Tag Archives: Grief and Loss

Counseling Connoisseur: Death and bereavement during COVID-19

By Cheryl Fisher June 2, 2020

“Grief does not change you, Hazel. It reveals you.”
― John Green, The Fault in Our Stars

Sarah pulls her black blouse over her head, trying not to smear her carefully painted makeup. The dark circles have settled beneath her puffy blue eyes, and she dabs another layer of cover up over top. She brushes her hair, overgrown with neglect, the color faded. The roots reveal her 52 years, and she covers them with a spray that is the deceptive color of her youth.

But none of this matters. Her father has died. Alone. Without family nearby. They will now gather to pay tribute to a man who was her everything. A man who taught her how to throw a softball and fish. A man who showed her what to expect in a partner by loving his wife wholly. Her mother grieves from afar. Phone calls, Facetime and Amazon packages bridge the miles–and the social distancing. No, no one will care that Sarah remains in the comfort of her jeans. Not really. No one will notice as she props herself on her couch with her laptop on a pillow and taps the “Start Meeting” button.

Rituals, memorials and funerals provide ways that those who survive a death have the opportunity to grieve. “We know that funerals date to at least 60,000 BC, and every culture and civilization has had funerals ever since,” says grief counselor and educator Alan Wolfelt, in the National Funeral Directors Association’s resource, 8 Talking Points for Funeral Directors, Crematory Staff, Cemeterians, and Other Death-Care Workers. “Funerals help us acknowledge the death, honor the person who died, and support one another. In other words, funerals help us mourn well and set us on a healthy path to healing.”

Wolfelt, who is the director of the Center for Loss and Life Transition in Fort Collins, Colorado, also advises finding ways to be with the body following death. Many funeral homes and crematoriums are finding ways to allow the immediate family to spend time with the deceased. One funeral home has created a particular time where family members can sit with the body one at a time. Another funeral home livestreams time when the family can be with the body.

The novel coronavirus that causes COVID-19 has changed the way we do many things in our daily lives. The need for social distancing has resulted in virtual meetings replacing physical gatherings. Zoom conferencing can be awkward, and online happy hour isn’t as satisfying as hanging out with friends at your neighborhood bar. But, the loss of one particular kind of in-person gathering has been completely devastating: shared mourning rituals. Grief is experienced in the support of community, often with hugs and handshakes. Now, some clergy and rabbis are making house calls, armed with sacred texts, masks and hand sanitizer. But it is not possible for extended groups of mourners to gather together. The final resting rituals that many communities of faith have observed for centuries are significantly altered. For example, during the Jewish mourning tradition of shiva, families, friends and the extended community offer comfort through condolence calls. These condolences are now taking place over the phone and via live streaming. Traditional Catholic funeral masses are now livestreamed with only immediate family present and upholding the six-foot rule. Absent is the physical contact so important in the grief process.

Even gatherings of immediate family and friends are restricted. According to Susan Coale, a clinical social worker and director of the Chesapeake Life Center in Pasadena, Maryland, even if people are able to gather following the death of a loved one, there is a 10-person limit–including the funeral director and any presiding religious figure, such as a priest, reverend, rabbi or imam.

“COVID-19 has complicated individual grief and community grief and loss,” Coale says. Not being able to participate in death and grief rituals can result in the experience of ambiguous loss, which can complicate the grief process leaving numerous loose ends, she explains.

According to family therapist and clinical psychologist Pauline Boss, who coined the phrase, ambiguous loss occurs when there is no closure or there are unanswered questions related to the death of a loved one. This can occur when people cannot be with the body or in community. Therefore, it is important to find ways to help families connect with loved ones. Coale says that some families are attempting to connect with loved ones through window visits or telephone calls at end of life.

People need community support in times of loss. Numerous technological resources have arisen to help fill the gap left by the inability to gather face-to-face. For example, grief support groups such as the Chesapeake Life Center’s Living with Loss are being offered online. The Life Center is affiliated with Hospice of the Chesapeake, but is available to anyone in the community who is grieving, whether or not they are using hospice services.

Thanatechnology sites such as Caring Bridge provide a virtual space to grieve in community. Yet, we must always be mindful of the disparities in both the availability of technology and understanding how to use it. Not everyone can—or wants—to replace in-person grieving with technology.

Coale has begun providing her clients with guided imageries that include detailed descriptions of physical touch. She has clients imagine the specific details of a hug experience. The warmth of arms wrapped around the person. The tickle of arm hair. The scent of the body. The brain responds to imagery in comparable ways as to a real experience and Coale is capitalizing on this phenomena in offering “hug imagery.”

Coping with loss during COVID-19

Grief can be an isolating experience and now, more than ever, it is important to have strategies to stay connected to family and friends. We can still be together while observing physical distance and small group limitations.

Connect

  • Check in with one another by calling, texting or through webcam or social media and don’t forget the virtual hug! This does not require an in-depth conversation. Just a reminder that you are thinking of the person and while they are isolated, they are not alone.
  • Drop off food or groceries while observing physical distancing. Send a care package or shop online to send items. Many restaurants offer curbside takeout and Amazon and Instacart will deliver groceries directly.

Observe virtual rituals

  • Offer or attend virtual group funerals, burials and memorials. It is important to honor the lives of our loved ones and to experience this in community. While we are limited in the number of people who can be gathered physically, we can use technology to host larger gatherings that include friends and extended family members. Photos and memories can be posted on virtual platforms and viewed by many to celebrate the life of the beloved member.
  • Plan an in-person memorial for when physical distancing guidelines are no longer in place. Sometimes the act of creating can be comforting even if the end result is delayed. Plan the memorial in great detail — to be hosted after travel and physical distancing restrictions are lifted.

Seek support and professional help  

  • Bereavement services are available. Many providers are offering their services by phone or webcam. You do not need to soldier this burden alone. There are virtual support groups, as well as individual counseling.
  • Check in with faith communities about online services and support. Faith communities are offering innovative alternatives to traditional worship.

This is a difficult time complicated by the inability to participate in traditional death and grief rituals and activities. Yet, we are a resilient people, capable of innovation as we craft creative ways to connect with one another during times of grief.

“As many challenges as the pandemic presents, it illuminates the hard stuff that causes us to grow…offering us as individuals and communities to do some work,” says Coale.

People are being intentional in how they connect. Some families are re-discovering family time. There are many things to be grateful for during this unprecedented time. People are complex, as well as resilient and we have the capacity to experience both grief and gratitude at the same time.

 

Further reading:

Counseling Connoisseur: Thanatechnology – Grief and loss in a digital world

Counseling Connoisseur: Children and grief

Grief: Going beyond death and stages

Grieving everyday losses

 

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Cheryl Fisher

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

 

 

 

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

Voice of Experience: It often comes down to grief

By Gregory K. Moffatt April 20, 2020

Somewhere along the way in our education as counselors, all of us studied great theoreticians such as Erikson, Piaget and Maslow. Their theories provide us with a general understanding of human behavior, and with that information we can develop clinical interventions. In my undergraduate days, I didn’t fully appreciate theory as much as I should have, but the further I traveled into my career as a counselor, the more I realized the importance of theory and how to use it.

But it isn’t just theory that is interesting to me. The insight behind the development of these theories is equally significant. How did these men and women come up with their theories to begin with? Have you ever looked at an invention and thought, “Wow, why didn’t someone think of that sooner?”

It is these potential blind spots that I have always tried to identify throughout the decades of my career. What am I failing to see? What might someone come up with in the future that would leave us wondering, “How did we miss that?”

And that is what brings me to the topic of grief. You’ve probably heard that “depression is really suppressed anger” or something very similar. We know there are often different emotions underlying the ones that we actually see in our clients. I’m convinced that grief is one of those underlying emotions in many cases.

When Elisabeth Kübler-Ross wrote her seminal work On Death and Dying in 1969, she was looking at grief only in the context of personal loss due to death. But later in life, she expanded her view to include other experiences of grief. Infertility, job loss, loss of health, and the death of a pet are among a host of other losses that one might grieve.

I’ve begun to believe that some of the dysfunction we see clinically is actually grief. When I was a very young man, my uncle once said to me that he grew up to “become everything I always hated.” What a sad thing to say. I didn’t realize it then, but I realize now that he was expressing grief to me — the loss of his dreams. He had hoped for one thing but achieved something quite different.

Addictions, affairs, anger and depression — to name a few things — may really be the client’s attempt to manage grief. A client struggling with fidelity in his marriage finally achieved an epiphany in therapy with me when he realized that his unfaithful behaviors had almost nothing to do with sex. Through extramarital relationships, he was seeking a fantasy — the thing he always hoped his marriage would be. In a way, he was in the bargaining stage of Kübler-Ross’ theory. “If I could just redo some choices in life, I would find happiness in a relationship with someone …”

Instead of grieving the loss of what he thought his marriage should have been, he tried to bargain his way through it. These bargains were illusions and, consequently, none of his extramarital relationships satisfied him. Once he was able to grieve the loss of the marriage he had hoped for, he was able to adjust his expectations and achieve a healthier relationship with his wife.

This doesn’t mean that we must settle for unhappiness. On the contrary! With resolution of grief comes peace of mind. Borrowing from yet another theory, perhaps this is akin to Rogers’ idea of the ideal self and the perceived self. No one suggests we stop dreaming of a better self, but there will always be a gap between these two “selves.” It is in the resolution of that disparity where strength of ego develops. Grieving the loss of the ideal can lead to healthier behavior.

In a sense, Erikson said as much regarding the final stages of psychosocial development — generativity versus stagnation and integrity versus despair. These two stages are successful, at least in part, when one has achieved a sense of accomplishment.

If a person can look back on life and find satisfaction with its direction, it provides a sense of “I did good” and allows one to sleep well at night. There is no grieving. On the other hand, looking back and ruing decisions and the direction of one’s life leads one to feel stuck and hopeless. This is grief — the loss of one’s expectations.

I suppose what I’m trying to communicate is that if we can see how grief might be driving our clients’ dysfunctions, then what we should be treating is grief rather than just depression, addiction or other symptoms of grief. We cannot change loss. Facing it and finding ways to cope are the keys to resolution.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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Recently published: See Gregory K. Moffatt’s article in the April issue of Counseling Today: “The need for standardization in suicide risk assessment

 

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

Helping clients grow from loss

By Sherry Cormier February 4, 2020

Loss is a universal experience and an underpinning of many therapeutic issues. The client who has just lost a job, the parents whose son is addicted to opioids, the client whose long-term relationship unraveled, and the client who received a devastating health diagnosis all have loss in common.

As a professional counselor and bereavement trauma specialist, I am sensitized to the ways that loss informs clients’ worldviews and emotional struggles. And as a grief survivor, I am aware of the unique ways in which loss can serve as a catalyst for growth. An African proverb captures this sentiment when it says, “Smooth seas do not make for skillful sailors.” But this raises questions: Is growth possible for everyone, and how do counselors help clients grow after a traumatic loss?

Posttraumatic growth: What is it?

Posttraumatic growth (PTG) is an approach that informs our practice as professional counselors. Richard Tedeschi and Lawrence Calhoun, who pioneered much of the research and theory on PTG, define it as positive change that follows the struggle after some kind of traumatic event. PTG represents change that occurs after a life crisis rather than during it. It usually involves longer-term change that occurs over an extended period of months to years as individuals cope with crisis by developing ways of thinking, feeling and behaving that are different from what they relied on prior to the life-changing event.

PTG is not the same as personal development or maturity. It may be thought of as something that occurs somewhat spontaneously as the result of trying to cope with a challenging life experience of seismic impact. Evidence of PTG does not imply that the loss or traumatic event was somehow desired.

Approximately 10% of loss survivors stay mired in grief, guilt and despair for an extended period of time following their loss. Clients who experience these emotions, coupled with an intense yearning for who or what was lost, might be suffering from complicated grief, which requires a particular kind of professional treatment (see complicatedgrief.columbia.edu). The majority of loss survivors do not get stuck in acute grief, however, and report some measure of growth during recovery from loss. For many of these survivors, growth may coexist with distress.

Research summary: What do we know?

In 1996, Tedeschi and Calhoun’s research resulted in the Posttraumatic Growth Inventory, a 21-item self-report measure that yielded five empirically derived markers of PTG:

1) Improved relationships with others

2) Greater appreciation for life

3) New possibilities for one’s life

4) Greater awareness of personal strengths

5) Changes in spirituality

These five markers of growth have been reported by a variety of survivors, including prisoners of war, veterans with posttraumatic stress disorder, people diagnosed with cancer or other life-threatening illnesses, people who became paralyzed from accidents, and those who have lost spouses or life partners. Although much of the research has been conducted with people living in the United States, other studies have explored PTG with individuals in other countries.

Among current findings on PTG, Tedeschi and his co-authors cited the following in their 2018 book Posttraumatic Growth: Theory, Research, and Applications:

  • About 30% to 60% of survivors report some experience of PTG following a difficult life event.
  • PTG is both a process and an outcome.
  • PTG is generally a stable phenomenon over time.
  • PTG is more evident in those individuals who score higher on measures of extraversion and openness to experience and is also related to optimism.
  • There are both universal aspects and culturally specific characteristics of PTG.

Critics of PTG point out that self-reported or perceived growth is not necessarily the same as actual growth. Some of the conflicting findings on PTG seem to be the result of differences in how growth is defined and measured across studies.

Growth-promoting practices with loss survivors

There has been less research about specific interventions and techniques that might facilitate PTG in survivors, although a predominant feature of a growth-oriented therapeutic approach involves working with client stories or narratives. The following practical strategies can be used to help facilitate growth with loss survivors.

Create a safe therapeutic environment. Traumatic loss erodes a sense of security and thrusts survivors into the middle of unfamiliar circumstances. Social support is crucial, yet many people in survivors’ social networks may be uncomfortable with grief or may offer well-intentioned comments that feel offensive to the survivor. Counselors’ first task is to provide a safe container that is comforting and companionable for loss survivors. Creating a therapeutic environment in which we listen closely and hold up a mirror to reflect these clients’ experiences will help loss survivors feel known.

Use self-care practices. Traumatic loss may disrupt the rhythm of survivors’ connections. One way to help loss survivors reestablish bonds with others is to encourage them to grow a new relationship with themselves. We can help clients do this by recommending effective self-care practices such as movement and exercise, adequate sleep, and the intake of nourishing food. In the 2012 book The Emotional Life of Your Brain, Richard Davidson points out that a lack of consistent self-care practices sabotages our ability to regulate our bodies and emotions. Mindfulness and self-compassion are additional self-care practices that can be used by loss survivors who feel emotionally flooded with anger, guilt or anxiety. Teaching self-compassion and mindful meditation to these clients can help them reestablish a connection with themselves and, ultimately, with others. These tools also enhance clients’ equilibrium, making further work toward growth possible.

Explore client narratives. An important part of therapy with loss survivors involves exploring their narratives or stories. PTG occurs most often with clients who create an adaptive narrative in which they are able to see themselves as survivors rather than victims. The following items play integral roles in exploring client narratives.

Timelines: Initially, clients can construct a timeline of their lives with significant events marked at various ages. Timelines provide critical clues about pre- and post-loss stressors as well as the loss event itself. Clients who have been subjected to many pre-loss stressors often have more difficulty discovering growth. Using strength-oriented queries when asking clients to review their timelines is useful. For example, “Juanita, I noticed you had a miscarriage when you were 20. How did you cope with that? What tools did you find that helped you through that loss?”

Clues of growth: Many clients are so affixed to the trauma of the event that it’s hard for them to detect anything positive about their story. Counselors can be most helpful by noting clues of growth and healing in clients.

For example, James, an African American in his mid-20s, is discouraged because he has been through multiple losses. The house he once lived in with his grandmother was recently obliterated by a tornado, and now she is in the hospital with multiple injuries. In addition, the business he started just folded. In recounting his narrative, James mentions that a local church has offered to help rebuild the home, and a nearby car dealership just offered him a job. He says having others reach out to him with offers of assistance feels so unfamiliar that it’s starting to change his opinions about the world and other people. Although he doesn’t identify this as an indicator of growth, his counselor does by pointing out ways in which James’ views of himself, other people and the world are shifting in a new direction.

Cultural context: Exploring client narratives within a cultural context is also crucial. Some clients may present narratives of cultural losses rather than individual losses in instances in which they have faced significant discrimination based on their race, ethnicity, gender, age, ability status or sexual orientation. It is important for counselors to be aware of the ways that clients’ cultural affiliations affect their lives and their views of traumatic loss and healing.

For example, James reveals that he has been working odd jobs since he was 14 to support himself and his grandmother, whose only source of income is a small Social Security check. James confides that this elevated level of financial stress and the recent losses he has experienced make him feel more vulnerable as a black man living in a predominantly white rural community.

Journaling: Counselors can also facilitate client narratives by encouraging the use of journaling as an adjunctive therapeutic intervention. Therapeutic journaling is a tool developed by James Pennebaker, who says that writing about traumatic events reduces stress and strengthens immune cells. Consistent journaling is most effective, but 15 to 30 minutes of journaling several days a week can be more productive than daily journaling, which may produce more rumination than growth, according to Pennebaker. When working with survivors of loss, counselors typically instruct these clients to write about their deepest thoughts and feelings regarding their loss.

Case example: Sharon

Sharon is a 62-year-old woman whose live-in partner of 40 years died of a sudden heart attack. Sharon resides in rural Appalachia, where she had lived with her now-deceased partner for many years. She has no children, and her one brother lives hundreds of miles away. Sharon stopped working in a dental office seven years ago to help take of her partner, who had uncontrolled diabetes. She has no real friends and reports that she has rarely been out of the house in the past seven years. She says that she has no neighborhood acquaintances or memberships in any social groups.

In the first several counseling sessions, Sharon sobs and indicates that she has no idea how she will go on after losing her partner. She has limited income but no real expenses other than rent and utilities. She insists that she does not want to return to work and has sufficient income to meet her monthly obligations. She presents herself as something of a loner and describes herself as isolated.

Sharon came to the community counseling center at the urging of her brother, but she is unsure that grief counseling can be helpful to her. Short of bringing her partner back to life, she doesn’t know how talking and crying about her loss will accomplish anything. She is not having trouble sleeping but feels compelled to get out of the house during the day. She drives around randomly and visits local discount stores just to have someplace to go.

Sharon becomes more interested in counseling when a grief support group is offered, and she attends several sessions. She returns to individual counseling in a much more animated state and is even able to laugh. Having made several friends in the grief support group, Sharon reports that the group has helped her feel less alone. She is able to construct a grief timeline in counseling and is amenable to doing occasional journaling when she has bursts of grief. Over time, she pursues recommendations for joining a local gym and a book club at the public library.

Four months into individual counseling, Sharon becomes interested in volunteering at a local animal shelter and starts doing so on a weekly basis. Several months later, she feels like a different person. She says she is ready to stop coming to individual counseling sessions but will continue attending the grief support group.

Not all grief survivors experience the kind of growth that Sharon experienced — or so quickly. Even though she continued to miss her partner terribly, her life as a caregiver for the past seven years had precluded her from developing much life satisfaction for herself. Her ability to make friends and develop social connections and her volunteering activities with the animal shelter gave her a great deal of self-efficacy and provided positive ways to deal with the absence of her partner.

Some people will not cope with loss as effectively as Sharon did. Those who experience losses associated with violence or who have coexisting diagnoses such as depression, anxiety or substance disorders are more likely to go through an extended recovery period for healing. In addition, many grief survivors feel guilty for experiencing any kind of satisfaction, as if it amounts to some kind of betrayal of the person who is no longer here.

At the same time, it is not uncommon for grief survivors to reevaluate and shift their priorities in life, in part because their life circumstances have changed. For example, Emilee lost her spouse Roberto, who was a retired military officer and active in veterans’ affairs. Roberto had spent his retirement years traveling internationally in support of this cause. Emilee had rarely accompanied him because of her fears of terrorism and plane crashes. After Roberto’s death, however, Emilee decided to engage with the same veterans’ foundation that Roberto had been active in and found herself traveling all over the globe. Emilee wanted to preserve her spouse’s legacy and share her own gifts with a larger number of people. Loss survivors such as Emilee and Sharon who find ways to give back or volunteer are more likely to report narratives of growth.

Being attuned to growth

Potential for growth exists when clients uncover meaning from their loss and construct narratives that fit into their worldview and sense of self. Skilled counselors can serve as guides to help survivors make sense of what has happened. No survivor should ever be pushed to grow, but having a counselor attuned to growth may be the missing piece that helps clients become more resilient in the face of traumatic loss.

In my own experience as a grief survivor following a series of personally devastating losses, awareness of my growth sneaked up on me. It was as if a dimmer switch got turned up again as my outlook and mood shifted in a positive direction. I include this because being attuned to indices of growth may be one of the best ways that we can help clients recognize growth possibilities and emerge from the darkness of a traumatic loss to find light again. As Jon Kabat-Zinn, founder of mindfulness-based stress reduction, has said, “You can’t stop the waves, but you can learn to surf.”

 

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Sherry Cormier is a licensed therapist, certified bereavement trauma specialist, and former faculty member at the University of Tennessee and West Virginia University, as well as being a public speaker, trainer and consultant. She is the author of Counseling Strategies and Interventions for Professional Helpers (ninth edition), senior author of Interviewing and Change Strategies for Helpers (eighth edition), and co-producer (with Cynthia J. Osborn) of more than 100 training videos for Cengage. Her newest book is Sweet Sorrow: Finding Enduring Wholeness After Loss and Grief. Contact her through her website, sherrycormierauthor.com.

 

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Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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 survivors of suicide loss

By Dana M. Cea October 29, 2019

Each year, more than 40,000 people die from suicide in the United States, making suicide the 10th-leading cause of death in our nation. Worldwide, more than 800,000 people are lost to suicide annually. These are devastatingly high numbers. But an even larger number encompasses the people who have been impacted by a loved one’s death from suicide. They are known as survivors of suicide loss.

In 1973, psychologist and suicidologist Edwin S. Shneidman — who founded the American Association of Suicidology (AAS) — estimated that for every suicide death, there were six survivors affected. Thirty-eight years later, research by psychologist Alan L. Berman — at that time the executive director of AAS — determined there were anywhere from five to 80 or more survivors of suicide loss for each suicide death. That year, 2011, was the same year my dad died from suicide.

The response to my dad’s death made Berman’s research findings seem like a significant underestimation. Hundreds of people showed up for my dad’s funeral and contacted our family after his death. A 2018 article published by the American Association of Suicidology found the number of people impacted by one suicide death to be around 135 people. Thus, approximately 6 million people in the United States are affected by suicide loss each year.

 

Survivor day

After I found out my dad had died from suicide, I called my previous college therapist. Even though I had not seen her in more than a year, she called me back. She listened, she validated, she empathized — all of the things you hope a therapist would do. She also told me about a day specifically to support survivors of suicide loss: International Survivors of Suicide Day (Survivor Day for short). In 1999, Sen. Harry Reid, who had lost his father to suicide, introduced a resolution to create an annual day for survivors of suicide loss to come together for healing and support. Congress designated the Saturday before Thanksgiving as Survivor Day.

The American Foundation for Suicide Prevention (AFSP) supports hundreds of Survivor Day events around the world. Each year, AFSP creates a documentary of the stories of suicide loss survivors that is shown at Survivor Day events. Both the documentaries and the events focus on healing, surviving and thriving. Survivor Day events offer survivors of suicide loss a safe space to “find connection, understanding and hope through their shared experience.” Past documentaries can be viewed on AFSP’s website.

Since 2012, I have assisted in hosting a local Survivor Day each year. This year, I am hosting the event in Greenville, North Carolina, at East Carolina University’s Navigate Counseling Clinic, part of the Department of Addictions and Rehabilitation Studies, where I am pursuing my doctorate. At past events, I have witnessed survivors talking about their loved one’s death from suicide for the first time — sometimes years or decades after their loss. I have heard survivors share their experiences of shame, guilt, anger and grief. I have also heard stories about funny, kind, caring, smart, artistic and achieving loved ones who have been lost to suicide. I have experienced connections that may not have been found anywhere else.

 

Support groups

In 2011, Survivor Day fell on the same day as my dad’s funeral, and in a sense, we held our own impromptu Survivor Day event. Without the actual designation or documentary, hundreds of people came together as survivors of the suicide loss of my dad. After I went back to Tennessee, where I was living at the time, I began individual therapy with a local provider. I remember feeling that she did not “get it”  — the “it” being all that comes with the loss of a loved one to suicide. However, she gave me information about the Tennessee Suicide Prevention Network, which was hosting a support group for survivors of suicide loss in my area. That support group is where I found others who did get it.

The support group members did not blame each other for their loved one’s death. They did not make comments such as “I hope God forgives your dad”; “You should have known this was going to happen”; “Your dad is in a better place now”; “I do not know how I could keep living if I were you”; “Why didn’t you stop him?”; “That was so selfish of him to do that to you”; or any of the other insensitive remarks that survivors of suicide loss so often hear.

Some of the group members had people in their lives who no longer talked to them or who actively avoided them. Yet the support group members continued to show up for each other. When group members tried to talk with other people about their pain or how their loved one had died, the conversations often shut down immediately. Yet the support group members encouraged one another to share and express their emotions.

Losing someone to suicide is very different from losing someone to another cause of death. And sometimes, finding someone who understands your loss requires finding someone who has also lost someone to suicide.

 

Postvention

Postvention is the work done to support survivors of suicide loss. In my master’s counseling program, we learned some about suicide prevention, yet suicide postvention was hardly mentioned. Although suicide prevention and intervention training can be inadequate in some counseling programs, suicide postvention training is often nonexistent. So, how can we as mental health professionals help clients who have lost a loved one to suicide?

First, we can be trained to provide services specifically tailored for survivors of suicide loss. AFSP’s website has a list of clinicians trained in suicide bereavement. These clinicians have been through a daylong training workshop that includes information about what being a survivor of suicide loss means, the impact the loss has on survivors’ mental health and well-being, and common themes survivors may experience in their bereavement. Clinicians also learn clinical techniques that can help survivors work through their bereavement and piece their lives back together. AFSP provides training for professionals interested in becoming suicide bereavement clinicians.

AFSP also provides training for clinicians who want to lead or facilitate support groups for survivors of suicide loss. There are two different versions of the training: one for facilitating adult support groups and another for child and teen groups. Each program lasts two days and includes lectures, interactive discussions, and role-playing.

Clinicians who are not interested in leading a group can still give clients a list of AFSP-curated support groups for survivors of suicide loss.

Hosting a Survivor Day in your area is another powerful way of helping suicide survivors, some of whom may be more comfortable with a one-day event rather than regularly attending a support group. The Out of the Darkness Community Walk is another one-day event. These walks, which take place in numerous locations nationwide, are not specifically for survivors of suicide loss. Their purpose is to raise awareness — and funds — to help prevent suicide. These walks are also where many survivors of suicide loss find support for the first time. Each walk is sponsored by a local chapter of AFSP, and being connected to those chapters can give clinicians access to resources to help themselves and clients.

 

Other resources

When I called to set up therapy after my dad died from suicide, I was told the wait was several weeks. During that time, I leaned on the support of family, friends and co-workers. I wish I had known about some of the resources available to recent survivors of suicide loss.

Healing Conversations is an AFSP program that connects recent survivors of suicide loss to volunteers who are also survivors and have been through a training and vetting process. Healing Conversations, formerly known as the Survivor Outreach Program, offers that connection to people without the pressure of therapy, groups or events. Survivors simply submit a form through the AFSP website, and a coordinator connects the survivor and a volunteer for an in-person visit, phone call, or video call.

AFSP’s I’ve Lost Someone page contains a variety of helpful tools, including practical information for immediately after a loss, resources to help loss survivors find support, and self-care recommendations. Schools, colleges and workplace managers can also access postvention toolkits. Survivors can use the page to identify ways to honor loved ones lost to suicide through digital and physical memory quilts, memorial funds, and Out of the Darkness walks.

AFSP is not the only organization that provides helpful resources and information. The Suicide Prevention Resource Center (SPRC) offers a variety of suicide prevention resources, training programs and toolkits, including “Suicide Prevention Competencies for Faith Leaders.” SPRC’s website also has sections devoted to postvention and supporting survivors of suicide loss.

The Tragedy Assistance Program for Survivors (TAPS) offers “compassionate care to all those grieving the loss of a loved one who died while serving in our Armed Forces or as a result of his or her service.”

The U.S. Department of Veterans Affairs (VA) has suicide prevention coordinators at each VA medical center nationwide. They can help active-duty members and veterans get counseling and needed services. The suicide prevention coordinators are also incredible resources for families, loved ones and communities.

 

Talking about suicide

The phrase “commit suicide” can be one of the worst things that a survivor of suicide loss hears. Where did this phrase come from? For hundreds of years, attempting or dying from suicide was an actual crime in Britain. Punishments may have included denial of a funeral, burial alone without a marker, desecration of the body, and confiscation of the person’s property. States such as Maryland and Virginia, despite having developed their own laws, continue to recognize this law. The phrase “commit suicide” reinforces the suggestion of suicide as a crime.

Two other phrases that come across as icky, for lack of a more scientific term, are “completed suicide” and “successful suicide,” as if death were the preferred outcome of an attempt. Advocates for suicide prevention and postvention encourage the use of “died by suicide.” While I see this as a much-preferred phrase, I take the phrase one step further and use “died from suicide.” I have never heard anyone say someone “died by” a heart attack, an accident, cancer, or any other disease. People commonly say that someone “died from” whatever the cause of death was. Therefore, I prefer “died from suicide.”

Other advocates prefer to say that someone “died from a mental illness” rather than from suicide. Although I can see the intention behind this phrasing, the reality is that not everyone who dies from suicide has a mental health condition. In 2018, the Centers for Disease Control (CDC), after examining suicide statistics in 27 states from 1999-2016, released a report showing that more than 50% of people who died from suicide did not have a diagnosed mental health condition at the time of their death. Reading and quoting these statistics can make the conversation confusing, and the bottom line is that there are tens of thousands of people dying from suicide each year who do not have a mental illness.

Regardless of your current or future involvement in supporting survivors, I ask one thing of each of you reading this: Please be aware of how you talk or joke about suicide. Both AFSP and SPRC have guidelines for talking about suicide: Speaking Out About Suicide and Suicide Reporting Recommendations.

 

Suicide’s impact on counselors

As mental health professionals, we are not immune to being impacted by losses from suicide. While I am not going to delve into our legal responsibilities, I will touch on our ethical responsibilities. If we lose someone to suicide, we may be affected by our grief more than we realize, and this can take a personal toll and negatively affect our work with clients. I encourage us as mental health professionals to take care of ourselves, to seek support, and to take off as much time as needed so that we can live up to the ethical responsibilities we have to provide competent care.

I also implore mental health professionals to bracket their values that may be harmful when discussing death from suicide with clients. If someone comes to me and says that they will not attempt suicide because that would be a sin, I will use that as a protective factor with the person. However, I would not tell someone that attempting or dying from suicide is a sin. The reality is that many religions and places of worship no longer view suicide as a sin and have come to realize the part that mental health and life situations play in deaths from suicide.

If you do decide to offer services specifically to survivors of suicide loss, or if some of your clients are or become survivors of suicide loss, please consider seeking training, consultation and supervision. Survivors of suicide loss are at higher risk of having thoughts of suicide due to their exposure to suicide compounded with their grief. Grief journeys can be difficult enough without the additional layers that come with a suicide loss. Gaining additional expertise in counseling survivors of suicide loss through training, consultation and supervision can make all the difference in the care you provide to clients.

 

Conclusion

As we continue to raise awareness and work to prevent suicide, we can expand our efforts to assist those who have been affected by suicide. Please join me in supporting survivors of suicide loss by being aware of and using available resources, encouraging postvention efforts, talking about suicide safely, and taking care of ourselves so that we can continue to provide effective mental health services.

 

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Dana M. Cea, pronouns she/her or they/them, is a volunteer for the National Alliance on Mental Illness and the American Foundation for Suicide Prevention, a mental health professional, a survivor of suicide loss, and a current doctoral student at East Carolina University. She focuses her research on mental health and suicide, the LGBTQ+ community, youth, and autism spectrum disorder. Dana lives with mental health disorders, her spouse, and their three dogs. Contact her at danamcea.com.

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

The invisibility of infertility grief

By Tristan D. McBain September 30, 2019

In my work as an outpatient mental health counselor, I have encountered numerous clients over the years with stories about reproductive loss. Not only were these stories fraught with sadness and grief, but some of the individuals were still experiencing acute grief even several years later.

As I branched out into my role as a researcher during my doctoral study, these stories stayed with me. So, I began a line of inquiry on reproductive loss that started with infertility and the accompanying grief. Since then, my research on infertility and miscarriage grief has resulted in numerous professional conference presentations and guest lectures. The purpose of this article is to share information that I have learned about those with infertility and to provide methods for best practice in counseling with these clients.

Infertility is generally defined as a condition of the reproductive system that inhibits or prevents conception after at least one year of unprotected sexual intercourse. To account for the natural decline of fertility with age, the time frame is reduced to six months for women 35 and older. According to the Centers for Disease Control and Prevention (CDC), about 12% of women between the ages of 15 and 44 have “difficulty getting pregnant or carrying a pregnancy to term.” Infertility can affect both men and women, despite a common misconception that infertility is a woman’s condition. Infertility in men may be caused by testicular or ejaculatory dysfunction, hormonal disorders, or genetic disorders. In women, infertility may be caused by disrupted functioning of the ovaries (such as with polycystic ovary syndrome, a condition that prevents consistent ovulation), blocked fallopian tubes, or any uterine abnormalities (such as the presence of fibroids).

Infertility can be categorized into one of two subtypes. Primary infertility refers to when a woman has never birthed a child and thus has no biological children. Secondary infertility refers to when a woman experiences the inability to birth a child following the birth of at least one other child. Both forms of infertility produce a cyclical pattern of strong emotion that is often referred to as a “roller coaster.”

Medical interventions

A number of available interventions may be used to increase the chances of becoming pregnant. The best course of treatment will be different for each couple and may depend on considerations such as whether the infertility is male factor or female factor, the cost and availability of insurance coverage, and cultural customs or beliefs. Some couples decide that pursuing any kind of medical treatment is not the right course of action for them. For others, medical treatment may include any of the following interventions.

  • Medication may be prescribed to stimulate ovulation or follicle growth in the ovaries, increase the number of mature eggs produced by the ovaries, prevent premature ovulation, or prepare the uterus for an embryo transfer.
  • Surgery may be necessary, perhaps to clear out blocked fallopian tubes or to remove uterine fibroids.
  • Intrauterine insemination (IUI), also known as artificial insemination, is a procedure in which sperm are inserted directly into the woman’s uterus. The woman may or may not be taking medications to stimulate ovulation before the procedure.
  • Assisted reproductive technology (ART) refers to fertility treatments in which eggs and embryos are handled outside of the body. This excludes procedures in which only sperm are handled (e.g., IUI). The most common and effective ART procedure is in vitro fertilization (IVF).

Undergoing IVF treatment requires a strong physical, emotional and financial commitment. Generally, medications are prescribed to stimulate egg production and may include a series of self-administered injections. Eggs are removed from the ovary using a hollow needle, and the male partner is asked to produce a sperm sample (or a sperm donor may be used). The eggs and sperm are combined in a laboratory, and once fertilization has been confirmed, the fertilized eggs are considered embryos. About three to five days after fertilization, the embryos are placed into the woman’s uterus via a catheter in hopes of implantation. The CDC reports that women under the age of 35 have a 31% chance of conceiving and birthing a child with the use of ART; the chances are closer to 3% for women ages 43 and over.

The IVF process can be a highly emotional time for the woman and the couple, marked by moments of excitement, hope, disappointment or uncertainty. The IVF cycle may be canceled if certain problems develop along the way, such as having too few or no eggs to retrieve, the eggs failing to fertilize, or the embryos not developing normally. Any of these situations may produce a sense of loss for the woman or the couple. After the embryo transfer, it is generally recommended to wait 10-14 days before testing for pregnancy. In some circumstances, a chemical pregnancy takes place. This is when implantation happens that results in an initial positive result, but then the pregnancy does not progress. In other words, a very early miscarriage occurs.

This section on medical interventions is important to include because these interventions are part of the infertility experience and may affect the emotional or mental health of the client. This is true even for women and couples who choose to not pursue treatment; at the end of the day, a decision was made and they must cope with the implications of that choice. Professional clinical counselors who are knowledgeable about the available medical interventions will have better context for recognizing the myriad decisions that these clients face and the potential losses that may occur throughout the process.

The invisibility factor

Take a moment to think about the grief that occurred for you after the death of a loved one. The relationship you had with your loved one was probably clearly defined, and you have memories of that person to look back on. The loss is easily identified and articulated, not only by you but by others who were aware of the death. You most likely had many people express sympathy and give you their condolences, perhaps verbally or by sending flowers. You may have taken time off work for bereavement and attended a ritual such as a visitation ceremony, wake or funeral that helped to facilitate your grief. Your loss was likely recognized, acknowledged, validated and supported in a multitude of ways.

Now think about the losses associated with infertility. One of the major losses is that of the imagined or expected family. Women with primary infertility, who do not have biological children, face the loss of the entire life stage of parenting. This may include pregnancy, passing on family or holiday traditions, and passing on the genetic legacy or surname, plus the eventual loss of other life stages such as grandparenthood. Counselors should recognize that meaning is often attached to these losses which further compounds the pain. For example, not being able to experience pregnancy means that the woman is also excluded from cultural pregnancy milestones such as going to the first ultrasound visit, thinking of fun and exciting ways to announce the news to family and friends, participating in a baby shower, and throwing a gender reveal party. With infertility, the loss comes from an absence of something that has never been rather than the absence of something that used to be.

The stigmatization surrounding infertility contributes to an atmosphere of silence and invisibility. Infertility and its accompanying losses are not as outwardly visible and may not be well known or understood by others unless the woman discloses them herself. Many women who experience infertility feel a sense of failure or self-blame toward their bodies, and some may withdraw socially, isolate, or struggle with their identity and sense of self. The stigma surrounding infertility can make it difficult for women to reach out for support. As a result, they find themselves navigating the experience alone.

When a woman does talk openly about her infertility, other people may not respond in ways that are validating or compassionate, which may make the situation worse than if she hadn’t disclosed at all. For example, comments such as, “Just relax,” and, “Give it time,” minimize the woman’s pain and invalidate her grief. Asking, “Have you tried (fill in the blank)?” or “Have you considered adoption?” implies that the woman is not trying hard enough to find a solution or that what she has tried already is inadequate. Most of the women with infertility I have encountered over the years acknowledge that people generally mean well and offer such comments in an attempt to provide hope or to decrease their own feelings of discomfort when talking about infertility.

Facilitating the grieving process

Professional counselors have a responsibility to provide compassionate and competent mental health treatment. Each infertility journey is unique, and counseling interventions should be tailored to fit the individual needs of every client. Taking clients’ cultural, religious or spiritual backgrounds into consideration, several interventions may be used to effectively assist these clients through their grief.

  • Counselors, first and foremost, can be present and listen. Typically, this is what is missing when family members, friends, co-workers, doctors or strangers offer comments that end up being hurtful or invalidating to the person or couple experiencing infertility. We do not have to have the answers — even as counselors. Just be there.
  • Counselors can assist clients in articulating what they need from others around them. This may also incorporate methods for helping clients increase their assertiveness or self-confidence.
  • Counselors can help clients redefine their life expectations and conceptualizations of womanhood, family and mothering. This may also include processing how clients perceive lost embryos, chemical pregnancies or miscarriages to fit within the family unit.
  • Counselors can help clients manage the roller coaster of emotions and ongoing stress as they are trying to conceive, rather than focusing on finding closure. Closure usually implies resolution, which may not be possible with the prolonged nature of infertility and the treatment process.
  • Counselors can assist clients in developing their own rituals while trying to conceive, undergoing fertility treatment, or after making the decision to stop treatment. For example, a woman once told me that she threw a party after she and her husband decided to stop IVF treatments. The party signified taking control over their decision to remain child-free and served as a celebration of the effort it had taken to come that far. 
  • Counselors can explore appropriate methods of client self-care, including engaging in hobbies, participating in creative or social activities, and even taking breaks (as needed) from trying to conceive or pursuing medical treatment.
  • Counselors can connect clients with appropriate resources. It may be necessary to provide clients referrals to group counseling if they wish to connect with others who have similar stories, or to couples counseling if they are struggling in their relationships. In addition, location or cost can be barriers to clients obtaining the services that would work best for them, so counselors who are knowledgeable about online resources can provide these options. Collaborating with other health care professionals with whom the client is working can also provide more comprehensive treatment.

This is not, of course, an exhaustive list. Grief is a personal experience. Which methods are the best fit for your client should be explored in a therapeutic setting that considers both individual and cultural contexts.

What do counselors need to remember?

Imagine that you are working in a private practice when you meet a new client experiencing infertility. You are a master’s-level clinician and are fully licensed in your state. You have taken one class in your graduate program on grief and loss but have no further specialization or experience with infertility. The client has heard numerous comments, questions and suggestions throughout the years regarding her infertility. She is unsure of how counseling might help, but she feels the need to seek support.

This scenario, while general, is a realistic picture of a possible situation that any clinician could experience. As such, I will provide thoughts on what every counselor should keep in mind when it comes to the areas of infertility grief. I am not attempting to reinvent the wheel when it comes to essential counseling tools; rather, I am striving to provide context for effectively using these tools with clients affected by infertility.

>> Convey empathy and understanding. If I could share only one thing I have learned in my work with women affected by infertility, it would be that so many of them feel and believe that you cannot possibly understand what infertility is truly like unless you have been through it yourself. Many women have asserted to me that they just need someone willing to sit with them through the anguish. Counselors who are attempting to provide encouragement and hope may instead end up inadvertently dismissing their clients’ pain or minimizing their grief. It is also possible that counselors end up avoiding a deeper exploration of the experience completely because they do not know what to say. Do not underestimate your basic counseling skills when working with these clients. Acknowledge, reflect and empathize.

One way that counselors can suggest understanding is through the careful use of language. For instance, matching the client’s chosen language of “baby” or “child” is more appropriate (and accepting) than using the more medically correct terms of “embryo” or “fetus.” Language can also offer a reframe from a label of “an infertile woman” to “a woman affected by infertility.” This choice of words depersonalizes the condition and acknowledges that her identity is separate from the condition.

>> Become familiar with client issues related to infertility. Clients who talk about their infertility journey will use a variety of terms and acronyms. For example, you may have clients talk about the time they were “TTC,” which stands for trying to conceive. They may also mention medications, medical procedures or basic biological functions with the assumption that the counselor is generally informed on these topics. Although asking clarifying questions of clients can help paint a clearer picture of their experience, it is not the client’s job to educate the counselor. Take the initiative early in the working relationship with a new client to learn about infertility in areas in which you are deficient. That way, you will be able to understand the client’s journey and experience in greater context.

>> Validate the loss. The invisibility of infertility may cause some women to wonder whether their losses are real or valid. For example, I met a woman during my research who had elected to try IVF after three years of actively trying to conceive, and she gave birth to a healthy baby after just one round. Still, she felt a sense of loss over the fact that her memories of the conception did not entail a moment of passion and love, but rather recollections of shame and fear. She referred to her husband having to masturbate in isolation to provide the needed sperm sample and her experience of lying on a cold table waiting for the doctor to transfer the embryo. She did not feel that she could verbalize this sense of loss to others, however, because it might make her sound ungrateful. A counselor could validate the loss of the ideal conception story and help her articulate feeling both sad for that loss and grateful for her baby at the same time.

The invisibility of infertility also means that some women may not have the vocabulary to identify and articulate their losses. Women with primary infertility endure the losses of pregnancy, delivery, parenthood and eventual grandparenthood but may not be able to understand for themselves that they are mourning the loss of an anticipated and desired life stage. Counselors can assist clients with developing language for their losses if they are struggling to verbalize their grief.

>> Get comfortable. Discussions about infertility may overlap with other taboo topics such as sex, masturbation, miscarriage and abortion. Many of the women I have met who have been affected by infertility have had miscarriages along the way. This brings about an additional — but connected — situation of grief and loss. Talking about miscarriage can be difficult to do without also bringing up abortion, given overlapping language (e.g., spontaneous abortion) and medical procedures (e.g., dilation and curettage). These topics can be slippery territory for personal bias, but counselors should regulate their own reactions and practice reflection to maintain appropriate neutrality and support. Engaging in self-care can be particularly important when counseling those affected by infertility.

Challenging infertility stigma

More and more, childbearing is being viewed as a choice rather than a societal or marital expectation, yet not having children is still considered to be somewhat taboo. Women are socialized from a young age to prepare for eventual motherhood through childhood play that often fosters a nurturing and caretaking role. Other cultural narratives suggest that women have an ability and responsibility to control their fertility. This contributes to self-blame and shame when they are unable to conceive. Infertility is infrequently discussed publicly and thus carries a sort of social stigmatization. Counselors can contribute to destigmatizing infertility by normalizing conversations about infertility, challenges to conception, fertility treatments, and miscarriage.

Stories related to infertility gained widespread media attention throughout 2018. That March, a fertility clinic in Ohio experienced a technical malfunction that caused the destruction of more than 4,000 eggs and embryos, a loss that most certainly had potentially devastating implications for the affected families. Then, in August, a rare visual of the emotional and physical struggle of trying to conceive was captured in a photograph that went viral of a newborn baby surrounded by the 1,616 IVF needles that it took to conceive her. In the months that followed, actress Gabrielle Union opened up about her emotional fertility journey that included numerous miscarriages and surrogacy, and former first lady Michelle Obama revealed her story that included miscarriage and IVF to conceive her two daughters.

These stories bring visibility to infertility and normalize conversations about the challenges that can come with attempting to get pregnant. Counselors can contribute to destigmatization by engaging in discussions and posing curious but sensitive questions about how resources and support can be bolstered for affected women and couples.

Conclusion

Each infertility story is unique, and no one-size-fits-all solution exists when it comes to helping women and couples work through their infertility grief. Whereas an obvious loss from the death of a loved one usually includes rituals and social support, the invisibility of infertility makes it difficult to identify the losses, often leaving women affected by these losses to deal with them in silence and isolation. Counselors can help clients find the vocabulary to articulate the losses they are grieving, give voice to what they need from the people around them, and create ways to process their grief in a warm, nonjudgmental atmosphere.

 

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Tristan McBain is a licensed professional counselor and licensed marriage and family therapist. She is a recent graduate from the Counselor Education and Counseling Psychology Department at Western Michigan University in Kalamazoo. Contact her at tristanmcbain@gmail.com.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Letters to the editor: ct@counseling.org

 

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Related reading on this topic, from the Counseling Today archives: “Empty crib, broken heart

 

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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.