a primary area of conflict for stepfamilies is the parent–child relationship, Haney notes.

The stepcouple need to agree on what they want to teach their children and what the family rules are in the home, she continues. For instance, if the stepmother thinks the children should stop using their smartphones at night and tries to enforce the rule without the biological father’s support, it will cause problems. In such situations, Haney often finds that the biological parent agrees with the overarching rule; the disagreement is in the details. Perhaps the father thinks that 8 is too early to restrict phone use and that 10 would be a better time.

“The moment that you allow the biology to divide, then the house is really two different houses,” Gold says. “So, there’s got to be a set of rules for the house.”

Haney suggests that stepfamilies establish basic rules about bedtime, homework and family dinners. Every family member should also have his or her own space in the house, she says. For example, one person shouldn’t sleep on the couch while the others have their own bed.

Haney believes that the biological parent needs to parent, and the stepparent needs to let that happen. Gold agrees. The stepcouple should figure out the household rules, and then the biological parent should present those rules to the family, he says. Then, both parents can enforce those rules.

If a couple disagree on this point, Haney draws the stepfamily triangle so they can visualize the dynamics. This can help the stepparent realize that he or she may have been overstepping. Haney then asks, “What does the family need to do to make the triangle stay upright?”

First, the partners must be on the same page and create a supportive relationship in which they respect each other’s experiences and perspectives, Haney says. Sometimes, stepparents will need to take a step back, she adds. Haney tells stepparents, “When you assert yourself as a biological parent when you are not … you’re putting a target on your chest because you will always be the bad guy. You will never win.” The biological parent’s job is to protect the stepparent by doing the parenting, she stresses.

Second, Haney says, stepparents have to strengthen their relationship with the stepchildren, but they must also accept that it will take time. One activity she uses to help with this is the emotional bank account. When stepparents marry or move in with the biological parent, they assume a parenting role, she explains. Because biological parents already have a strong emotional, legal and biological bond with their children, they can discipline, set boundaries for, and offer advice and make comments to their children, Haney says. However, stepparents don’t have this emotional connection yet, so with every negative action (e.g., punishing, yelling, making comments, rolling eyes), they make a withdrawal from the emotional bank account with the child, she continues. “It’s not one deposit and one withdrawal,” she points out. “It’s one deposit, but for every negative nonverbal or negative interaction, it’s five withdrawals.”

Haney often helps stepparents realize that they are depleting this emotional bank account faster than they recognize. In such cases, they need to stop making withdrawals and start making deposits. Recently, one of Haney’s clients, a stepfather, was having a difficult time with his 14-year-old stepdaughter. He expected a lot of her and often critiqued what she did. For example, he would point out that he often needed to remind her to take out the trash and even made comments about the way she tied the garbage bag rather than thanking her for her efforts. Haney encouraged him to start making deposits in his stepdaughter’s emotional bank account by giving her compliments, texting that he was proud of her, or saying that he noticed how hard she had been working. When he followed through, their relationship took a 180-degree turn within a week’s time, Haney says.   

When a biological parent finds a new partner, the children are often expected to show love and respect for that new partner right away, Skinner says. However, it’s important to remind stepfamilies that neither children nor adults love immediately. It takes time.

In addition, the child’s developmental stage can affect the degree to which the stepfamily bonds. If children are approaching or into adolescence when the stepfamily forms, they may never feel connected to the stepfamily unit because they are focused on forming their
own separate identities at that point, Gold notes.

In her stepfamily, Haney and her husband developed a plan to handle the stresses and problems they faced. She encourages couples to follow a similar plan, which includes:

  • Talking to and reassuring each other that things will be OK
  • Creating daily habits that provide a sense of connection and support
  • Going out on dates
  • Limiting how much time they discuss children, stepchildren and exes

Haney also reminds clients to laugh. She and her husband found watching a daily episode of Seinfeld helpful during the difficult early part of their stepfamily’s life.

“A lot of times with stepfamilies, you’re sacrificing the me for the we,” Haney says. “If the couple … is willing to make these changes for each other, then it can be a really powerful experience.” In addition, the behavior of asking for help, finding solutions and making changes serves as a powerful model for the children, she says.

Focus on the solution, not the problem

“I think the big mistake that counselors make is they try to start with the problem,” Haney says about counseling stepfamilies. Often, stepfamily couples come in experiencing so much angst, frustration and confusion, they don’t know where to begin. If the counselor asks the couple to talk about their problems and feelings, the couple and the counselor all become problem saturated and risk becoming overwhelmed, she says. 

To avoid this, Haney starts sessions with a basic genogram, which provides her with all the names and connections between the family members. She uses colored markers and construction paper, drawing a circle for each woman and a square for each man in the family, including the stepfamily couple, the ex-partners and the children. Haney then asks the stepcouple’s ages and living arrangements, when the couple first met and when they started dating, and she adds that information to the genogram. For those who are married, she will also ask if they lived together before they got married, when they got married and how long they have been married. Finally, she asks about the most serious relationship that each of the partners had before they got involved with each other.

Next, she draws smaller circles and squares for the ex-spouses or ex-partners and asks similar questions such as age, length of time together, when they separated and if they have children together. If they do have children together, Haney connects the ex and adds in the children’s names and ages, as well as how the parents split their time with the children and how involved each one is with the children.

Haney always ends this exercise by asking, “Is there anybody else that we’re going to be talking about today or who is creating challenges in your stepfamily life?” By asking this question, she often discovers other people, such as one of the partner’s siblings, a grandparent or even the ex-spouse’s new partner, who are adding to the stepfamily’s problems.

In addition to serving as a reference tool that counselors can use throughout their work with the stepfamily, the genogram provides structure to the session. “Structure is a big part of doing a successful stepfamily session,” Haney says. “[It’s] knowing what you’re going to do and how you’re going to do it so that you don’t allow [the session] to become problem saturated.”

Tovar-Murray uses a narrative approach to separate the family from the problem. For example, if a child feels divided between family members, he would have the family name the problem and then ask, “When did the sense of divided loyalty enter your family system? How has it caused you to think you are not a family who can be a cohesive unit? What would your future look like if divided loyalty were no longer present and you were operating as a family unit?” This approach encourages the family to fight together against the problem rather than letting it divide them, he explains.

To strengthen stepfamily cohesion, counselors can also ask family members to describe activities that might make them feel more connected and then encourage them to carve out time over the next week to engage in those activities, Tovar-Murray suggests. “We’re always looking for those unique outcomes, and those are the times in which the stepfamilies are not being saturated and influenced by whatever the problem is,” he says.

Separating the family from the problem is also helpful when there is resistance to the new family structure, such as when one of the partners resists embracing or blending two racial or ethnic identities. For example, in a household with a Latinx stepfather and an African American biological father, the biological father might say, “Maintaining my African American identity is extremely important, and I’m not giving that up. I’m going to see this as an African American family.”

“That resistance piece is just showing [the counselor] how important that identity is,” Tovar-Murray says. With this situation, the counselor could attempt to separate the family system from the resistance piece and reframe it. For example, the counselor could respond, “I can see that you have a strong sense of pride in being African American. Now, I also wonder how you can have that same sense of pride in the relationship that you just formed.”

The counselor can help the family reframe this racial pride and create pride in the new structure the family is developing. Otherwise, the stepfather may feel isolated, which makes cohesion and integration almost impossible, Tovar-Murray says.

Take a step forward

Both Gold and Skinner acknowledge that busy schedules and finances can be big issues for many stepfamilies. As a result, these families often are not looking to engage in long-term counseling.

Gold says that any counseling approach that is more “present-focused” works well with stepfamilies. He often relies on a brief therapy model — six to eight sessions — and finds that most clients will make a commitment to therapy if they know how long it will take. This model also works well with family schedules, he adds.

Counselors “need to remember that a stepfamily couple is going to be less likely to come once a week, every week, for six months,” Haney points out. “So, when [counselors] work with stepfamily couples, [they’re] really doing that solution-focused piece.”

In fact, Haney finds that when stepfamilies come to see her, they have already thought and talked a lot among themselves about the issues they are struggling with, so they want to know what to do. “They know where they are and they know where they want to be, but they do not know how to get there,” she says. Haney doesn’t direct stepfamilies on what to do, but she does help them figure out different paths for getting where they want to be.

After Haney finishes the genogram, she asks the stepcouple directly, “How can I help you today?” Some couples may get to the heart of the matter, whereas others may not have an answer. In those cases, Haney provides the stepfamily with information on the importance of partnering together, the stepfamily triangle and the emotional bank account.

Haney also asks the stepfamily, “What are the two or three things you want to accomplish or work on while you are in counseling?” The family’s answers must be something they have control over, she says. “You don’t have any control over the ex or the stepchild,” she explains. “You do have control over how you respond to the ex. … You do have control over how you respond to the stepchild, how you talk to your partner about the child, and what kind of stepparent or parent you want to be.”

In part because stepfamilies may attend only a few counseling sessions, Haney often spends a longer amount of time in the initial session getting to know the family members, figuring out why they came to counseling and making sure they leave with an action plan. In the initial session, which often lasts up to two hours, she spends approximately 15 minutes on the genogram and 15 minutes educating clients about common stepfamily issues. For the remaining time, she helps families determine two or three things that they want to accomplish.

By the time the family leaves, each family member “need[s] to have something that they’re going to do that’s doable and that they can work on,” Haney says. “Then they leave empowered because they know what to do. [They] leave … educated because you’ve shared with them some insights that help them change their perspective and reframe how it’s working. And … it helps them see their story and their family differently.”

 

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Invisible stepfamilies

The concept of stepfamilies can challenge traditional assumptions of the word family, which often evokes an image of a married father and mother with their biological children. But as Darrick Tovar-Murray, an associate professor of counseling at DePaul University, points out, this image doesn’t account for the diversity found within stepfamilies. In fact, because this assumption doesn’t recognize other types of partnerships or unions, it renders them “invisible,” he says. That’s particularly the case when these families include a noncustodial and custodial parent with at least one child from a previous relationship and encompass multiple racial, ethnic and sexual orientation identities — which he refers to as invisible stepfamilies of color.

“When you look at invisible stepfamilies of color, they tend to come from cohabitating relationships where there isn’t a marriage or legal contract,” Tovar-Murray says. “That legal contract should not be what defines a family.”

As society continues to grow more diverse, counselors will encounter more invisible stepfamilies of color and thus may need to challenge their own views of what family means, Tovar-Murray argues. Counselors also shouldn’t assume that a couple is married, he continues. In addition, asking “How long have you been dating?” implies that the couple’s relationship may not be as close or as integrated as a couple who is married, and that may not match the perspective the clients have of their relationship.

Tovar-Murray also advises counselors not to make assumptions such as thinking that a stepcouple’s decision not to hold hands is related to their lack of affection for each other. Based on their experience of racial/ethnic or sexual orientation microaggressions, many of these couples may engage in this or similar displays of affection only in spaces they consider to be safe. “As counselors, we cannot assume that invisible stepfamilies of color are going to be out in all spaces that they walk in,” he says.

For this reason, Tovar-Murray, an ACA member and co-author of a chapter on blended families of color in the book Intervening for Stepfamily Success, advises counselors to be open and direct about microaggressions. He will often tell clients, “I want to talk about something I think is important. We know that racism exists and sexual orientation microaggressions exists, and I’m wondering if you as a couple or if this family has ever experienced those things.” He also suggests saying, “I know biases exist, and some of the things that may affect a family system like this may even be biases within your own cultural groups. Have you experienced any of those? How have you successfully dealt with those things?”

“The assumption that [counselors] make sometimes is that [they’re] not going to bring [these issues] up because the client didn’t bring it up,” Tovar-Murray says. “But sometimes clients, couples and families may not know that [counseling is] the space [where they] can talk about those things.”

— Lindsey Phillips

 

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

Letters to the editor: ct@counseling.org

 

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

Supporting clients through the anxiety and exhaustion of food allergies

By Bethany Bray November 27, 2018

The diagnosis of a food allergy is life-changing, not just for the individual but for those who love and live with that person. In addition to avoiding exposure to certain foods, the condition requires that these families and individuals explain, over and over again, the seriousness of the allergy at schools, restaurants, social gatherings, workplaces, daycare facilities and countless other places.

It can all be exhausting, says Tamara Hubbard, a licensed clinical professional counselor whose son was diagnosed with a peanut allergy six years ago. Families receiving a new allergy diagnosis face steep learning curves that can cause them to worry and to overthink every detail of what their child or other loved one eats or might be exposed to.

“It’s almost like Russian roulette. You don’t know when an [allergic] reaction will happen, even when you take precautions,” Hubbard explains. “There’s a constant level of fear and anxiety at all times in the background that parents and caregivers need help managing.”

Food allergies affect an estimated 4 to 6 percent of children in the United States, according to the U.S. Centers for Disease Control and Prevention. Between 1997 and 2007, food allergies increased 18 percent among American children and adolescents younger than 18.

A food allergy reaction sends someone in the United States to the emergency room every three minutes, reports the nonprofit organization Food Allergy Research & Education (FARE).

Counselors can help clients work through the anxiety and other mental health issues that food allergies sometimes exacerbate, but they can also be a source of support simply by serving as a listening ear. Clients may come to a counselor’s office worn out from the self-advocacy and constant vigilance that a food allergy requires, explains Hubbard, who has a private practice in the suburbs of Chicago that specializes in supporting clients (and their families) with food allergies.

With food allergies, there is sometimes “a constant feeling of having to fight in every conversation to get your point across,” she says. “Just being an empathic, listening ear [as a counselor] and wanting to learn, that makes a huge difference in their anxiety level and ability to release tension.”

At the same time, counselors should research and learn about food allergies to become a competent support to clients, Hubbard emphasizes. For example, they should know that an intolerance or sensitivity to a food is very different from a diagnosed allergy.

With a food allergy, the immune system views the allergen — for example, wheat, shellfish or peanuts — as an invader and overreacts whenever it enters the body. Someone who ingests a food that he or she has an intolerance or sensitivity to will experience discomfort but not the potentially life-threatening reaction that comes with an allergy, Hubbard explains.

Counselors who understand the biological and mental health implications of food allergies can help these clients to live fuller lives, Hubbard says. Although the most important thing counselors can do is learn about and understand food allergies, exercising compassion is also essential, she says.

“Sometimes, even medical professionals aren’t good at that part. They send [people] off with an EpiPen and say, ‘Come back in six months.’ In a perfect world, they would send them off with a list of resources for mental health and wellness,” says Hubbard, an American Counseling Association member. “Counselors can play a very important part to fill in that gap, even if it’s just an empathic ear. That is incredibly therapeutic in itself.”

 

Tempering the uncertainty

The anxiety that families and individuals with food allergies often experience is more complex than simply worrying about possible exposure to an allergen, Hubbard says. Anxiety can spike over everything from sending a child to school and worrying that the staff won’t follow allergy-safe protocols to second-guessing whether a food product might contain nuts, even when the label says it doesn’t.

In the United States, companies are required to note on food labeling whether a product contains one or more of the eight most common allergens. These potential allergens are:

  • Milk/dairy
  • Eggs
  • Fin fish (e.g., salmon, flounder, cod)
  • Shellfish (e.g., crab, lobster, shrimp)
  • Tree nuts (e.g., almonds, walnuts, pecans)
  • Peanuts
  • Wheat
  • Soybeans

However, U.S. companies are not required to disclose whether a product is made in a facility or on equipment that is or was exposed to those eight allergens, Hubbard notes.

With that in mind, navigating grocery stores, restaurants and social gatherings involving food can be anxiety-provoking for those with food allergies — and especially for newly diagnosed families, Hubbard says. Some parents react by restricting their child’s activity to reduce the risk of exposure.

Allergy diagnoses are sometimes given after a person has experienced one initial anaphylactic reaction. This can create uncertainty concerning how much of the allergen is too much. For example, is it OK to be near someone else who is eating the food to which the person is allergic?

“There is fear of the unknown: ‘How much of the allergen will it take for my child to react?’ There are different layers to the anxiety, and it’s important [for counselors] to understand each layer,” Hubbard says. “Also, the anxiety affects each member of the family; they will all feel it. There’s a lot to unpack when you are assessing a client who is dealing with food allergies.”

Counselors who understand the complexity of the issue can help clients find balance and equip them with tools to manage the anxiety, Hubbard notes.

“Ultimately, the goal is to help the client — whether it’s the allergic person themselves or a caregiver — assess the risk for every situation they’re going to be in. Is their anxiety based on fact or emotion? We can tell ourselves that everything is unsafe, or we can navigate [the risk] and take precautions,” she says.

 

Finding balance

There is a balance between living in fear and frustration because of food allergies and still enjoying a good quality of life, Hubbard stresses. “Understand that in many cases, when someone is newly diagnosed, especially if it’s a young child, the person or family may be very overwhelmed initially,” she says, “as there can be a steep learning curve when your lifestyle needs to suddenly change due to a food allergy diagnosis. Some people navigate this well, while others need support and guidance. I typically encourage people to remember that it will take time to get used to the diagnosis and gain all of the necessary knowledge to live a well-balanced life between food allergy fears and empowerment. I also encourage those who are newly diagnosed to learn the basics at first and, over time, as they feel ready, branch out to other related food allergy topics, such as potential treatments, research and advocacy.”

Here are some tips for counselors to keep in mind related to food allergies:

> Prepare for an emotional roller-coaster: Food allergies can be life-threatening, so it’s understandable when individuals (or their families) experience strong emotions such as fear, sadness, anger or guilt connected to the diagnosis. Of course, these emotions can eventually lead to becoming overwhelmed or burning out, Hubbard says.

“If a child has a [allergic] reaction, the parents can feel strong emotions of ‘what did I do wrong?’ At the same time, they could have done everything 100 percent right,” Hubbard says. “The reality is that it’s a big deal, but that doesn’t mean it has to be a … crisis every day.”

Equipping clients with coping mechanisms will not only help them manage their own anxiety and strong emotions but will also keep them from transferring those feelings to the child or family member with the allergy, Hubbard says.

Counselors can also help clients work through their feelings of loss concerning what their life (or their child’s life) might have been like without the limitations of a food allergy. For example, they may yearn to eat at a restaurant without having to ask about the establishment’s allergy protocols or to eat lunch with friends in the school cafeteria instead of sitting at a separate table or worrying about what foods they could be exposed to.

“These children [with food allergies] have to grow up a little quicker in some respects. They have to learn to speak up for themselves and make decisions,” Hubbard says. “It’s about managing the feelings and finding ways to help them empower themselves and advocate to come through with some balance.”

> Move toward acceptance: One of the most important things counselors can do is help clients reach acceptance of the food allergy diagnosis, Hubbard says. This can have similarities to grief work, including helping clients come to terms with the fact that they can’t change the situation, she explains. Narrative therapy can assist clients in reframing their feelings and taking control of their story.

Role-play can be beneficial for clients of all ages because it helps them learn to navigate their feelings and the language they will need to use to advocate for themselves. (For example, how will they explain that they can’t eat the cake at an upcoming birthday party?) Hubbard says she also finds play therapy, mindfulness and cognitive behavior therapy helpful for clients with food allergies.

Above all, she says, counselors should make sure their approaches are tailored to and appropriate for the individual client. “For kids, it’s not appropriate to talk about the risk of death [involved with food allergies], but coping with their feelings and worry is appropriate,” she notes.

Counselors can also model acceptance for clients in session, Hubbard adds. It can be a relief to find that “they don’t have to walk into a session defending themselves,” she says. “They can learn that not every conversation has to be fight-or-flight. It’s a marathon, not a sprint, for sure, just as with any chronic illness. Help clients pace themselves.”

> Find the right words: An individual with food allergies (or the parents of a child with food allergies) will need to explain the allergy to everyone from school staff to well-meaning relatives who are hosting a holiday dinner. Be aware that there can be cultural and generational differences in levels of understanding and flexibility surrounding food allergies, Hubbard advises.

“This can be hard for people who aren’t comfortable speaking up. If they’re not a natural advocate, it will now fall to them to educate [others] and advocate,” she says. “A counselor can help them manage the feelings around that, [including] frustration, burnout and exhaustion.”

> Guide children (and parents) as they grow up: Parents may find themselves growing anxious as their child with food allergies ages, develops more independence and spends more time away from home. Counselors can offer support as these families navigate the child’s developmental milestones. This might include encouraging the family to gradually give the child more freedom and responsibility to make safe choices independently.

For example, teenagers who are beginning to date may have to inform their love interests that they shouldn’t kiss for a while after the person has eaten something containing an allergen. “For every phase of life, there will be an additional need to explain and educate [about the allergy], and that can be exhausting,” Hubbard says.

> Be aware that “relapses” are possible: Clients who have made progress on accepting a food allergy and managing the emotions that come with it can “go back to ground zero” anytime they experience an allergic reaction or exposure scare, Hubbard says. Counselors shouldn’t be disappointed if these clients sometimes backslide on the progress they have previously made in therapy.

> Work with the allergist: Professional counselors shouldn’t hesitate to contact a client’s allergist (if the client grants permission). Counselor practitioners can learn a lot about the specifics of a client’s needs from the allergist, Hubbard says. For example, some food allergies are milder, whereas others can cause a reaction even from airborne exposure (for example, peanut dust). “Each client will have a specific set of data [regarding his or allergy],” Hubbard explains. “It’s important to stay connected with their allergist and check in to help you better understand.”

> Be cognizant that allergy-related bullying does happen: Being aware of allergy-related bullying is especially important for counselors who work in school settings or with children and adolescents in their practice, Hubbard notes. Up to one-third of children with food allergies have faced bullying, according to FARE.

This can include overt bullying, such as taunting or threatening a classmate with an allergen. But allergy-related bullying can also come in less obvious forms, such as when an adult (teacher, sports coach, etc.) points out the individual with an allergy and labels them as the “reason” the class or team can’t have certain foods. This type of scenario can make individuals feel bad about their allergies and the inconveniences they may present, Hubbard says.

 

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The Food Allergy Counseling Professionals Networking Group

Started by Tamara Hubbard, this group is open to counselors who work with clients who are managing food allergies. Connect with them on Facebook: facebook.com/groups/FoodAllergyCounselingProfessionals/ to share resources and network with other professionals who specialize in this area.

 

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Contact Tamara Hubbard and find resources at her website: foodallergycounselor.com

Hubbard also writes a blog on allergy-related issues, including a series titled “Four things counselors should know about food allergies.”

 

 

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Related reading

Hubbard suggests the following resources for counselors or clients looking to learn more about food allergies and their connection to mental health:

 

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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

 

Helping families cope with cancer

By Laurie Meyers November 26, 2018

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

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

Dark times

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

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

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

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

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

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

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

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

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

Family dynamics

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

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

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

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

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

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

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

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

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

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

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

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

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

Giving care

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

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

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

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

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

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

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

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

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

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

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

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

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

Coping with the unknown

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

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

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

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

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

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

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

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

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

 

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Supporting the client who has cancer

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

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

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

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

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

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

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

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

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

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

— Laurie Meyers

 

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Additional resources

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

Counseling Today (ct.counseling.org)

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

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

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

  • Resources for Professional Counselors

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

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

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

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

 

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

Letters to the editor: ct@counseling.org

 

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

Working with foster and adoptive families through the lens of attachment

By Somer George October 4, 2018

“He just got kicked out of his second preschool program! We’re nearing the end of our options here. What do we do?” I could hear the desperation in the mother’s voice as she described the past few months with the 5-year-old she and her family were fostering and would soon be adopting.

“He threw a chair at the teacher and punched a little girl, and nothing we do seems to make it better,” the father explained, describing the detailed behavior plan on which they had collaborated with a well-meaning social worker.

“And it’s not just at school,” the mother continued. “Even when he’s home with us, he often gets out of control. He even peed on his dad’s lap” — her voice lowered to a whisper — “on purpose!”

I nodded my head, empathetic to the immense strain this family had been under for the past several months. The mother and father were friendly and confident, well-educated and sincere. They had wanted to do something good for the world by fostering and adopting children in need. They had so much to offer. And yet here they were, barely surviving each day and feeling the shreds of normalcy slip through their fingers as this little boy pushed every emotional button they had, leaving them exhausted and discouraged.

My years of experience working with the Secure Child In-Home Program and the Virginia Child and Family Attachment Center helped me to frame their experience in terms of attachment. The situation they were in was not unique among parents who had adopted a child or made the decision to provide foster care, the initial good intention and early excitement slowly turning to exhaustion and sometimes regret. Often, these children who need it the most push away every offer of help and comfort that is provided to them.

Where healing happens

So, what do we do when parents who have adopted a child or are providing foster care come to us, asking for advice or counseling for their troubled child? Certainly, there is benefit in providing these children with play therapy, giving them a chance to form a new relationship and to express themselves through their own language of play.

And yet, that strategy speaks to only one side of the coin. Attachment theory tells us that children heal best in the context of secure caregiving relationships. And parents are the ones who provide the day in, day out caregiving, wielding the most influence on the development of new patterns in the child’s relationships and behaviors.

According to attachment theory, a child is biologically wired to turn toward a caregiver in times of distress. When the child’s emotional needs are met, the child develops patterns of soothing and regulation that are essential for healthy development. When these emotional needs are denied or rebuffed, however, or if the child experiences the caregiver as frightening, the child learns dramatically different adaptive strategies. The child may become withdrawn and inhibited or bossy and aggressive. These patterns aren’t quick to change when a new caregiver comes along. Add to this the trauma of abuse and the loss of a biological parent, and you have a situation full of misunderstanding and relational strain.

New caregivers often come into their role with little awareness of the child’s experiences and the patterns necessary for surviving a young life filled with turmoil, anguish and uncertainties. When these coping strategies show up in the new relationship, parents are (understandably) distressed and often seek help to “fix” the child’s confusing and challenging behavior.

What these parents may not realize is that their own ability to read through the confusing signals and meet the child’s emotional need is the place where most of the healing will happen. If the parents can provide both a secure base from which the child can explore the world and a safe haven for the child to return to, the deeply rooted patterns of behavior and interaction will begin to shift. This is not a quick and easy process. It is messy to be sure, often following a pattern of one step forward, two steps back. However, if parents are given the support they need, it is certainly an attainable and worthy goal.

The counselor’s role

So, what is the counselor’s role in helping form new patterns of interaction, leading to more emotional stability and better child behavior? How can we help move these relationships toward greater security, helping each family to become a haven of safety for children who have experienced significant neglect, rejection, fear and loss?

I’d like to offer some suggestions for counselors who desire to help these parents form stronger relationships with their children and experience a reduction in the difficult behaviors that create such chaos.

  • Provide empathy and understanding to parents. Often, by the time parents seek out a counselor, they have already been through a great deal of distress, frustration and turmoil. Yes, they are coming to receive help, but first they need to feel heard and understood without being judged. Parenting is extraordinarily difficult, and parenting a child with extensive emotional needs is even harder. Take the time to empathetically hear these parents’ concerns and welcome their expressions of distress.
  • Educate parents about normal development and the impact of trauma/loss. Sometimes foster and adoptive parents have already successfully raised biological children, so these difficult behaviors on the part of the child they are adopting or fostering don’t make sense to them. What they did with their other kids doesn’t seem to work with this child. Spend time teaching these parents about how their child’s brain may have developed in a dramatically different way due to the impact of neglect, trauma and loss. Talk about the fact that forming new secure relationships takes time and how important their role is in this process.
  • Help parents to practice observation skills. We human beings so naturally take in information and draw conclusions without even realizing we are doing it. Unfortunately, we aren’t always right. Parents who are living in highly stressful situations may have trouble stepping back and paying attention to what is happening in the moment. Help them to slow down and notice their child’s body language, facial expressions and tone of voice before making assumptions about what the behavior means or how to stop it. With foster and adoptive children, parents often say they don’t know what is going on inside the child; this is often the most important place to help them learn. It is essential that they obtain a developmentally accurate view of the child’s inner experience, feelings and thoughts in the context of the child’s earlier experience and relationship patterns.
  • Invite parents to pay attention to their own experience. How does mom feel when the child is screaming that he hates her? What is dad’s experience when his request to come for supper is repeatedly ignored? As parents become better at observing their child, it is important that they also attend to themselves. What are they feeling in these moments, and what is their body language and tone of voice communicating to the child? Help them to consider their own needs and to find ways to regulate their own strong emotions that are activated when the child is pushing them away.
  • Encourage parents to think about what the child is feeling in these difficult moments. So often, the focus of parents is on how to manage the child’s behavior. Traditional strategies that use rewards and punishment are rarely successful with children who have experienced neglect, trauma and loss. Although the child’s behavior doesn’t make sense at first glance, there is often much to be learned if we slow down and pay close attention.

Have the parents set aside quick assumptions and, instead, help them to observe carefully, giving consideration to what the child might be feeling. The child might look and sound angry at first glance, but might he or she instead be feeling scared or sad? The child already has emotional and behavioral sequences established that, once activated, run automatically. These unintentional and automatic patterns need to be shaped into healthier ones.

  • Ask parents to think about what the child needs from them. Does the child need to feel heard and validated? Does the child need comfort, protection and co-regulation of automatic well-learned patterns? Does the child need the parent to stay close by and help him calm down because he feels out of control? If the child is anxious, might she need the parent to provide soothing rather than correction?
  • Encourage parents to try new strategies aimed at fostering connection. Instead of putting the child in timeout, try bringing him in close for a cuddle and some conversation. Instead of sending the child to her bedroom to calm down, try going with her and staying close by. Remind parents that new approaches may not work right away, but with persistence and practice, they can begin to make a significant difference.
  • Facilitate parents’ exploration of their own attachment histories and how this influences interaction with the child. We know from research that a foster child’s initial relationship patterns are often a mismatch for a parent’s natural caregiving patterns. We also recognize that parental patterns of attachment have a strong influence on the child’s patterns. Increased reflection on these experiences can help us become better caregivers.

Invite parents to think about how their own experiences with caregivers have influenced the way that they react and respond to their child. What expectations do they hold? What automatic reactions are happening outside of their awareness? What automatic reactions happen outside of the child’s awareness?

  • Celebrate small (and large) victories. The little moments are the big moments. Provide plenty of affirmation and support for parents as they try new approaches and persevere in the day-to-day tasks of parenting. Acknowledging their efforts and celebrating successes, however small, can go a long way toward giving them the courage to continue through the hard times.

Working with these families can be immensely rewarding. They are often highly motivated and desperate for support. As counselors, we need to be aware of our impulse to provide a “quick fix” to try and make things better. We can make concrete suggestions, but we also need to recognize that the process of building stronger relationships and changing behavior takes time.

The type of relationship that we build with the child’s parents can itself be a catalyst for change. We can provide a place where the parents feel safe expressing their distress and their shortcomings, knowing that we will support them in their efforts to help guide their child on the path to healing.

A different path

As I continued working with the family mentioned at the beginning of this article, I could see the changes taking place. They began having more positive interactions with their child and seeing new qualities in him that they hadn’t noticed before; they were thinking about him in a different way. Their own self-reflection helped them to catch themselves before they reacted and think more about what he needed from each of them.

“I noticed that the collar of his shirt was often wet from him chewing on it. I stopped reprimanding him for this and realized that it meant he was feeling really anxious,” the mother told me one day.

“Yeah, and this was a sign that we needed to pick him up and give him some reassurance,” the father quickly added. “It really seems to calm him down.”

The mother continued: “I think that before when he was anxious, his behavior would spiral out of control. And the behavior chart was part of what contributed to his anxiety, which just made things worse instead of better. I don’t think we need it anymore.” As she spoke, she glanced at dad and noted his nodding head.

“They still use one at school,” she said, “but we’ve been talking to his new teacher about how to connect with him and what helps relieve his anxiety. Also, I stuck a picture in his book bag of the three of us together so he can get it out and look at it when he is at school. I think it helps him feel more secure. It’s a way for him to carry us with him.”

As I listened to them share these stories, I couldn’t help but smile. They still had a long road ahead of them, but they were headed down a very different path than the one they were on originally. We celebrated each of these moments together and reflected further on their experiences with their child.

I continued to come alongside them to support them in this journey for a little while longer, serving as a secure base and safe haven for them. Soon, however, they decided that they no longer needed counseling. Through a lens of attachment, they saw that their relationship with their son was much stronger, and although his behavior was still challenging at times, they possessed the confidence that they could handle it, moving forward together as a family. Once again, the experience of a healthy attachment proved itself to be a powerful force, propelling another family toward greater health and healing.

 

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Somer George is an adjunct professor at James Madison University and is currently completing her doctorate in counseling and supervision. She also works for the Virginia Child and Family Attachment Center and the Secure Child In-Home Program, where she helps to provide comprehensive attachment assessments, intensive in-home therapy and research-based parent courses. Contact her at somer@george.net.

 

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Related reading, from Counseling Today:

Fostering a brighter future

Through the child welfare kaleidoscope

 

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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.