Tag Archives: Family

The costs of COVID-19: Parental anxiety syndrome

By Rebekah Lemmons September 8, 2020

As counselors in the age of COVID-19, we have seen a lot. We have been on the front lines of treating a new wave of counseling crises, from broad-reaching trauma symptoms to an increase in panic attacks.

One such example is related to parental anxiety. This is a term that stems from an increase in parental stress and accompanying anxiety related to the reopening of states, businesses and schools.

COVID-19 has changed the day-to-day lives of many parents and caregivers. These individuals have been forced to make adjustments in major areas of life, including child care, schooling for children, work dynamics and social supports. These changes create deeper concerns and uncertainties for many adults.

To best help clients effectively manage parental anxiety, we need to understand this phenomenon, who is at risk, what contributes to higher risks, how to effectively cope with these issues, and how to maintain overall health as the pandemic continues.

What is parental anxiety?

Clinically, parental anxiety is comparable to separation anxiety. It includes a high level of anxiety around opening up schools, day cares and related activities in which parents leave their children in the care of others. It has added components of stress and worry that derive from our ongoing transition to a new normal.

For some parents, this leads to increased panic attacks, decreased stress tolerance, sleeplessness, irritability, head and body aches, and exhaustion. It can also lead to increases in family conflict or parental conflict, largely based on disagreements about parenting in a pandemic. Conflicts about transitioning back into school, work or social situations can create tension and magnify existing areas of disagreement.

Who is at risk?

Any parent or caregiver is at risk for parental anxiety. From full-time working parents to stay-at-home parents, any caregiver can develop symptoms of this condition.

Parents who have been keeping their children at home and are preparing to transition children back into child care or school settings outside of the home are at higher risk. Parents and caregivers are also at risk for parental anxiety if they are preparing to return to the office themselves and transition children out of the home.

Any additional stressors or traumatic events can further complicate this condition. For example, if clients have lost a loved one during the pandemic or known someone with COIVD-19, their symptoms of parental anxiety may become stronger. In addition, Black, Indigenous and people of color (BIPOC) may be at increased risk for parental anxiety because civil rights violations and racial trauma from current events have a layered impact on the effects of the pandemic.

What creates these risks?

Collectively, we have all experienced a crisis. This has been described using many terms, including “collective grief” and “collective traumatization.” As we look at how individualized coping is in general, it is no surprise that during major societal shifts and global-scale issues, there is no one way to manage all that is being thrown at us. Even those with higher supports and increased levels of stress tolerance can struggle with parental anxiety.

For this reason, counselors need to be attentive to clients who appear to be doing well despite the circumstances as we transition to normalcy. As with other types of trauma and toxic stress, it is common for people to release feelings when they are in a safe space. With the transition back to routines and schedules, some parents and caregivers may feel increased stability and become able to release deeply suppressed feelings related to the collective grief and traumatization from recent events.

Clients may have been put in positions in which they had to push through difficulties to continue working, parenting and performing in the various roles they played. Even parents and caregivers who report being ready to return to work or to have children return to school can experience this unexpected flood of traumatic symptoms.

How can we help parents manage these symptoms?

In one sentence, healing from collective trauma requires collective compassion. It is important to promote connection and healthy attachments to recover from the negative impacts of compounded events and societal issues.

We can provide a safe space for clients to unload difficult emotions and worries by being empathic, demonstrating patience and providing psychoeducation about trauma. Counselors can also assist clients with increasing their awareness of feelings related to these issues and provide them with stress-reduction interventions.

Additionally, empowering clients to talk to their employers, child care providers and children’s schools about transition plans can help to alleviate fear of the unknown. This also assists parents and caregivers in making informed choices that will best work for meeting their needs and the needs of their families. With education on transition plans and safety precautions in place, parents and caregivers can focus on areas that they can control.

In response to the array of physical, psychological and sensory impacts from this symptomology, integrated psycho-sensory therapy may be beneficial. This therapeutic model includes using aspects of physical wellness such as recommending and referring clients to engage in yoga, exercise classes and related supportive services (e.g., physical therapy/occupational therapy, chiropractic care, massage therapy). It includes aspects of psychological wellness (the theoretical model of choice). Then it adds sensory considerations based on the client’s needs. These considerations may be related to lighting and colors (low lights, wearing and having a background with calming colors or nature), gentle music, and the presence of calming smells (lavender, lemongrass, etc.). See the visual (below) for model components. The diversity of each component added to the next assists clients in minimizing the impacts of how trauma is felt in the body and how it affects our functioning.

Even with telehealth sessions, counselors should consider creative ways to engage clients by giving them options to move around throughout sessions.

Click on the image to see it full size

Other considerations

For many clients, feeling prepared and having a plan can help to eliminate some of their added stress and anxiety. However, it is crucial that counselors continue to help clients maintain flexible thinking and increase adaptability because much about life today is unpredictable.

On a final note, counselors have experienced this pandemic too. We have also taken on the brunt of addressing mental health needs in a time unlike any other. Furthermore, many counselors are also parents or caregivers. It is vital that we take care of ourselves and commit to our own overall wellness. We must embody the level of integrative and holistic self-care that we communicate to our clients.

One thing I have encouraged others to do in these times is to give grace — to themselves and to others. We must have grace as we navigate these challenges so that we can rise above our circumstances and emerge resilient.

 

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Rebekah Lemmons strives to improve outcomes for children, emerging adults and families. For the past decade, her practice and research primarily has been based in the nonprofit sector, with an emphasis on program evaluation, teaching, service leadership, consulting and providing supervision to clinicians. Contact her at rebekahlemmons@yahoo.com.

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

Supporting families with engagement strategies during COVID-19

By Carson Eckard June 18, 2020

To combat the toxic stress caused by the COVID-19 pandemic, I have created a list of activities to positively engage children during this time. The following list includes a description of what each activity is, what materials are needed (with an understanding that many families are under financial hardship) and the possible psychological benefits of the activity.

These activities are designed for entire families, including adults, to reduce stress and promote healing during the pandemic. Most of these activities can be done either inside or outside and can be tailored to individual interests, ages and ability levels.

 

Obstacle course

This activity will get the whole family moving. Use objects around the house to get the family involved. This could include climbing under or over chairs, throwing a bundle of socks into a laundry basket, spinning, using paper strips in place of lasers, and so on.

Inside, a slower pace can be taken to ensure that nothing gets broken and no one gets hurt. If you have access to an outdoor space or a sidewalk in front of your home, you can create an obstacle course out of chalk. Here’s an example.

This website includes a list of materials to use.

This slideshow has ideas for children in wheelchairs.

Materials: Whatever you have in the house

Ages: Toddlers and early elementary-age children

Psychological benefit: Obstacle courses can target many aspects of a child’s brain, including sensory input, motor planning, coordination, sequencing and problem-solving. They can also reduce psychological stress and anxiety. When more people participate, the teamwork and competition can provide some of the social interaction children have been missing from environments such as school.

 

Broadway play

This activity allows children to engage in imaginary play by creating plots to their own stories. When the story is written, have the child cast the characters in the story, find props (or imagine them) and direct the scene. If there aren’t enough family members to act out the scene, consider playing multiple parts at once or having the child draw the characters instead. Children may need direction and prompting, but allow them to be in control of constructing their own narrative. Activities that could be added include constructing sets and props and making movie posters.

Materials: Whatever you have in the house — paper, markers, drawing materials, prop-making materials and so on

Ages: Toddlers through early middle school age

Psychological benefit: During the pandemic, children may be struggling with an inability to control the situation. When they are able to control a scene and story in a healthy way, it can reduce their stress and promote individuality and resilience. Furthermore, creativity reduces anxiety and depression and can help children process toxic stress.

 

Board games and card games

When everyone is stuck at home, board games and card games are a great option for helping the entire family to connect. For younger kids, games such as Go Fish, Candy Land, and Guess Who? could be hits, whereas older kids may like Monopoly, Clue, and Sorry!

If you don’t have any board games at home, use paper or cardboard to create your own. WikiHow has information on steps to take when you’d like to create your own board game. Make sure your child is part of the creative process of creating the game if you choose to make your own.

For more information on why board games are good for a child’s mental health, as well as a breakdown of age-appropriate games, check this link from Manhattan Psychology Group.

Materials: Cardboard, paper, markers, small toys, etc.

Ages: Any

Psychological benefit: Playing fun games decreases anxiety and can increase confidence in children. Some games include aspects of problem-solving and can access the cortex for children who feel safe. Board games allow for healthy cognitive and social development for children.

Mazes and finger labyrinths

Mazes and finger labyrinths are easily made at home. They are a great brain teaser for kids and can also be extremely relaxing. Finger labyrinths are just like mazes, but instead of drawing a line to the exit, a finger is used to follow the path. When paired with deep breathing exercises, this can have a meditative quality.

For help on constructing labyrinths made out of materials such as rice, play dough, paperclips and more, go to this website.

The Labyrinth Society offers an online resource for downloadable and printable finger labyrinths.

The All Kids Network has many printable mazes for kids.

Materials: Paper, printer, something to write with

Ages: Whereas mazes are most engaging for children ages 3-6, finger labyrinths are a good mindfulness activity for children of all ages

Psychological benefit: Mazes offer many benefits to a child’s development, including problem-solving and motor control. Children will need patience and persistence to complete the puzzle and, once done, may experience a boost of confidence. Finger labyrinths originated in prayer but are also used as a grounding exercise.

 

Dance party

Turn up your favorite songs and get moving. Be sure to build a playlist the entire family can move to. Only upbeat jams! Spotify is a free service you can use to build playlists if you establish an account. Spotify playlists that might make for super fun dance parties can be found here. You may need to look around to find a playlist without explicit lyrics, but Spotify does offer an explicit content filter in its settings. Other free services include Amazon Music, Pandora, iHeartRadio and YouTube, but most have ads and can incorporate explicit lyrics, so be careful.

Materials: A phone, laptop, tablet or any device that plays music

Ages: Any

Psychological benefit: Dancing is both great exercise and a form of creative expression. Dancing keeps your heart healthy and muscles strong, improves coordination and balance, and provides an outlet for emotions. Music activates the cerebellum, stimulates the release of hormones that reduce stress, and improves self-esteem.

 

Karaoke party

On a similar note to a dance party, a karaoke party could be another viable option for the family. Because you want family members to sing, I recommend using YouTube and allowing each person to pick a song of their choice, unless you have a premium subscription for a music streaming service. As a finale, try singing a few songs that everyone knows together. For an added bonus, try creating a song by making your own lyrics and finding objects around the house to use as instruments.

Materials: A phone, laptop, tablet or any device that plays music; maybe a prop to use as a “microphone”

Ages: Any

Psychological benefit: Singing releases hormones that reduce stress and make us feel happy, improves mental alertness and helps us control our breath flow, which can help us regulate. Singing also helps children’s communication skills and self-esteem. Studies show that singing stimulates the vagus nerve responsible for our senses, motor function, digestion, respiration and heart rate. When stimulated, the vagus nerve reduces stress, lowers the heart rate and blood pressure, and reduces inflammation.

 

Play teacher

Let your child become the expert and pretend to be a teacher of whatever they are passionate about. This can take a more “formal” approach by pretending to be in school, or it can be more informal, simply asking them questions about the things they are interested in. This helps children realize that adults don’t know everything and allows them to develop as individuals.

Materials: None

Ages: Elementary school age (Note: It is beneficial and important to ask children of any age what their interests are to strengthen your relationship with them)

Psychological benefit: Taking on a formal “school” scenario involves imaginative play. Imaginative play allows children to experiment with different interests and skills. Furthermore, children who engage in pretend play are understanding social relationships, expressing and understanding emotions, expressing themselves both verbally and nonverbally, and practicing problem-solving skills. If imaginative play isn’t your cup of tea, have conversations with your child about what they are passionate about or interested in. Having these kinds of conversations will help you and your child relate to each other more.

 

Yoga

Although it may be difficult to practice advanced yoga poses with younger kids, it is possible to find something appropriate for their level. One of the most important aspects of yoga is breathing. Try doing the yoga poses with your child. Model a positive attitude and a willingness to try new poses, and compliment the child when poses are attempted. Make sure the poses are not too advanced for children or they may become frustrated.

Here is a free YouTube video of yoga poses that you can do with children. If you do not have access to a video device or the child would not benefit from structured instructions found in a video, you can find printable yoga poses from Kids Yoga Stories. If you and the child are new to yoga, it is vitally important to follow a guide to ensure that you are not hurting yourself or the child.

Materials: A guide to follow (either pictures or a video)

Ages: Any

Psychological benefit: It is no secret that yoga has therapeutic qualities such as offering a sense of calmness and relaxation. Furthermore, yoga enhances children’s flexibility, strength, coordination and body awareness. Doing yoga can reduce muscle tension held in our bodies and is another activity that stimulates the vagus nerve, which reduces stress, lowers the heart rate and blood pressure, and reduces inflammation.

 

Indoor sports

This category can depend on whether there is space to move around and interact with each other, but there are options for small spaces too. Each activity is meant to allow children to have fun and can be created with multiple objects around the house.

The Fatherly website has many ideas, such as balloon tennis, for bigger spaces. Roll up some paper and make a ball or a puck to kick, throw or hit around the house. Use a balloon to play volleyball or keep-up. If you have a smaller space, perhaps finger football might suit your needs.

Materials: Anything you can find around the house

Ages: Early elementary to early middle school age

Psychological benefit: If your family doesn’t have much space to run around and play, even the simplest games such as finger football increase coordination. In addition, these sports need multiple participants, which assists in the social development of the child.

 

Video games

Many video games are not family friendly or age appropriate for children. However, many options are available for younger kids both online and offline. PBS Kids offers many educational games for young children. Older kids may benefit from playing games online with their friends. Among popular options are Fortnite, Roblox, Minecraft, League of Legends and titles usually found on consoles, such as NBA 2K and Call of Duty. Many of these games are not free (some can be very expensive), and many are not appropriate for all kids. Have a conversation with the children in your life about what their friends are playing, and then set healthy boundaries around screen time.

There are also online video games that you can play with your family and friends. Popular options include Kahoot!, Jackbox Party Pack, digital board games through apps, Mario Kart Tour and others. Many of these games require only your phone or another device with internet access.

Materials: Games to play and something to play on

Ages: Any (as long as you monitor what games they are playing)

Psychological benefit: Your child is likely missing their friends from school and other environments. Allowing children to play video games with their friends online can help them stay connected and have fun. With all ages, video games offer an outlet for motor development, the release of stress relief hormones, social interaction, problem-solving, development of leadership skills, and increased alertness.

 

Call-and-response songs

If you’ve ever been to summer camp, call-and-response songs will be familiar to you. These songs are started by one person and imitated by another person or group. For children, particularly children with special needs, transitions between activities may be challenging. Side note: I worked at a summer camp with children with autism spectrum disorder, and mealtimes were one of the most stressful parts of the day for them. Singing a simple song such as “We put our foot up on the tree, we put our foot up on the tree, we put our feet up on the tree so that we can eat” makes these times less stressful for all.

Performing a quick redirect activity such as a call-and-response song can lighten the mood and offers a fun incentive for completing an activity. Although there are already call-and-response songs that you can utilize, you can also make your own (or change the words to an existing song) to suit the child’s needs. This activity could also be paired with dance moves or even a camp-themed day.

Go to Ultimate Camp Resource for a list of call-and-response songs. Design Improvised has a great list of themed summer camp ideas to use if you’d like to host a camp-themed day at home.

Materials: None

Ages: Toddler through elementary school age

Psychological benefit: Singing has profound mental health benefits. Singing forces a person to control their breathing. If someone is anxious and having trouble regulating their breathing, singing can help. Singing also improves mental alertness and confidence.

 

Grounding activities

The purpose of a grounding activity is to refocus on reality. It is particularly effective for children who suffer from anxiety, high levels of stress, trauma, dissociation, self-harm tendencies and suicidal thoughts. When children experience these events, they are more likely to enter a state of fight, flight or freeze because they feel they are in danger. Grounding techniques help move the brain from survival mechanisms to a calm state.

Although grounding activities are used in circumstances of higher emotion, they should be practiced often (and even when children are feeling happy) to ensure that children can perform them while in a dysregulated state of mind. You should take time out of the day for all family members to practice these skills together.

Sound search: Sit calmly in a comfortable position. The person lists the sounds they hear. Focusing on other senses helps bring the child back to safety and stabilization.

Coloring break: Although this is most effective for younger kids, it can be used for any age. Even if you do not have coloring pages, encourage the child to draw or color on a piece of paper. Support whatever they need to create in the moment. Crayola has printable coloring pages both for kids and adults.

Sensory bin: A sensory bin is a container filled with materials to stimulate the senses. You must know what types of sensations the child feels are soothing and what sensations may make the child excited. When used with soothing objects such as water or sand, a child may be able to focus on the container instead of overwhelming thoughts. The good thing about sensory bins is that they are easy to make and easy to store when needed. This technique is used mainly with younger kids, but a child of any age may appreciate a sensory bin if it is filled with the appropriate objects. Go to Your Kids Table for a list of ideas on what to put inside a sensory bin.

Positive affirmations: Building a mantra, based on a child’s strengths, that the child can repeat when they are feeling overwhelmed may be beneficial. The idea of having a child repeat a positive mantra when overwhelmed is to help the brain focus not only on the words they are saying but also on the breath needed to form the words. Whenever a family member or friends see the child becoming overwhelmed, they can support the child by guiding the child through the mantra.

Breathing techniques: You can teach children to utilize many different breathing techniques. Breathing exercises calm the brain’s reactions to threats by getting more oxygen. The adult should make sure the child has no anxiety about breath retention and that the child is slow and intentional instead of hyperventilating. If the child is hyperventilating, try to get them to exhale longer than they inhale. Model the techniques for them. Repeat the technique for as long as it takes the child to calm down. Breathing techniques take many forms, such as:

  • Sniff the Flower, Blow Out the Candle: The child imagines holding a flower in one hand and a candle in the other. The child must focus on breathing in through their nose while bringing the “flower” to their face, as if sniffing it, and then exhaling out the mouth while bringing the “candle” to their face.
  • 4-7-8 breathing: The child should breathe in through the nose for 4 seconds, hold their breath for 7 seconds, and exhale out their mouth for 8 seconds.
  • One-nostril breath: The child should place their finger over one nostril and breathe in deeply. The child should then switch to the other nostril and breathe out.

 

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Carson Eckard is a rising second-year graduate student in the community and trauma counseling program at Thomas Jefferson University. He graduated with his B.S. in psychology from Thomas Jefferson University in December 2019. He is passionate about advocating for clients, particularly LGBTQ+ youth. Contact him at Carson.Eckard@jefferson.edu.

 

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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.

Affirming all shades of the rainbow

By Laurie Meyers May 27, 2020

Licensed professional counselor (LPC) Laura Brackett’s specialties include counseling LGBTQ+ individuals. A frequent complaint she hears from her clients is that those outside of the LGBTQ+ community — including some mental health practitioners — see it as one big, happy family that shares all of the same problems and concerns.

This is, of course, not the case. “There can be deep and painful divides between the various groups that make up this community,” says Brackett, an American Counseling Association member who practices and is the director of community engagement at Change Inc. in St. Louis.

That is especially true for marginalized communities within the LGBTQ+ population. For example, American society has made significant progress in accepting differences in sexual or “affectional” identity but remains distinctly uncomfortable with alternate gender expressions such as transgender and nonbinary, says ACA member Christian Chan, an assistant professor in the Department of Counseling and Educational Development at the University of North Carolina Greensboro. People can generally grasp (even if in some cases only reluctantly) being gay, lesbian or bisexual as being about whom one chooses to love. However, the idea of someone being assigned the wrong gender at birth or a person rejecting that they must choose the binary of either male or female undermines deeply held notions of what constitutes a person’s identity, explains Chan, whose research interests include intersectionality and issues affecting queer people of color.

Even the LGBTQ+ community tends to prioritize affectional identity over gender identity, says Chan, a member of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of ACA. For too long, there has been a hierarchy of whose needs matter, he asserts, and transgender people — particularly women of color — have been at the bottom.

“Mental health providers are not really culturally responsive to the needs of [diverse] communities — particularly communities that have multiple identities,” he says. Even counselors who are affirming of LGBTQ+ clients don’t always take the time to consider clients’ intersecting identities and how those identities affect their mental health needs, Chan adds.

When transitioning is not an option

LPC Jessica Jarman Hayes says the transgender clients she counsels are often not out and almost “sneaking themselves into therapy.” Hayes, whose Columbia, South Carolina, practice specializes in LGBTQ+ issues, explains that being transgender anywhere in the surrounding area is just not accepted. If anyone in the communities where her clients live learned that these individuals are struggling with their true identity as a transgender woman or man, her clients would lose everything, she says. If married, their spouses would leave them and take their children. Their families, friends and neighbors would reject them, leaving them with no social support. The need for secrecy is so great that it can be challenging for these clients to even schedule appointments with Hayes.

Other of Hayes’ clients live out in isolated areas of South Carolina’s Low Country. They cannot easily get to her office, so their only option is teletherapy, sometimes from a car in the parking lot of a grocery store because they have no safe space available to them at home.

“It reminds me a lot of when I was working in domestic violence,” says Hayes, who is also a volunteer at the Harriet Hancock LGBT Center in Columbia. “You just have to be there to support them, sometimes for years, when they finally reach a place in which it [denying their identity] is no longer acceptable, and then come up with a plan to get out of Dodge.”

Violence is an ever-present threat for people who identify as transgender and gender nonconforming or “nonbinary.” According to the Human Rights Campaign report “Violence Against the Transgender and Gender Non-Conforming Community in 2020,” at least 26 individuals who were transgender or gender nonconforming were murdered in 2019. Most of the victims were African American women.

As the report notes, “These victims were killed by acquaintances, partners or strangers, some of whom have been arrested and charged, while others have yet to be identified. Some of these cases involve clear anti-transgender bias. In others, the victim’s transgender status may have put them at risk in other ways, such as forcing them into unemployment, poverty, homelessness and/or survival sex work.”

Hayes says the fear of violent retribution is another reason, in addition to fear of losing family and friends, that her transgender clients feel unable to express their identities in any way. One client hid underwear in a wall in the house, and their spouse gave them a severe beating when they discovered it, Hayes says.

There is no protection for the abused in these cases because the local police do not take such incidents seriously, according to Hayes. This lack of concern is present even when a juvenile is involved, she says, recounting the story of a suicide hotline call from a transgender teen that got routed her way. The teenager was actively suicidal and in danger. The father had found girls’ clothing and had severely beaten the teen. Hayes called the police and made it clear this was a domestic violence incident involving child abuse and a victim who was actively suicidal.

“The police went in there and teamed up with the dad,” Hayes says. “They said, ‘If you would just stop pretending to be a girl, your dad wouldn’t have to do this.’”

For a time, the girl was able to maintain touch with Hayes by using a self-wiping app on her cell phone to avoid being detected. Hayes called the police repeatedly, but they continued to refuse to take action. Eventually, the father discovered the girl was making calls and took her phone, her computer and his computer out of the house so that she had no means of reaching out. Hayes and other volunteers at the Hancock Center have done their best to check on the teen’s welfare since losing contact but have been unsuccessful. Her school has been ordered not to give out any information, and the local police aren’t providing any help. A Columbia-area police officer has agreed to keep his ears open for any news, but thus far the Hancock Center hasn’t heard anything.

In search of support

Closeted transgender women (i.e., people presenting as men, in accordance with their assigned gender at birth, but who secretly self-identify as women) who are discovered are at risk of violence not just from spouses but, potentially, the spouse’s family, Hayes says. “This is seen as an act of great betrayal.”

Hayes recommends that all of her transgender clients use the time after their phone sessions with her (or any other time they have 15-20 minutes of private time) to connect with virtual support groups. She wants clients to find at least one “safety buddy” to whom they can reach out if they just need to talk or if something serious is going on. She also makes sure that all clients have the transgender peer support and crisis hotline number (Trans Lifeline: 877-565-8860).

Hayes also uses radical acceptance to help her clients cope with the inability to embrace their true identities. “OK,” she tells clients, “we can radically accept that this situation really sucks and is really uncomfortable, but we have to accept that we are in danger of losing a job or family, even if we never come out but someone else finds out.”

Hayes urges her transgender clients always to have a go-bag packed, but recommending places for refuge is a challenge. A few domestic violence shelters in Georgia are trans-affirming, but they are a significant car ride away. The Columbia area has some homeless shelters that will accept transgender individuals. Still, these are not always great options because some of them are run by religious organizations that require those seeking refuge to read “applicable” Bible verses. Hayes generally encourages clients to think of relatives with whom they could stay. Clients don’t necessarily need to explain the whole story of what is happening — just that they need to get away, Hayes says.

In an environment in which wearing gender-affirming underwear or painting one’s toenails can have devastating consequences, Hayes acknowledges that it is incredibly challenging to help make her clients’ situations more livable. Even so, she has found a few small ways for her transgender and nonbinary clients to explore their identities, including gaming, an environment in which having avatars of different or no fixed gender is common.

Another outlet she suggests — but only if clients believe their phones are safe from scrutiny — is the social media platform Tumblr, which is very graphics-oriented and functions a bit like a cross between Facebook and Twitter. Users can set up an account and post or follow others who share art, graphics, GIFs and other visual content. Crucially for Hayes’ clients, it’s also possible to search content without registering. Why is this an affirming outlet? Because Tumblr is a hive for many kinds of interests, including fashion, design, décor and art. Hayes tells her clients to use the platform to explore what their “aesthetic” (personal style) would look like if they had complete freedom, encompassing not just their appearance but also their surroundings. 

Hayes began her career counseling domestic violence survivors in the Miami area, where the shelters are transgender and LGB affirming and intimate partner violence between gay men or a trans woman and cisgender man is taken seriously by the legal system. Although Hayes, who considers herself a member of the LGBTQA+ community, has been in South Carolina for several years, she is still sometimes surprised by the virulence of the hatred many in the area feel toward transgender and other queer people. She echoes Chan in saying that although different affectional orientations are now more tolerated (even if sometimes grudgingly) in some quarters, alternative gender expression is still largely viewed as unacceptable. She believes there also remains significant transphobia within the LGBTQ+ community itself, which leaves her transgender clients with very few resources for social support.   

Family struggles

When ACA member Bethany Novotny moved from Pittsburgh to Johnson City, Tennessee, to begin teaching as an assistant professor of human services at Eastern Tennessee State University (ETSU), she wasn’t sure how friendly her new surroundings would be to those identifying as LGBTQ+. Novotny, who went on to start a local lesbian dine-out group, was pleased to find that Johnson City had a robust LGBTQ+ community and that it and the university were a haven among the surrounding Appalachian towns for queer young adults.

Over time, Novotny, who is an LPC in Pennsylvania, found that students viewed her as a safe and sympathetic person to talk to. That rapport, her desire to help transgender and nonbinary students, and Novotny’s friendship with staff at the campus counseling center led to her taking over ETSU’s transgender support group, now called ASPECTS — Aligning Support, Pride, Education and Community for Transgender Students. The group originally included only students who had been referred by the campus counseling center. But Novotny opened it up to all transgender and gender-nonconforming students because she feels they have unique challenges apart from the rest of the queer community. “People are more afraid [discussing alternative gender expression] than they are when we talk about sexual orientation,” she notes.

Novotny supervises while students lead the group, which meets once a week. The students share practical information such as where they can go to receive hormone therapy and find affirmative health care providers. Obtaining these services usually requires traveling to either Knoxville, Tennessee, or Asheville, North Carolina, which is a challenge, especially for those students who don’t have cars. Novotny says the group often works together to make sure members get rides when necessary.

Not surprisingly, acceptance is a constant topic in the group, Novotny says. The students feel safe — many for the first time in their lives — at ETSU, but they still have to navigate family and community attitudes when they go home on breaks.

“We would talk about coping skills [before breaks],” Novotny says. “Sometimes they would choose to stay with a friend or another family member. I would remind them to have a crisis plan — making sure if things got bad, they knew what to do.” A crisis plan resembles a suicide safety plan, with a list of local and campus resources, shelter locations and the number for the national suicide hotline.

Once, a student who had started taking hormones decided that they should come out to their family on break. The group talked it through for several weeks beforehand, Novotny says. The student’s parents did not take the coming out announcement well, and the student was forced to seek shelter with a cousin. The cousin turned out to be very supportive and even helped the student come out to their grandmother, which they never thought possible, Novotny recounts. All too often, however, students would return to school without getting any affirmation from their families.

Although revealing oneself as transgender is particularly challenging, coming out to family and friends isn’t easy for anyone in the LGBTQ+ community. Even among families who want to support and affirm their loved ones, the coming out process can be a difficult transition, Brackett says. Some family members — often parents in particular — grieve letting go of the future they had envisioned for their loved one, she adds. “That’s not to say that they reject their family member’s future as an LGBTQ+ person, simply that they may need to adjust the specifics of what that future may be. Maybe the vision was of a son who [would have] a wife and children, and now that vision needs to be adjusted to [having] a husband instead of a wife,” Brackett says.

In other cases, families fear their loved one will become an entirely different person, she says. Brackett explains to families that although changes in expression and personality are very likely, it isn’t a foregone conclusion that in coming out, their loved one will undergo a complete transformation.

“Even when there are substantial changes, I try to remind families that the person they knew was possibly more of a mask than they want to accept,” she explains. “This person is now trying to discover who they really are, and that process will take time. It’s important to be patient, be curious, be respectful, and [for families to] find their own support.”

Novotny says many of her group members have parents who struggle because they perceive the transition of their child’s gender expression — from the one the student was assigned at birth to their true gender — as an alteration that has transformed their child into someone they don’t recognize. This comes in part from a lack of exposure to and understanding of what being transgender means.

One student’s mother couldn’t even grasp the concept, telling her child, “You have a penis, so you’re a boy,” Novotny recounts. “The student was trying to communicate to [their] mom, ‘I’m still the same person. I’ve actually been this person the whole time, and you don’t see that. I am trying to share something scary and vulnerable with you.’” At the student’s request, Novotny helped them talk to their mother.

“I always respond first with empathy,” Novotny says. “I know that what they [parents] are going through is difficult, and I don’t want to minimize or dismiss their feelings. It’s all about meeting them where they are, even though sometimes I want to shake them and scream at how horrible they are being. I also worked to affirm the love and support that it took for mom to show up in my office that day. The fact that she was there was huge. She was willing to talk even though she didn’t understand, and I wanted both mom and my student to recognize what a big step that was.”

Novotny listened to the mother’s concerns and helped correct misinformation by inserting “tidbits of information that might help mom put the puzzle pieces together. I did this very gently and only where appropriate because I did not want to come off as though I was lecturing her,” Novotny says. “As an educator, I know how important it is to plant seeds. We may not always see that come to fruition, but it is so important to plant those seeds gently. … I also try to communicate to parents that they don’t need to fully understand to provide support, love, affirmation and acceptance.”

In some cases, the family conflict isn’t rooted in a lack of understanding but something more fundamental. Brackett, like Novotny, tackles these struggles with understanding and empathy.

“I seek to understand what their resistance or hostility is connected to and move from there,” she says. “Working with a family that has deeply rooted religious beliefs that condemn sexual or gender minorities is drastically different from working with a family that is afraid of the changes that may occur within their family system. At times it can be necessary to have these discussions without the LGBTQ+ family member present in order to not only protect them from hearing this process in its most raw form, but also to allow the family space to be open about what they are feeling. Additionally, recommending outside support groups or resources can help alleviate some of the misinformation and isolation the family may carry.”

Families also fear the treatment their loved one might experience in the outside world. “Will they be bullied or ignored or even physically hurt or killed?” Brackett says about some of the common concerns families voice. “Will they suffer mental anguish and be at higher risk for addiction or suicide?” 

“It’s important for families to remember that a huge protective factor for members of the LGBTQ+ community is the presence of a supportive family,” Brackett asserts. “When working with family members in this place of fear, I try to highlight for them the power they have in creating a safe and loving environment for their loved one. While a mother can’t make the world safe for her gender-nonconforming child, she can at least work to ensure that she is safe for them.”

The process of coming out

In some cultures, such as those Hayes’ clients live in, as well as other racial and ethnic communities, coming out may be dangerous to the LGBTQ+ individual and perhaps to their family. Or an LGBTQ+ person may have some family members who would support their coming out but others who would not be affirmative or accepting. Some individuals choose to honor both their LGBTQ+ identity and their familial or cultural identity by coming out only to certain family members or friends.

“I frame coming out as an ongoing process and remind my clients that the need for a grand unveiling isn’t necessary unless it’s important to them,” Brackett says. “Often, I see my clients come out by degrees, starting with the safest people or environments first to gain support. By identifying safe people and thinking through the possible outcomes of coming out, the client can begin to amass protective factors they need as they go through the process. Deciding not to come out to people they identify as unsafe or unnecessary doesn’t have to be framed as a betrayal to their identity, though it’s an understandable reaction. It can also be framed as a means of protecting themselves. They are not required to disclose information that puts them at risk.”

With any major life change, there is grief at whatever is lost, and this is very true in people who are negotiating the ways in which they want or don’t want to be publicly out, Brackett continues. “Being rejected by a family member or important institution like a religious community or friend group can be devastating,” she says. “Gentleness, empathy and nonjudgmental discussions are important in allowing clients the freedom to connect with the impact coming out is having on them. Holding the grief is important, but so is guiding them toward creation of a new life and support system: ‘Yes, this is horrible and heartbreaking. Is there someone who has acted differently or where you’ve felt acceptance?’”

Counselors can help clients build a new support system by working with them to change their concept of family, says ACA member Leah Polk, a licensed clinical social worker and clinical director at Change Inc. in St. Louis. Clients are not limited to their families of origin; they can assemble ones of their own choosing, she emphasizes. So, even though their families of origin may have set a priority on traditional scripts or rituals, the families they choose can be inclusive and view each member as inherently valuable, says Polk, whose specialties include LGBTQ+ issues. 

“The important part here is that the client gets to spend time identifying what is most important and valuable to them as it relates to family,” she explains. “They are able to map out how they establish family and gain reliable reflections that emphasize what they like about themselves.”

Peer support for transgender youth and young adults

Laura Boyd Farmer, an LPC whose specialties include affirmative LGBTQ+ counseling, helped found a peer group for youth and teenagers 10 years ago in the Roanoke, Virginia, area. She and other area professionals saw a need among the area’s LGBTQ+ youth, who were frequently ostracized and bullied and had little family support. “Our intention was to create a safe and supportive space,” says Farmer, a member of ALGBTIC. Farmer and others sat with teens in the area and asked them what they needed and what kind of support would be helpful. The result was Youth SAGA (Sexuality & Gender Alliance) of Roanoke.

“The kids created the name,” Farmer says. “They were very passionate that they wanted this to be a group for queer-identified kids, but also for anyone who was affirming of gender and sexuality diversity.”

SAGA meets twice a month, and there are always two leaders with mental health experience (Farmer and three volunteers take turns serving as the two leads). Meeting times are posted on Facebook, and the group gathers in public spaces such as coffeehouses, libraries and bookstores so that teenagers who are not out to their families will have a ready-made excuse to drop in.

The group follows two basic rules: Respect participants’ chosen identities, names and pronouns, and give everyone time to talk. Group members are also asked not to talk about what goes on at meetings outside of SAGA. All of the participants are so invested in preserving a place where they can find and give support that there has never been an issue with breaking confidentiality, according to Farmer.

The structure of each meeting depends on the size of the group. If only a few teens are present that week, the session is relatively informal, with group members simply discussing what is going on in their lives. With larger groups, leaders pass out pieces of paper so participants can write down any topics they would like the group to cover. The group leaders put all the pieces of paper in a bowl, which is then passed around. Each person removes a piece of paper and reads out the topic for discussion.

Topics range from concerns such as “My parents don’t want me to transition and I don’t know what to do” and “I don’t know how to come out to a family member” to the practicalities of expressing gender identity. The group has covered logistical questions about the physical and hormonal aspects of transition, as well as ways that youth can present themselves in a way that affirms their gender expression when their families are not letting them transition. The teens also ask each other about how to find good chest binders and affordable makeup.

Dealing with bullies and finding allies are also common topics, Farmer says. She recounts an approach to bullying that she thought was particularly effective: “This trans youth shared that he found the best way to deal with bullies was to choose a direct statement to respond with and to use it repeatedly,” Farmer explains. “For example, when a bully would say to this youth that he was really a ‘she’ and just confused, the youth would reply, ‘That sounds like a you problem.’ This kid also had his friends use the same response when they heard anyone say anything unkind about him or toward him. I loved this approach because it puts responsibility back on the bully to educate themselves, like holding up a mirror for them to see that whatever mean things they are saying are actually about them, not the person they are trying to bully.”

Sometimes the group features outside speakers. For example, because the intersection of religion with sexual and gender identity is a common concern in southwest Virginia, Farmer had a pastor lead a discussion on how spirituality and sexuality intersect. The pastor also talked about what the Scriptures actually say (and don’t say) about the topic and gave the group recommendations for discussing the topic with family.

Farmer emphasizes that SAGA is not a therapy group but rather peer-based support. Because discussions about sexual and gender identity sometimes include topics such as trauma that can be triggering for others, she and her co-leaders have developed a signal that group members can use if they are being triggered. If someone puts a hand on their heart, it is a signal for the leaders to gently and respectfully move the discussion away from the current topic. Farmer and the other leaders are careful to check in afterward to see whether the teen who brought up the topic wants to continue the discussion privately.

“The beauty of this group is that I don’t have to know the answers,” Farmer says. “The kids are sharing their wisdom with others. It’s a beautiful thing to witness.”

Providing affirmative counseling

Even professional clinical counselors who have experience with the LGBTQ+ community may have biases and blind spots, say the practitioners Counseling Today interviewed for this article. Brackett and Polk offer some suggestions for counselors who want to make sure they are offering affirmative counseling to LGBTQ+ clients.

“The first thing I recommend is self-reflection on how you are connected to the LGBTQ+ community outside of being a clinician,” Brackett says. “Understanding your own involvement and comfort within the LGBTQ+ community will help you be present with these clients in an authentic way.”

She suggests that counselors ask themselves the following:

  • Are you a member of the LGBTQ+ community? If so, what elements do you connect to versus what elements do you find yourself separated from? Are there parts of the queer community that you (consciously or unconsciously) avoid or dislike? If so, why? Do you feel like you “belong,” and how does that impact your willingness to connect with others in the community? How do your opinions change if the race, ethnicity, income, gender or gender presentation of the person changes?
  • If you don’t consider yourself part of the LGBTQ+ community, how open and connected are you to people within it? Do you seek out or seek to avoid places or events that are heavily attended by the queer community? How comfortable do you feel when you are in those spaces? How do your opinions change if the race, ethnicity, income, gender or gender presentation of the person changes?

“Remember that there are generalized experiences, and then there are your client’s experiences,” Brackett continues. “Trust your client to tell you their reality. It may align with your own experiences or general narrative you have of the LGBTQ+ community, but it may not. Your goal is to be present with them where they are, as they are.”

Polk has some additional suggestions:

  • Allow the client to determine the pace. It is not the counselor’s job to set an agenda for coming out or transitioning.
  • Frequently reassess goals in therapy. What the client needs when they enter therapy is often not the same as what they need after eight to 10 sessions have taken place.
  • Monitor for clients’ sense of safety and agency. For example, ask them how their relationships are and how they experience safety in an environmental context (e.g., employment, social events, political environment).
  • Continue to scan and assess for co-occurring disorders such as substance abuse. Individuals who identify as LGBTQ+ tend to have a disproportionate number of stressors that could lead to comorbid emotional and mental health concerns.

“Additionally, I would suggest some form of participation in LGBTQ+-affirming communities,” Polk says. “For example, attend a support group, view LGBTQ+ art [and] film, or read literature written by queer authors. Ask to interview LGBTQ+ counselors, or seek out LGBTQ+-specific supervision and psychotherapy training. Finally, perform a self-assessment of your own attitudes and biases of LGBTQ+ people to determine your growing edges in counseling.”

Brackett offers a closing thought: “If you find that you are uncomfortable with LGBTQ+ clients or are concerned about your ability to work with this population, seek out clinical supervision, and engage in your own therapy.”

 

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Additional resources

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

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Affirmative Counseling With LGBTQI+ People edited by Misty M. Ginicola, Cheri Smith and Joel M. Filmore
  • Casebook for Counseling LGBT Persons and Their Families edited by Sari H. Dworkin and Mark Pope
  • Group Counseling With LGBTQI Persons by Kristopher M. Goodrich and Melissa Luke

Continuing Professional Development: LGBTQ (aca.digitellinc.com/aca/specialties/137/view)

  • “Transgender — Moving From Awareness to Advocacy” with Becca Smith
  • “Affirming Counseling Practice With Queer People of Color: From Margins to Center” with Adrienne N. Erby and Christian D. Chan
  • “Resiliency Factors of Trans-College Students: Implications for Professional Counselors and Higher Education Professionals” with Jane E. Rheineck and Matthew Lonski
  • “Lesbian, Gay, Bisexual, Transgender and Queer Youth: Family Acceptance and Emotional Development” with Julie Basulto
  • “The Counseling Experiences of Transgender and Gender Nonconforming Clients” by Rafe Julian McCullough, Lindy K. Parker, Cory Viehl, Catharina Chang, Thomas M. Murphy and Franco Dispenza

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

  • LGBTQ
  • Grief and loss

Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (algbtic.org)

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@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 families on their autism journeys

By Lindsey Phillips May 1, 2020

Maria Davis-Pierre, a licensed mental health counselor (LMHC) in Lake Worth, Florida, first suspected her daughter might be on the autism spectrum when she was 6 months old and showed signs of sensory issues. Then at 10 months, her daughter, who had been saying simple words such as “mama,” “dada” and “ball,” suddenly stopped speaking. When Davis-Pierre and her husband tried to get their daughter to mimic them saying the words, she acted as if she had forgotten them. As a therapist, Davis-Pierre understood the importance of early intervention, so she was proactive about getting her daughter a diagnosis. But it wasn’t easy.

Her pediatrician referred her to health professionals who specialized in developmental delays in infants and toddlers. They tested her daughter and thought she had autism spectrum disorder (ASD), but because she was still so young (around 18 months), they didn’t feel comfortable officially diagnosing her. They recommended she see a pediatric neurologist.

After more tests (which cost the family thousands of dollars out of pocket), the pediatric neurologist agreed about the presence of ASD but was also uncomfortable officially diagnosing the child at such a young age. Davis-Pierre told the doctor she was going to sit in his office every day until her daughter got a diagnosis. One week later, that finally happened.

Davis-Pierre thought the next steps would be easy, especially given that both she and her husband are in the health care field. But what she experienced was more frustration.

“At no point — even with the neurologist — was there a check-in with the parent: ‘OK, this is the diagnosis. This is what happens next,’” Davis-Pierre recalls. “It was, ‘OK, here’s your paperwork. This is the diagnosis. Now, go figure it out.’” According to Davis-Pierre, the health care professionals didn’t provide her family with resources or give any consideration to how the family’s culture would factor into their daughter’s treatment.

When Davis-Pierre spoke with other parents of children on the autism spectrum, she found out that this treatment was the norm. And it left her — and the other parents — feeling overwhelmed.

This experience prompted Davis-Pierre, an American Counseling Association member, to start Autism in Black, a private practice that specializes in helping black parents of children with autism get the help they need.

In a blog post on the website GoodTherapy, Janeen Herskovitz, an LMHC in Ponte Vedra Beach, Florida, points out four areas in which counseling can help parents of children with ASD: adjusting to the diagnosis (which is often traumatic for parents), learning parenting skills, staying connected to their partners, and managing stress. Professional counselors can also help families prepare for developmental transitions, learn to effectively communicate with one another and extended family, and navigate cultural barriers.

Working through developmental transitions

ASD “is a neurodevelopmental disability, which means at different developmental stages, our clients are going to run into different developmental barriers, and they’re going to need us as counselors,” says Chris Abildgaard, a licensed professional counselor and director of the Social Learning Center in Cheshire, Connecticut. So, it’s important for counselors to understand where families are on their journeys, he points out. Is the family adjusting to the diagnosis? Are they struggling to communicate with their child? Are they helping a child through puberty? Counselors should also prepare to help families with life milestones such as going to prom, getting a driver’s license or grieving a death, Abildgaard adds.

Some families experience grief when they first learn about the ASD diagnosis, says Michael Hannon, an assistant professor of counseling at Montclair State University in New Jersey. These families will be reconciling a new reality and having to let go of certain elements of the relationship they expected to have with their child. “It’s really about [the family] learning to adjust to the needs, strengths, capacity, and some challenges of the people they love living with autism,” he adds.

Another challenging transition for parents and caregivers is when the child enters adulthood. Parents have likely been involved in every aspect of the child’s life, especially in the school system, so it is a significant adjustment when the child takes over this responsibility, Davis-Pierre says. She helps ease this transition by having parents teach their children to advocate for themselves before they reach adulthood. The more parents involve children with ASD in the day-to-day decisions about their lives and school, the more they realize that their children are capable of advocating for themselves, she says.

Abildgaard, an ACA member who specializes in ASD (and author of the 2013 Counseling Today article “Processing the ‘whole’ with clients on the autism spectrum”), has noticed that families sometimes push their child to do something that the child isn’t ready for or doesn’t want. For example, parents often ask him how they can make their child have a friend. Counselors need to educate parents that relationships take time and that individuals on the spectrum may not fully understand the intricacies of relationships and friendships. They will need support and coaching in this area well into their late teens, early 20s or beyond, he says.

Counselors can also help parents make plans and prepare for certain life events and developmental transitions, Abildgaard says. He finds visuals useful in helping families with a child on the spectrum to process events. Recently, he had a family who was going on a trip to a large city. He brought out his whiteboard and on one side wrote down all the thoughts and feelings the parents were having about the upcoming trip, such as feeling anxious that their child would have a tantrum and run from them. Then, Abildgaard asked the parents to consider their child’s perspective and why he might have a tantrum. On the other side of the whiteboard, he wrote down the child’s thoughts and feelings, such as being overwhelmed by all the lights and sounds.

This activity helped the parents realize the link between their own thoughts, emotions and behaviors and those of their child. It also started a discussion about proactive strategies the parents could take to decrease the likelihood of their child experiencing sensory overload. This, in turn, lowered their anxiety about the trip, Abildgaard says.

Helping families stay connected

Having a child with autism affects the entire family system, Abildgaard says. It affects how parents interact with each other, how parents interact with each of their children, how siblings interact with each other, and how the family interacts with extended family members.

Couples don’t typically preemptively discuss the possibility of a having a child with a disability, Davis-Pierre notes. So, when a child is first diagnosed with autism, parents often have to reassess the roles, expectations, responsibilities and core values of the family, she says.

Counselors may also have to coach families through complicated life events such as divorce. Abildgaard, an adjunct professor in the Department of Special Education at the University of Saint Joseph, reminds counselors that regardless of the situations that families bring to them, it is important to break these situations down into manageable parts for the clients.

When the parents of a client with ASD were going through a divorce, Abildgaard, a nationally certified school psychologist, brainstormed with the parents how best to explain the situation to their son. Abildgaard also learned from the client’s school that the child had been making comments about the divorce there. Abildgaard says his role as a counselor was to help the client process and express his feelings about the divorce. To do this, he said, “Tell me some things your eyes are noticing that are different at home.” He made his language concrete and specific, which allowed the child with ASD to talk about what he had been noticing, such as his parents arguing more. The boy also said he was scared to talk about these things with his parents, so he and Abildgaard worked through his anxiety together.

Then, Abildgaard brought the entire family into his office to discuss these issues. He chose to have them come in during the morning hours when his office would be quiet so the family would be more comfortable and not feel rushed or distracted.

Balancing the parenting of both neurotypical and neurodiverse siblings is another common challenge that Hannon and Davis-Pierre hear about from their clients. They try to help parents learn how to better communicate with their children and to maximize and be intentional about the time they spend with each child.

Hannon, a licensed associate counselor in New Jersey, uses empathizing strategies to help parents understand what their neurotypical child is feeling. For instance, he asks, “What would your neurotypical child say about this experience right now?” and “What would the child say about how you attend to the sibling with autism compared to how you attend to his or her needs?” This exercise allows parent to empathize and reconcile some outstanding issues with their neurotypical children, he explains.

Davis-Pierre’s clients also report struggling to know how to engage with their neurodiverse children. “We’re so used to looking for [the child to verbalize] … the actual feeling that we’re not looking at the behavior of what the child is showing,” she says.

She has parents role-play to gain perspective on what the child might be thinking or feeling and to increase awareness of behavioral patterns. (For example, Davis-Pierre has noticed that her daughter expresses happiness by flapping her arms and spinning in circles.) If appropriate, she has the child role-play with the parent, but if that is not possible, Davis-Pierre does it herself. To increase understanding, parents can also keep a behavioral journal or use the picture exchange communication system, which allows individuals with little or no verbal communication to present a feeling card to communicate their feelings, Davis-Pierre adds.

Children on the spectrum pick up on their parents’ and caregivers’ emotions more often than people think, Abildgaard points out. However, if they do sense these emotions, they often don’t know what to do with them. Children on the spectrum may appear to be ignoring the person or emotion, but in many cases, they just don’t have the language or perspective-taking ability to process the emotion and the “right” response to it, he explains.

So, Abildgaard works with parents to help them process their own emotions and then explain those emotions to their children so they aren’t left to interpret them on their own. In fact, parents can overtly model how to handle certain emotions such as anger or frustration. Abildgaard often suggests that parents (especially those with younger children on the spectrum) put themselves in “time out” to show their children that even adults need breaks.

Cultural implications

According to a 2014 report from the Centers for Disease Control and Prevention, 1 in 59 children in the United States have been identified with ASD. But this number doesn’t take into consideration cultural and racial implications such as delayed diagnosis. According to a 2019 news report on Spectrum, which bills itself as “the leading source of news and opinion on autism research,” black children with autism are often diagnosed later than white children, misdiagnosed more frequently with other conditions such as behavioral problems or intellectual disability, and underrepresented in studies of autism.

Hannon attributes the disparities in diagnosis rates to 1) inequalities in access to health care, 2) mistrust of health care systems among people of color and 3) greater misdiagnosis of symptoms in minority children as behavioral rather than developmental.

Davis-Pierre says the history of racism and discrimination in U.S. health care may persuade some black families not to be completely honest with health care professionals when discussing their children because they fear their children will be taken away. For example, frustration and exhaustion are normal responses for families caring for a child on the autism spectrum, perhaps leading someone to say or think to themselves in a particular moment, “I just can’t do this another day.” But many black families fear serious repercussions should they admit to such passing thoughts with a counselor, Davis-Pierre explains.

Even the treatments families choose for their children are often informed by one’s culture. Applied behavior analysis (ABA) aims to help individuals on the spectrum increase behaviors that are helpful and reduce behaviors that may be harmful to them by positively reinforcing desired behaviors. Debate has swirled, however, over whether ABA is helpful or harmful. According to a 2016 article on Spectrum, some have criticized the therapy for being too harsh in how it corrects maladaptive behaviors and for attempting to make people on the spectrum “normal” instead of advocating for neurodiversity.

But for some families, Davis-Pierre says, ABA makes sense. For example, a black child spinning in circles and banging his head against something in public will often be viewed differently than would a white child who exhibits the same behavior. In this instance, ABA can help protect the black child by helping him learn to replace the maladaptive behavior — one that could put him in danger — with a more socially accepted behavior, Davis-Pierre explains.

The harsh reality is that black people often have to operate differently in public settings because of prejudice and racism, she continues. So, she advises families to consider their child’s behavior and safety when choosing the best treatment for their child’s autism.

Davis-Pierre, author of Self-Care Affirmation Journal and Autism in Black, also finds that clinicians often don’t respect the culture of the home when treating children who are on the spectrum. A client once told Davis-Pierre that she had a therapist come into her home and not remove their shoes despite seeing a place for them by the front door. This act made the parent feel disrespected, and she no longer wanted the therapist in her house working with her child.

Another of Davis-Pierre’s clients was upset by a therapist who had made a decision involving her child without consulting the mother first. While the therapist and child were working together in the family’s home, the child wet himself. The therapist wanted to help the parents by changing the child herself. When the mother discovered that the therapist had gone through her child’s clothes drawers to find clean underwear, she felt as if the therapist had been snooping.

Abildgaard says his role as a counselor is to help clients on the autism spectrum adapt to different social situations and understand social context and social norms for particular settings and cultures. Counselors need to be aware of clients’ cultural and religious norms before instilling certain perceived social skills such as maintaining eye contact, he says. For example, as Abildgaard points out, some Asian cultures make eye contact only with certain people or in certain situations. So, counselors should understand the whole child before prioritizing what social skills or competences are most relevant to focus on in session, he asserts.

Religious beliefs can sometimes pose another barrier to seeking treatment. For instance, Davis-Pierre says, people in the black community are often taught to pray about their problems and not to discuss problems with anyone outside of the family. Counselors may assume that families who aren’t willing or enthusiastic participants in therapy are resistant, but as she points out, they may actually be having an internal struggle between seeking counseling and feeling that they are still maintaining their faith in God.

Davis-Pierre often uses genograms to help clients identify family patterns, such as other family members with a developmental disorder, or cultural values that have been passed along that no longer work for the family. Through genograms, she has noticed that her clients’ families often inherit a pattern of keeping secrets that hurts, rather than helps, the family dynamic. Davis-Pierre acknowledges that even she had a difficult time explaining to her extended family why she and her husband are so vocal about their daughter being on the autism spectrum.

Hannon and Davis-Pierre say that counselors have to be brave and willing to talk about clients’ and families’ cultures and about inequalities based on race and ability status. Starting this conversation can be as simple as including a question such as “What cultural traditions should I take into consideration?” on the intake form, Davis-Pierre says. This question shows that the clinician is already thinking about how culture affects treatment, she explains.

Supporting dads

Abildgaard argues that fathers are often overlooked when thinking about an autistic individual’s support network, so mental health professionals must do a better job of incorporating dads into the therapeutic process. He has noticed that mothers with children on the spectrum are often more proactive about independently finding and supporting each other, whereas fathers, even though they are involved in their children’s care, don’t tend to form support groups on their own. Abildgaard suggests that counselors could offer focused support services such as fathers’ groups or “dad’s night out” events to help these men learn from and bond with other fathers in similar situations.

Such support groups matter when it comes to providing care to individuals on the spectrum. Hannon, an ACA member who specializes in the psychosocial aspects of autism on fathers and families, often co-leads a group for fathers who have children with ASD. These men have reported that just being connected with other fathers who share similar experiences can be life-changing. In these groups, dads find others who speak their language and understand their journeys, which makes them feel heard, Hannon says. Groups also help fathers become more aware of their own needs and challenges and discover effective coping and adjustment strategies, he adds.

Fathers also spend a significant amount of time thinking about their children’s prognoses, their children’s futures, and the ways they can prepare their children to live full lives, Hannon says. In his dissertation, he studied the experiences of black American fathers of individuals with autism. At the ACA 2018 Conference & Expo, Hannon presented his findings from a grounded theory study on how diverse fathers orient themselves to their children’s diagnoses. Fathers often want to help their children who are on the spectrum, he continues, but if they have been raised with certain gendered expectations, counselors may need to take a few extra steps to help these dads increase their efficacy with day-to-day activities such as helping with temper tantrums.

Counselors may also need to help fathers retain focus on their emotional journeys because men are often task-oriented in how they solve problems, Hannon points out. Also, because men have often been socialized to engage only with specific emotions such as lust and anger, counselors may have to dig deeper with them to reveal the other underlying emotions. For example, counselors could suggest, “You’re angry, but it sounds like the source of your anger is fear for your child’s safety.”

Generational pushback

Parents sometimes face generational challenges in caring for their children. Hannon describes a common scenario that fathers often share with him: They leave their children in their grandparents’ care, providing suggestions for ways to best communicate with the children and guidance on particular eating preferences. To which the grandparents might respond, “We’re not doing any of that. We’ll do what we want with our grandchildren. They just need a good talking to.”

Such scenarios often leave parents of children on the spectrum feeling frustrated. If the parents and grandparents have a good, healthy relationship, then counselors can help parents learn to communicate openly and honestly with the grandparents. Hannon advises parents to lead with love and acceptance before critiquing the grandparents’ interaction with the children. Parents can first emphasize how the grandparents love their grandchildren before saying that they just want to show them additional, special ways to show love to a grandchild on the spectrum. 

When Abildgaard works with grandparents who need help accepting their grandchild’s diagnosis of ASD, he starts by saying that he could use the grandparents’ help to allow him to better understand their grandchild. Once this barrier is broken down, he finds that grandparents tend to ask more questions and start honest dialogues about grandchildren who are on the spectrum. 

Counselors can also help clients realize that while it is OK to establish boundaries with extended family, they should aim to set realistic boundaries that honor both the child on the spectrum and the family, Davis-Pierre says. For example, if a family depends on grandparents to provide child care, then the family must be particularly careful in setting boundaries. At the same time, the family can still have a respectful conversation with the grandparents about the needs of the child and family.

Adjusting language

Abildgaard’s clients with ASD sometimes complain that their parents always ask the same question after school: “How was your day?” Because, from their perspective, their days are always the same, the children wonder why their parents ask something they already know the answer to. 

Abildgaard advises parents to instead use concrete language such as “Tell me two good things about your day and one thing you would have changed.” This phrasing gets to the heart of what parents actually want to know from their child and makes the conversation more productive, he says. 

Abildgaard is also careful about the language he uses with clients with ASD and their families. Recently, the mother of one of his clients (a boy in sixth grade) told him that her son ran out of his classroom at school. When the boy walked into his office, Abildgaard said, “Tell me two good things about your day and one thing you would have changed.” This prompted the client to tell Abildgaard he had run out of his classroom.

After admitting this, the boy looked at Abildgaard, seemingly waiting to be chastised. Instead, Abildgaard asked the boy, “What do you think I’m thinking right now?”

The boy responded, “You’re thinking you are mad at me.”

Abildgaard drew a thought bubble on a whiteboard and wrote the client’s thought inside the bubble. Then he drew another thought bubble and wrote what he was actually thinking: “I’m wondering what made him run out of the room.”

The boy’s body language instantly relaxed. This exchange took Abildgaard out of the authoritarian role and shifted the conversation from focusing on the problem to focusing on how to solve the problem.

Similarly, Hannon recommends that counselors focus on strengths, and not just deficits and challenges, when working with families who have a child on the spectrum. He makes a point of asking parents about the victories they have had that week or month.

This question prompted one of Hannon’s clients to share how his son had used appropriate language and displayed empathy — a skill the child had previously struggled to demonstrate — that week.

The child’s mother had said, “I’m going to run through the shower.”

The child on the spectrum responded, “No, you can’t do that because you’re going to fall.”

Even though the child hadn’t grasped the true meaning of his mother’s words, he had shown concern for his mother and responded appropriately, which was a huge victory for this family, Hannon says.

Support often makes all the difference. Davis-Pierre and her family’s autism journey may have had a challenging start, but they eventually found health care providers who worked with them as a team. With this support, Davis-Pierre and her husband were able to stop focusing so much on the challenges and instead start enjoying their child for who she is.

 

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

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

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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