Tag Archives: Marriage

The relationship as client

By Laurie Meyers September 22, 2016

Among the most common difficulties that bring couples to counseling are infidelity, financial problems, sex and intimacy issues, parenting challenges and ongoing tensions with the in-laws. Each of these problems has its own unique characteristics, but according to couples counselors, they tend to share a similar root cause — namely, lack of communication. The challenge for couples counselors (and their clients) is to identify how communication went awry — or if it ever truly existed in the first place — and then work to reestablish it.

Couples counseling is fundamentally different from individual counseling, says Paul Peluso, past president of the International Association of Marriage and Family Counselors, a division of the American Counseling Association.

“Too often, counselors think that couples counseling is ‘individual counseling times two,’ and they conduct individual counseling with each person, while the other partner observes,” Peluso says. “That really isn’t couples counseling. Instead, with couples counseling, you have not just branding-images_inkhearttwo perspectives in the room that you have to balance, but you have the … relationship that you are working with. In fact, it is the couple’s relationship that technically is your client, not the individuals in the couple.”

Having a relationship as the client instead of an individual makes it much more challenging to build a therapeutic alliance, says Barbara Mahaffey, a licensed professional clinical counselor and ACA member who practices in Chillicothe, Ohio. The relationship is not just an entity, but rather two separate people who have different thresholds for opening up and trusting, she explains. Couples also come in with different goals and expectations. Mahaffey, who specializes in counseling couples and families, says her task as a counselor is not just to address these goals and expectations, but to help the couple discover how they can reconcile their personal expectations and establish new goals that will allow them to move forward as partners.

“Couples will come in and want to fight over who is right and who is wrong in the relationship,” Peluso says. “It is the couples therapist who has to sell the idea that no one is wholly ‘right’ or wholly ‘wrong.’ Paradoxically, neither is to blame and both are to blame — in the technical sense — for the state of the relationship at the same time. Both have played a role in setting up the conditions for the relationship. So the focus is on how each person’s behavior and reactions to [the] other affect the couple’s relationship. If each person wants to be in the relationship, then they have to take responsibility for how their behavior impacts the health of the relationship. And this is very different than individual counseling.”

Confronting infidelity

Unfortunately, the catalyst that most often pushes couples into a counselor’s office is also one of the most difficult issues to move past.

“The single most common issue that brings couples into therapy is infidelity,” says Peluso, a licensed marriage and family therapist (LMFT) who has written several books about both infidelity and couples counseling. “Over the last 20 years, researchers have demonstrated that this is the most common presenting concern, and if it is not revealed initially, it is often disclosed in the course of couples therapy. Infidelity can take many forms, from sexual to nonphysical intimacy, and it now includes relationships online.”

“In terms of who cheats, researchers have found that women are just as likely as men to participate in infidelity,” Peluso continues. “As a result, practitioners have to know how to deal with the complex and often devastating issues that accompany infidelity. Unfortunately, when couples counselors are asked about it, they overwhelmingly say that it is the topic they feel least prepared to treat.”

Amber Lange, a licensed professional counselor who owns and practices at Bedford Health, a group practice in Lambertville, Michigan, can attest to the high demand for infidelity counseling. Her practice has become known for specializing in issues surrounding infidelity and betrayal. Initially, the sheer need for counselors knowledgeable about and willing to tackle this particular relationship threat astounded her. “I’ll never be out of a job [as an infidelity specialist],” she says ruefully.

Among couples for whom the act of infidelity is fresh, the nonoffending partner is typically experiencing acute stress and may even have symptoms that resemble posttraumatic stress disorder, Lange says. The offending partner, on the other hand, is typically feeling beaten down because he or she has repeatedly been asked blunt questions that shine a direct light on his or her indiscretions: What did you do? Where? How much money did you spend?

In cases in which the infidelity is years in the past, the core counseling issue more often involves a lingering lack of trust, Lange says. “The nonoffending partner [may have] forgiven the offending partner, but they have never rebuilt trust,” she explains. “So the nonoffending partner is hypervigilant about trust and the [possibility of the] offending partner reoffending.”

If the act of infidelity is recent, Lange helps the couple work through their “why, who, where, how” stage. “I talk about the idea of how you can’t ‘unknow’ something once you know it,” says Lange, a professor of counseling at Capella University. “There’s a lot of knowledge that you can gain that may further traumatize you, such as the sexual positions that your partner was in with someone else.”

Clients may also wonder if their partner did things with another person that the nonoffending partner refused to do. If this information is disclosed, Lange explains, it can lead the nonoffending partner to do things he or she is uncomfortable with in an attempt to please the offending partner.

Instead of attempting to get answers to questions that can further damage the relationship, Lange encourages the nonoffending partner to ask structured questions such as: When did you start having sex? When did you stop? Did you have unprotected sex? These types of questions provide information that the nonoffending partner needs to know, Lange says.

The next phase of Lange’s therapeutic approach involves narrative therapy. As part of this stage, Lange might ask couples who delayed getting therapy after the infidelity to briefly touch on information about the affair as a way to see if there are lingering questions. This process also helps Lange to assess the strength of the couple’s bond.

The story of ‘us’

Regardless of whether the couple is confronting a recent infidelity or the infidelity happened years in the past, constructing the story of their relationship represents the core of the healing process, according to Lange. Couples build the narrative to gain a clearer understanding of how and when the cracks in their relationship developed, she explains. They talk about the beginning of their relationship and explore how they interacted. Were they friends and true partners? What happened that started pulling them apart?

“Life” — deaths, births, work, money and so on — is usually the answer to that second question, Lange says. In addition, people typically change over time, which further alters the nature of the relationship, she notes. All of these factors in combination can make a relationship vulnerable to disruption. Add in misperceptions and unmet expectations, and once tiny relationship fissures can turn into large cracks that cause couples to drift apart.

Among the most common life events that can start to pull some relationships apart is the birth of a child, Lange says. “Before the birth, couples were able to spend all their time and energy and money on each other. After the birth of a child, ideally, you love that child and invest all of that [time, energy and money] in parenting and child rearing — which is not bad, but [couples] come into my office, and they haven’t been on a date in three years.”

In addition to not making time for the romantic relationship, the couple may be trapped in patterns that are actively pulling them apart, Lange says. “You’ve been great parents, but the mother is staying home or working and raising kids at the same time, the father is working and overworking to pay for the mortgage and save for retirement — those kinds of things can hurt a relationship,” she says.

When a couple stops talking to each other, it creates a gap, and it is tempting to fill that gap with other people or activities, Lange notes. Partners may begin to betray each other in different ways, whether it is spending time on social media instead of with each other, watching pornography or working long hours, she says. “In the process, we’ve let the relationship go awry,” Lange observes.

But this risk of unraveling is not exclusive to couples with children. Those who get married or enter into domestic partnerships too quickly upon meeting or when they are very young are also particularly vulnerable, Lange says. For example, those who form romantic relationships in their teens or early 20s are in the midst of experiencing significant personal development. This may not happen at the same rate for both partners, eventually leaving them feeling as if they don’t know each other, Lange explains. Likewise, people who get married or form a domestic partnership in the matter of a few weeks have not typically had enough time to establish a strong base of friendship. Over time, it’s not uncommon for them to realize that they don’t even like each other, Lange says.

Lange asks clients not to make a decision about whether to stay together until after they have gone through the process of identifying what went wrong. Then, if they choose to stay together, Lange helps them start to discuss how to protect the relationship going forward. This typically includes setting aside time to talk with each other more frequently, being intentional about making time for dates and even going on vacations without the kids. But it also involves each partner identifying the behaviors in which he or she engages that play a role in pulling the relationship apart.

For example, Lange recounts something that a client recently shared. “One of the things that I have recognized about myself over the past six months is that I tend to withdraw,” the client told her. “When my partner and I got into an argument, I went away, slept in the kids’ room and wouldn’t talk. I would work 85 hours a week. Even when I wasn’t in the office, I was checking my email.”

In essence, Lange says, the client just wasn’t “there” in the relationship. Other people do the same thing by burying themselves in hobbies such as sports or scrapbooking. As a result, they end up spending more time with friends or with hobbies than they do with their partner and family, Lange says.

The process of building the couple’s story in counseling and finding the cracks and vulnerabilities is a long one. For the first four to six weeks, when a couple is still going through the initial trauma phase of the infidelity, Lange has them come to counseling every week. Once a couple moves on to the storytelling stage, she has them come to counseling only about once per month, in part because she feels that much of the processing and healing needs to take place between sessions as the couple slowly rebuilds the relationship.

“They have to have time to figure out things … how to be in relationship, how to recreate their friendship and how to build [new] good memories,” Lange says. During the process of rebuilding the relationship, trust is also being reestablished and forgiveness is being granted. Then the couple can move forward, she explains.

Ideally, the couple will also identify potential problem areas and reach compromises on how to address those issues. For example: “You say I can’t work 90 hours a week, but we need money, so how are we going to figure that out? … This is [our] story. Here’s the way we go forward. Here’s what we need to do.”

Symptom vs. problem

Brian Canfield, a past president of ACA, also says that infidelity is the event that most commonly brings couples into his office. But he believes infidelity is always indicative of other underlying problems in the marriage or relationship.

“I view an affair not as the problem but as a symptom,” he says. “An affair is like malarial fever. It’s uncomfortable, but it’s not the fever itself that’s going to kill you — it’s the disease.”

Canfield believes that if a counselor addresses the underlying issue first, it will help to stabilize the couple, which will then allow them to deal with the ramifications of the infidelity. “You [the counselor] have to assess if there is a commitment and desire to save the relationship,” says Canfield, an LMFT whose practice has offices in Louisiana, Arkansas and Florida. “Trust and betrayal, that’s not where you put the spotlight. The trust will return once you stabilize the relationship.”

Canfield starts by asking the couple what they want out of the counseling process and their relationship as a whole. “What would you like to see happen? If it is possible to salvage the marriage, would you be willing?” Canfield asks. “A lot of people want to know why [the affair happened], but here is where we are. Where do you want to be? If you were going to redesign marriage, how would it look?”

Canfield says financial difficulties are the most common underlying issue that couples bring into his office. In his experience, there is so much shame surrounding finances that most couples would rather talk about the details of their sex lives than money. He frequently encounters situations with couples in which one partner has been maintaining a hidden bank account or run up the balance on their credit cards without the other partner knowing. He tells couples that part of the counseling process involves full disclosure.

“A lot of couples are in tremendous denial,” Canfield says. “They don’t know how much debt they are in, what their bills are or have a good picture of how much income they are bringing in.”

Sometimes people feel entitled or convince themselves that it’s OK to buy what they want regardless of how it affects their spouse or partner. They tell themselves that they work hard and that they deserve it. Canfield sees part of his role as helping to bring clarity to these situations to encourage better choices.

“The other spouse may say that if this doesn’t change, I will exit the marriage for my own survival. Which circumstances are more important? Keeping the marriage or continuing to spend?” he asks.

Canfield doesn’t try to play the part of financial adviser to couples (although he does recommend that couples seek professional financial advice elsewhere if needed). Instead, he helps couples recognize their need to possess a clear picture of their financial situation and to develop a reasonable budget.

“It’s a matter of priorities and trade-offs,” he says. “The key as a couples counselor is to have the couple work together as a team. Most couples, when they work as a team, can find common ground.”

Canfield emphasizes that as a couples counselor, it’s not up to him to dictate how much a couple will spend on their priorities. Instead, his focus is simply on making sure that they have agreed on a plan going forward.

Once the underlying issues have been addressed, Canfield helps the couple deal with what he calls the “moral disparity” in a relationship in which infidelity has occurred. The nonoffending partner may feel like he or she has the higher moral ground, but to move forward, the couple must try to reach a “mutual amnesty,” Canfield says.

This involves a delicate balance. Canfield tries to make the couple aware that the infidelity occurred because of the underlying problems — to which they both contributed — that were straining the relationship. However, he always makes it clear that it is not the fault of the nonoffending partner that the other partner cheated. Yes, they both contributed to the relationship’s problems, but the offending partner chose to act out by having an affair.

Matters of miscommunication

Mahaffey, an associate professor of human services technology at Ohio University–Chillicothe, finds that relationship difficulties usually involve a significant degree of miscommunication, which is exacerbated by a number of factors. She helps couples understand how communication can get mixed up by explaining the pieces of a “miscommunication model” that she has devised.

Mahaffey starts by asking both partners to list all of the traits they possess that are different from their partner’s traits. She then takes these lists and draws two people facing each other. This represents two people talking, whereas the lists represent their different — and sometimes conflicting — points of view. Mahaffey often also draws a “family rule book” between the two figures. This represents how a person’s family of origin can affect the way he or she interprets interactions with a partner. Mahaffey often asks couples about their family backgrounds and experiences to illustrate the influence of the family of origin.

Mahaffey will then ask both partners to think about all the times they asked for something and didn’t receive what they wanted from their partner. As they voice these details, it’s not unusual for one partner to exclaim, “You never said that!” Typically, the case is not that either partner is lying, Mahaffey says. Rather, it’s that one of the partners has not been phrasing the requests in a way that effectively communicates what he or she needs, Mahaffey explains. She also informs the couple that humans think at about 500 words per minute but cannot speak more than 125 words per minute, meaning there is ample opportunity for the intended message to get lost.

Other complicating factors in communication include different coping styles (such as one member of the couple shutting down verbally or retreating physically or emotionally during times of stress), the fact that women often process information differently than men and the daily anxieties of life, Mahaffey says. For example, it’s hard for a couple to communicate effectively when one or both partners are stressed about finances, work or the car breaking down.

The last part of Mahaffey’s model entails explaining how words themselves — or how people define them — can get in the way. For example, Mahaffey might ask a couple, “What’s the definition of love? Is it that supper is on the table when I come home? Or liking to snuggle? Or texting 60 times a day?”

At this point, Mahaffey has the couple use “I” statements and talk about what needs they feel are being unmet. One partner might say, “I like to have help with housework.” The other partner might note that the request usually comes during a football game or while engaged in something else that he or she enjoys doing. At this point, Mahaffey might ask if the partner would be willing to provide help either before or after the game. This exercise highlights just one example of an area of possible compromise. The larger point is that the couple needs to sit down and talk about what they need from each other and how those needs can be met, Mahaffey says.

Intimate partner violence 

All counselors, but couples counselors in particular, should be looking for signs of intimate partner violence (IPV) among their clients, asserts Ryan Carlson, an ACA member and couples counselor who has done research on screening methods for IPV.

Because IPV is such a prevalent societal problem, all counselors — knowingly or unknowingly — will encounter clients who have experienced or are currently experiencing violence at the hands of their partners, Carlson says. According to data gathered in 2011 and published in 2014 by the Centers for Disease Control and Prevention, more than 1 in 4 women and more than 1 in 10 men in the United States have in their lifetime experienced sexual violence, physical violence or stalking by an intimate partner.

Providing counseling in the presence of such interpersonal violence can be dangerous, not just to the victim but also to the counselor, says Carlson, a licensed mental health counselor practicing in Columbia, South Carolina. That is a primary reason it is important for counselors to be alert to the signs of IPV and to have a protocol to follow should a client be a victim.

Perhaps the most beneficial thing counselors can do is to get connected to the people Carlson calls the “real experts” on this issue — those who work at local domestic violence shelters. “Most of what I have learned [about IPV] has come from domestic violence advocates,” he acknowledges.

Not only can these advocates help counselors assess whether it is safe to work with a couple in which IPV is a reality, but they also stand ready to assist clients who are looking for help, says Carlson, an assistant professor of counselor education at the University of South Carolina.

Carlson says he uses the term IPV because it is more inclusive than domestic violence. There is an IPV continuum, and domestic violence is on the extreme end of the spectrum, representing the most severe cases that involve, as Carlson puts it, “power and control,” as opposed to nonlethal violence or verbal abuse. From Carlson’s perspective, it is not safe to try to conduct counseling in those cases involving power and control.

Carlson advises counselors to use a formal screening tool for IPV at intake but says there are other red flags to look for, including a client’s unwillingness to take responsibility for actions. “Control over finances or transportation is [also a] red flag,” he continues. “Is one partner restricting access to cell phones, finances, the car, who the other partner can interact with? … Look for body language. Does one partner consistently look to the other when they answer questions? Is it permission seeking? Is there inconsistency in their answers? For example, as part of a meeting to determine whether or not a couple would want to participate in a research study I was doing, I asked about income. The husband gave me an answer, but when I met with the wife separately, she said the husband wasn’t really working and that she wasn’t allowed to talk about that.”

This one disparity turned out to be an indication of severe domestic violence. Carlson followed his protocol and was able to get help for the victim.

What does a protocol look like? Carlson says he has a formal memorandum of understanding with the local domestic violence shelter saying he can call at certain hours when he has a need for consultation. The memorandum also states that he will not provide identifying information about the client, only basic relevant information. This includes the presenting problem and any context he feels is important. The consultant can then advise him on whether the couple’s case might be a power-and-control situation. In those instances, Carlson must find a way to offer help to the victim without tipping off the partner who is engaging in the abuse.

With all of the couples Carlson counsels, his regular practice is to meet briefly with each individual separately at the beginning of each session. This is primarily so that he can get each partner’s point of view independently on the difficulties the couple is experiencing, but it also provides him with a chance to provide contact information for the domestic violence shelter if circumstances warrant. Carlson and the partner who is the target of the abuse may even call the shelter together.

In some cases, however, the victim of the abuse is not ready to leave the relationship. Carlson say many counselors may have a hard time relating to that. “We think we need to get the person out of the relationship immediately, but [we] need to do it safely,” he cautions

The victim has typically been living under abusive circumstances for years and may not yet have reached a crisis point, Carlson explains. Again, he uses consultation with his domestic violence resources to help him navigate this terrain. Regardless of whether the victim is ready to leave, Carlson says the average counselor should not try to continue providing services in these power-and-control cases. Telling the couple that he feels this particular modality will not work for them has proved to be a successful way of terminating treatment without escalating the problem of abuse, he says.

Lynn Linde, senior director of the ACA Center for Counseling Practice, Policy and Research, adds the caveat that counselors should make sure their states do not require them to report suspected cases of IPV under mandated reporting laws.

There are IPV cases for which Carlson thinks couples counselors are qualified to help. These involve lower lethality or “situational couple violence” (as opposed to one partner begin generally aggressive outside of the relationship as well). In such instances, a couple’s arguments may get out of hand and they may engage in behaviors such as pushing or throwing things at each other. “This can be dangerous, but it’s not as dangerous as choking or using a weapon,” Carlson says. However, he says, it is important for the couple to acknowledge that this behavior is unhealthy and to show a willingness to learn more appropriate ways to interact. It’s also essential that neither partner is afraid of the other, Carlson stresses.

In contrast, partners who engage in power-and-control tactics usually show little or no remorse and may exhibit antisocial-type behavior, Carlson explains. In fact, he says, studies have shown that when engaging in the abuse, these types of offenders typically experience a drop in heart rate rather than an escalating heart rate that is typically associated with anxiety over one’s situation or actions. Carlson also notes that whereas research indicates that men are almost always the perpetrators of power-and-control types of IPV, situational IPV is gender neutral.

None of this information constitutes a foolproof method for deciding whether it is safe for a counselor to work with a couple with a history of IPV. That’s why Carlson continues to do research on screening methods that are better at identifying the presence of violence among couples and where on the spectrum of severity that violence falls.

“Getting it wrong can be very dangerous,” Carlson concludes.

Counseling LGBTQ couples

Although the issues that bring lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) couples into counseling are generally the same as those that affect heterosexual couples, the legalization of same-sex marriage has raised some issues unique to LGBTQ relationships, say counselors who work with this population.

“There is a tremendous validation both from the legal system and from society upon their relationships,” says John T. Super, an LMFT who is also a clinical assistant professor of counselor education at the University of Florida. “This validation can provide an emotional confidence or boost surrounding a same-sex relationship that lessens the perceived stigmatization that has occurred. Additionally, since the Supreme Court decision [legalizing same-sex marriage], we have seen a large number of those in long-term relationships choosing to marry and report feeling equality to traditional marriages.”

Although the Supreme Court’s decision is a huge advancement for the LGBTQ community and has given many couples the opportunity for which they have long waited, actually getting married has not been absent of negative consequences for some couples, says Super, a member of ACA. “Clients have explained [that] when they announced their marriage … it was in many ways similar to the coming-out process in that those who are choosing to marry and are in same-sex relationships may face resistance from friends and family as they legalize the relationship,” he explains. “I have heard clients say that their friends and family accepted their relationship, but when they choose to marry, the thought of the same-sex couple entering into a legal marriage is a line the friends or family are not comfortable crossing.”

Counselors have an important role in helping same-sex couples navigate the resistance they may face when they decide to get married, agrees Joy Whitman, a past president of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling, a division of ACA. Amidst the joy of getting married, there may be feelings of hurt and loss from being rejected all over again by certain individuals or segments of society, she says. Counselors can help couples grieve and process this loss.

According to Whitman, who previously worked as a couples counselor, marriage can also exacerbate a common problem in same-sex relationships: unequal comfort levels with being “out.” Marriage can make the partner who is less “out” feel especially vulnerable, she explains.

Counselors should also be aware that for the first time, LGBTQ couples are facing divorce, Whitman says. Not only is this a new experience, but the need in many cases to stand up in court and disclose intimate relationship details can be particularly disconcerting for clients in same-sex relationships, she says.

Super and Whitman also note that counselors need to be aware of the generation gap among different LGBTQ couples. “Couples who are in their 20s experienced a very different level of social acceptance than couples in their 50s or older,” Super points out. “This generational difference can be important to understand when determining the levels of internalized oppression the individual or couple has experienced.”

Despite these issues and other issues that are specific to the LGBTQ community, Super and Whitman emphasize that couples counseling is couples counseling. Peluso, an associate professor of counselor education at Florida Atlantic University, agrees.

“In many respects, the practice of couples counseling shouldn’t change that much,” he says. “Focusing on the relationship means taking the relationship as it is created by the partners involved. The only judgment that the couples counselor is making is, ‘Is this healthy for you right now?’ and then seeing how the couple can change that. That is fairly universal.”

 

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Additional resources

To learn more about the topics addressed in this article, see the following select resources offered by the American Counseling Association.

 

Books (counseling.org/bookstore)

Podcasts (counseling.org/continuing-education/podcasts)

  • “Love and Sex and Relationships” with Erica Goodstone

Webinars (counseling.org/continuing-education/webinars)

  • “Crazy Love: Dealing With Your Partner’s Problem Personality” with W. Brad Johnson
  • “The Secrets to Surviving Infidelity” with Scott Halzman

VISTAS Online articles (counseling.org/continuing-education/vistas)

  • “Five Counseling Techniques for Increasing Attachment, Intimacy and Sexual Functioning in Couples” by Elisabeth D. Bennett, Jaleh Davari, Jeanette Perales, Annette Perales, Brock Sumner, Gurpreet Gill & Tin Weng Mak
  • “Helping Couples Reconnect: Developing Relational Competencies and Expanding Worldviews Using the Enneagram Personality Typology” by Thelma Duffey & Shane Haberstroh
  • “Loving Kindness Meditation and Couples Therapy: Healing After an Infidelity” by Laura Cunningham & Yuleisy Cardoso
  • “Supporting Same-Sex Couples in the Decision to Start a Family” by Debbie C. Sturm, Erika Metzler Sawin & Anne L. Metz
  • “Working With Intercultural Couples and Families: Exploring Cultural Dissonance to Identify Transformative Opportunities” by Cheryl L. Crippen
  • “Working With Sexual Addictions in Couples Therapy” by Sara L. Wood

Practice Briefs (counseling.org/knowledge-center/practice-briefs)

  • “Counseling Couples With a Trauma History” by Catherine J. Brack & Greg Brack

ACA Divisions

  • The International Association of Marriage and Family Counselors helps develop healthy family systems through prevention, education and therapy (see iamfconline.org).
  • The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling seeks to promote greater awareness and understanding of LGBT issues and improve standards and delivery of counseling services provided to LGBT clients and communities (see algbtic.org).

 

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

Letters to the editorct@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.

 

Behind the Book: Stepping In, Stepping Out: Creating Stepfamily Rhythm

By Bethany Bray August 30, 2016

It can take anywhere from four to seven years for a stepfamily to successfully blend, according to Joshua M. Gold in his book Stepping In, Stepping Out: Creating Stepfamily Rhythm.

The formation of a stepfamily is “uncharted water for everyone,” he says. Not only do parents and children each carry the dynamics and histories from their previous family arrangements but also face a myriad of societal stereotypes that often paint stepfamilies as dysfunctional.

“What must become clear to clinicians is that the old myths of the stepfamily drastically interfere with effective clinical understanding and therapeutic assistance to these family constellations,” writes Gold, an American Counseling Association member and professor in the Branding-Box-Stepping-in-outcounselor education program at the University of South Carolina. “Therefore, clinicians must educate themselves beyond comparisons with nuclear families to truly appreciate the unique strengths and challenges in working with a family system whose numbers are predicted to become the dominant family form in the United States in the 21st century.”

Gold is a stepparent himself and says that his “lived experience” contributes to his professional focus on stepfamily dynamics. He is also a member of the International Association of Marriage and Family Counselors, a division of the American Counseling Association, and is a contributing editorial board member of IAMFC’s journal, The Family Journal.

 

CT Online recently contacted Gold for a Q+A about his new book, which is published by the American Counseling Association.

 

In your opinion, what makes professional counselors a good fit to work with stepfamilies?

To my mind, there are several facets to being a good fit to support stepfamilies. I believe that a foundation in systems thinking is a critical part of family intervention. Each family member brings unique resources to counseling to help the family function more successfully, and the clinician must have the orientation and skills to facilitate their emergence. Implicit in that statement is a focus on a wellness model of stepfamily functioning, which entails understanding the stages of stepfamily evolution, a capacity to legitimize stepfamily struggle within a developmental, rather than pathological, context and a deep appreciation for the characteristics and dynamics of stepfamily life.

In addition, a strong clinician would be able to recognize external family members whose input is critical to stepfamily progress and be sufficiently adept to invite the stepfamily to encourage their participation in whatever mode may be feasible. I also think that sensitive clinicians understand the interaction of ethnicity and sexual orientation with stepfamily life and are prepared to embrace the stepfamily’s experience of self and of the larger society. Clinicians must be prepared in all cases to understand any personal biases or societal misperceptions about stepfamilies that may interfere with the efficacy of their interventions.

 

Your focus in this book is helping stepfamilies through the use of narrative therapy. Why did you choose that particular method? What makes narrative therapy a good fit for working with stepfamilies?

I believe that any marginalized group in society experiences definition through the social lens of dominant social structures. So, for example, in terms of family functioning, all other family constellations may be compared in membership, roles and perceived success to the nuclear family ideal. This comparison leads to perceptions of deficiency or inherent dysfunction based on oft-repeated, yet perhaps unfounded, social narratives. These perceptions focus attention not on how the family is succeeding but rather on ways in which it fails — if not soon, then sometime in the foreseeable future. This expectation of dysfunction, member unhappiness and marital dissolution may create a self-fulfilling prophecy within the stepfamily.

Narrative therapy seeks to identify and evaluate the validity of these social myths based on the lived experience of the client. By recognizing the negative lens through which the family has viewed itself, members have the opportunity to create more positive expectations of their stepfamily life and then to interact with each other reflective of those expectations.

 

It’s predicted that the stepfamily constellation will be the most common family form in the U.S. by 2020. Do you think the counseling profession, as a whole, is aware of or ready for this demographic shift?

I believe there is not an area of counseling which has not already felt this shift. For example, any school counselor could recount, just looking at a child’s folder, the new names and addresses added to the roster and the names of new individuals permitted to [interact] with the school on behalf of that child. Any family-focused clinician or mental health professional who conducts a social history of a child presenting in pain would identify the number of stepfamilies in one’s assigned caseload. I also believe that the profession’s commitment to client welfare and provision of ongoing professional development training, in multiple venues, ensure the availability of continual upgrading of clinical skill.

What becomes important, to my thinking, is whether a clinician faced with a stepfamily situation ponders the extent to which that family constellation can be activated to help the individual presenting [with] pain to overcome that life challenge. While stepfamily life may or may not contribute to the presenting issue, I am of the opinion that stepfamily members can contribute to its resolution.

 

In your experience, do stepfamilies often seek out counseling on their own, or are they more likely to come to counseling in a roundabout way, such as referral from a school counselor?

I believe that family counseling is constantly challenged to expand the focus on counseling from the identified client to the entire family. This therapeutic intent can probably best be accomplished by focusing on assignment of blame or responsibility for current stepfamily dysfunction to identifying potential resources within differing stepfamily relational schema.

This situation of “roundabout counseling” is no different in stepfamilies, except where counselors can provide resources to ongoing stepfamily support communities. Within those peer support systems, counselors can offer psychoeducational interventions on multiple levels: to stepfamilies as a whole, to the marital system, to the stepsibling system, to the involvement of ex-spouses, etc.

 

In the book, you stress the importance of combating stepfamily myths that members of a family may have. What would you want counselors to know about this? Why are myths a key part of understanding the stepfamily dynamic?

Societal myths influence stepfamily expectations and offer templates for role expectations of differing stepfamily members. However, these myths are imbued within social lore and espoused by social institutions as well as individuals. Therefore, stepfamily members are influenced subtly as to what to expect of others and of themselves within stepfamily roles.

From a clinical orientation, cognitive behavioral counseling, in general, speaks to the function of beliefs, thoughts and assumptions as precursors to action. From that perspective, interventions that seek to modify behaviors, such as conflict-resolution skills, step-parenting, marital communication training, etc., are overlooking attention to the attitudes which drive the actions. Narrative therapy encourages clients to identify, evaluate and perhaps reauthor dominant social beliefs in a way that results in more positive views of stepfamilies in general and each role within that family specifically.

More importantly, in a situation where the dominant myths seem to portray family constituents in negative lights, this process introduces the idea that the issue lies not within that individual but rather within the assumptions one holds about the role that person enacts in the stepfamily. By distancing the negative portrayal from a person to a social perception, the client can better author that perception based on real-life experience and interactions with that specific individual.

For example, stepchildren may view a new stepfather as aloof and uncaring, while the stepfather’s intent is to allow the children time and space to warm up to him. In this situation, it is easy to envision the emotional distance between them and the emergence of negative assumptions about each role. However, by transcending these social narratives about the role of “distant” stepfather and “unappreciative stepchildren,” the adult and children can begin to learn about each other’s gifts and capacities in more positive ways.

 

Do you think stepfamily dynamics receive enough focus in the education and training that people receive before becoming licensed marriage and family therapists? What do you want students and new counselors to be aware of related to working with stepfamilies?

I think that training programs are challenged to provide both generic and client-population-specific knowledge and skills. To my thinking, as clinicians encounter clients with whom they have not had previous experience, they hold a professional obligation to seek the knowledge and skills that have been found to be relevant for that specific client group. It is the purpose of post-graduation supervision to support each new clinician in expanding one’s generic knowledge and skill sets to ensure efficacious treatment of new and diverse client groups. The career-long expectation for professional development is founded in the understanding that any graduate program cannot prepare a clinician for every client situation. [It] must be augmented by individually determined specialized study to meet the clinical needs of one’s client populations.

In terms of preparation to work with stepfamilies, I would want students and new counselors to be aware of the wealth of current professional knowledge, as compared with self-help resources, and to honor that an admission of “not knowing” is not a sign of clinical unreadiness, but rather of receptivity to new learning.

 

What inspired you to write this book?

The roots of this work can be found in my clinical, personal and scholarly pursuits. I began providing counseling many years ago and was referred to a stepfamily support group to offer a psychoeducational workshop to normalize stepfamily challenges. Through working with stepfamilies as clients, I had recognized how dissimilar their family challenges were to those experienced by nuclear families, and had dedicated myself to learning what was known about stepfamilies in hopes of offering better clinical service.

Even then I intervened from a systemic perspective and saw the symptom bearer as the “voice” of family pain, requiring systemic change to allow the family to become unstuck. However, before I could intervene effectively, I needed to develop conjointly with the family an orientation toward healthy stepfamily functioning.

From personal perspective, I co-created a stepfamily over a decade ago, [composed] of two teen stepdaughters, their mother and a 6-year-old mutual child. That life experience has provided me with a reality-based template through which to evaluate my thinking and relationships as a husband, stepfather and father. That personalized learning has proven invaluable to continually reinforce the maxim that there is a gulf between theory and lived experience, and both are critical components of deeper and more profound understandings.

From a scholarly perspective, I trace my current book to my clinical experiences in my predoctoral days, my doctoral dissertation focusing on stepfamily marriages and then subsequent publications dealing with differing aspects of stepfamily life and growth. Driven by the identified failure rate of stepfamilies, plus the ongoing escalation in their numbers, I wanted to present to the profession what I hoped would be a useable and understandable treatise about how to help these families become more successful.

Finally, I hoped to contribute to the helping professions a guide for clinicians who work with stepfamilies, and for stepfamily members themselves who wish to analyze their unique family strengths and challenges.

 

 

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Stepping In, Stepping Out: Creating Stepfamily Rhythm is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222

 

 

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Stepfamily statistics

  • Approximately one-third of all weddings in the United States today create a stepfamily.
  • It’s predicted that stepfamilies will be the most common family form in the U.S. by the year 2020. An estimated 9,100 new American stepfamilies are created each week.
  • Thirty-three percent of all Americans are in a stepfamily relationship, including an estimated 10 million stepchildren under the age of 18.
  • The divorce rate for remarried and stepfamily couples varies but is at least 60 percent. At least two-thirds of stepfamily couples divorce, and divorce occurs more quickly in stepfamilies than first marriages.
  • About 46 percent of U.S. marriages today are a remarriage for one or both partners, and about 65 percent of remarriages involve children from the prior marriage, thus forming a stepfamily.
  • Four recent U.S. presidents were members of stepfamilies: Barack Obama, Bill Clinton, Ronald Reagan and Gerald Ford.

Source: Stepping In, Stepping Out: Creating Stepfamily Rhythm

 

 

 

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

 

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

 

 

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

 

Parent-child relationship problems: Treatment tools for rectification counseling

By Monika Logan December 8, 2015

As counselors, we come in contact with clients who are angry or heartbroken and oftentimes feel defeated. This sense of pain and loss is frequently realized in the forensic setting in which I work with parents who are desperate to rebuild a parent-child relationship that is severely damaged or estranged. I also work with children who assert that they never want to see or speak with one of their parents again.

SadKidThese are not parents who have abused or neglected their children. They are parents who previously had what would be characterized as a good relationship with their children — until the time of a separation or divorce. I have worked with families in which the conflict has continued for longer than 10 years prior to therapy.

It should be noted that many people in the helping professions refer to this troubled parent-child relationship as “parental alienation.” Through the years, various nomenclatures have been applied in an attempt to give this pathological post-divorce phenomenon a name. But even as we settle on what to call it, we must help these children and the counselors who work with them.

Most counselors working with children or families have witnessed this dynamic to varying degrees. There are ample articles on child alienation, yet many counselors remain conflicted about how to effectively treat these troubled parent-child relationships.

I’ll provide a case example. “Sarah” contacted me and said she had been divorced for 15 years. She told me she had been happily remarried for five years, held a doctorate degree in mathematics and was employed as a full-time professor. But she indicated she had a damaged relationship with her 15-year-old daughter, “Julie.”

In chronicling her story in my office, Sarah vacillated between sobbing and seething with anger. She said that when Julie spent time with her biological father, “Michael,” that he undermined Sarah’s parenting boundaries, spoiled Julie and used every opportunity to denigrate Sarah. Sarah went on to say that she was worried because Julie was disregarding curfews and skipping classes, had been in trouble with the juvenile court system and had recently been caught smoking marijuana.

When I contacted Michael, he presented with a jovial disposition. He stated he was engaged to be married and was employed as a plumber. He initially appeared supportive of his daughter. Although he said he didn’t see any reason that Julie might need therapy, he indicated that he wasn’t opposed.

When Julie’s therapy sessions began, she insisted that she loathed her mother because Sarah was unreasonable. Julie stated that her mother grounded her for “trivial” reasons such as skipping school and smoking marijuana. When discussing her father’s approach to parenting, Julie described Michael as a superb parent because he did not stoop to “ruining” her life. In addition, Julie mentioned that her father was planning on buying her a car. She stated that her father would talk with her and not carry out “ridiculous, over-the-top consequences for trivial, normal teenage mishaps.”

 

Treatment tips

Step one: The first step is to ask yourself if you possess the skills and advanced training to work with families engaged in transition and ongoing conflict. If not, that is OK. This is a good time to seek referrals from colleagues who are comfortable with court-connected work.

Step two: When working with parents who are separated, divorced or are in the middle of a child-custody evaluation, counselors should request a copy of the court orders prior to starting treatment with their children. Counselors should be aware that some parents “therapist shop” and are actively looking for a counselor who will tell them what they want to hear, not necessarily what is helpful. Some potential clients are searching for a counselor to align with them and join in with them about how awful their ex-spouse is. Counselors should keep in mind that failure to contact the child’s other parent may introduce a host of issues (for example, board complaints), especially if the parent seeking treatment for the child does not have the right to do so per court order. Also make certain to obtain all necessary releases before conversing with any previous counselors who have worked with the family members.

Step three: Counselors working with parents who are irrationally rejected by their children need to be well-versed in the literature. Failing to recognize and treat alienated children and their parents prolongs emotional damage for the child and can harm the entire family system.

Step four: As a counselor, you must know who the client is. Are you working with the child, the child and the parent(s), or one/both of the parents? It is vital to understand how the client ended up in your office. Additionally, your role must be clear. Are you working as a court-appointed counselor or a court-involved counselor? Recognize that in cases of child alienation, other parties — such as other counselors, attorneys or parenting coordinators — are often involved.

Step five: Know your definitions, but do not diminish your clients by labeling them. When conversing with other professionals, it is acceptable to refer to the parent to whom the child aligns as the “favored” parent. The “rejected” parent (or “target” parent) is the parent whom the child rejects or refuses to spend time with. When working with the courts, and depending on their jurisdiction, counselors may want to use behavioral descriptions, not diagnostic labels.

Counselors should remember to focus on behaviors that can be described. Although it is acceptable to discuss the concept of triangulation, gatekeeping, pathological alignment or irrational alienation with your colleagues, it is not helpful to use these terms with clients.

Step six: Do not diagnose if you have not actually met the client or witnessed the parent-child interactions. For instance, if one parent seeks your services and reports that the other parent is alienating the child and is a narcissist and/or borderline, you cannot diagnose that other parent as borderline because you have not met with or witnessed that parent.

 

Therapeutic fallacies

Richard Warshak is a world-renowned expert on parental alienation. He has written countless peer-reviewed publications on custody disputes, divorce, alienated children and stepfamilies, and has developed educational materials. Warshak recently provided strategies that can guide counselors in working with this difficult parent-child dynamic. According to a study he published earlier this year (see http://psycnet.apa.org/psycinfo/2015-27699-001/), several fallacies can compromise the therapeutic process.

  • Children never unreasonably reject the parent with whom they spend the most time. The first fallacy counselors should recognize is that more time does not necessarily equal quality time. Using rapid clinical judgment, it is easy to conclude that a child identifies with the parent whom he or she sees the most. If counselors do not recognize this fallacy, they may determine that the parent must have done something that warranted poor treatment by the child. This line of thinking contributes to additional emotional distress. In turn, under this assumption, counselors can go on the lookout for flaws within the rejected parent to substantiate their beliefs. Counselors should be aware that when a child spends time with the nonresidential parent, that parent could be using that limited time to teach the child to disrespect and disobey the custodial parent. To offset this fallacy, counselors must stop thinking in unidimensional terms.
  • Children never unreasonably reject mothers. According to Warshak’s study, “Those who believe mothers cannot be the victims of their children’s irrational rejection are predisposed to believe that children who reject their mothers have good reason for doing so.” He advises that counselors should keep an open mind about both parents and consider that mothers may be rejected without good reason.
  • Each parent contributes equally to a child’s alienation. Counselors should not generalize that both parents are always equally at fault for a child’s alienation. Counselors would not place equal blame for intimate partner violence on the victim. Likewise, it is not helpful to equally blame both parents for a child’s unwarranted rejection when one parent may be instigating the child’s actions and attitudes.

One bias that comes into play is repetition bias. Those working in the field are permeated with the term “high conflict” and may deem that parental alienation is synonymous with that term. As described by Warshak, the term high conflict “implies joint responsibility for generating conflict.”

In my practice, I developed a nuanced view. There are times when both parents contribute to and could benefit from parenting education or family therapy. However, in the case of Sarah and Michael, Michael openly defied the court’s orders, ultimately refusing to let Sarah spend time with their daughter. He also denigrated Sarah in front of the child. I would not be practicing the concept of “non-maleficence” when working with Sarah if I were to suggest that she was at fault. Demanding more of Sarah and blaming her only adds insult to injury.

As Warshak points out, “When the rejected parent’s behavior is inaccurately assumed to be a major factor in the children’s alienation, therapy proceeds in unproductive directions.” At this point, counselors may wonder, “What am I to do?” A counselor should remain neutral and avoid making unwarranted assumptions.

  • Alienation is a child’s transient, short-lived response to the parents’ separation. This fallacy is damaging because child alienation may be deemed to be a normal byproduct of divorce that will resolve on its own. Prior to going into private practice, I co-led a support group for adults who had lost all contact with their children. These cases were not due to a background of abuse or neglect; instead, many involved a contentious divorce.

Unfortunately, some counselors espouse the notion that the child should decide when to see the rejected parent and suggest that over time, the child will come around. In some cases, the child may re-establish a relationship with the parent. However, not all children reconnect. And even if they do, parents cannot reclaim lost time.

Counselors understand that they should practice within the scope of their license. In many states, counselors are prohibited from making access or possession determinations. Counselors do not have the right to supersede a court order and tell an alienated child that he or she does not have to spend time with the rejected parent. Again, it is necessary to obtain a copy of the client’s current court orders prior to starting counseling.

Another practice tip is that counselors should encourage the parent who is the target of unwarranted rejection to remain in constant contact with his or her children. Counselors can also aid parents in knowing and understanding the stages of development and helping parents to formulate proper responses to a child’s verbal insults.

  • Rejecting a parent is a healthy short-term coping mechanism. Counselors can identify this fallacy by reflecting on common biases, many which are covered in counseling programs. Counselors must be cautious about the bias of wishful thinking because it provides a false hope to clients. As Warshak (2015) explains, “Counselors who believe that rejection of a parent is a healthy adaptation encourage parents to accept the children’s negativity until the children feel ready to discard it.” He goes on to say that “this is especially true when therapists assume that the alienation is destined to be short-lived.” Although we have specialized training as counselors, it is important to remember that we cannot predict future outcomes.

Another way to think about parental rejection is to consider whether the parents would ignore their child refusing to speak to one of the parents if the whole family still resided together. Understandably, most would find this unacceptable.

  • Alienated adolescents’ stated preferences should dominate decisions. This fallacy can be offset by using analytical thinking and a basic understanding of brain development. Many adolescents know more about adult matters than we would want them to know. Regardless, adolescents are not adults and should not make adult decisions. Adolescents are prone to peer pressure and are in the process of discovering their identity. Most adults cannot imagine asking if an adolescent would like to attend school. As Warshak writes, “Adolescents’ vulnerability to external influence is why parents are wise to worry about the company their teenagers keep.”

Counselors can help rejected parents to not personalize it when a teenager has a soccer game and prefers to forego parent-child time. Or when working with a favored parent who claims the child does not enjoy time with the target parent, counselors can point out that some adolescents do not enjoy their homework, but they are expected to do it anyway.

 

Treatment goals and tips

When working with the child:

  • Promote a healthy relationship with both parents.
  • Help the child to correct cognitive distortions.
  • Work with the child to maintain a balanced view of both parents.
  • Improve the child’s critical thinking skills.
  • Recognize when a child’s behavior is incongruent from one setting to the next.
  • Augment the child’s coping skills.

When working with the rejected parent:

  • Recognize that the parent may feel misunderstood.
  • Work with the parent not to counter-reject the child.
  • Be aware of avoidance and passivity; the parent may want to escape the poor treatment of the ex-spouse and the child by avoiding the problem altogether.

When working with the favored parent:

  • Recognize there may be a role reversal. The child may be meeting the emotional needs of the parent. Help the parent recognize his or her role as a parent and encourage the parent to engage in adult relationships to find emotional support.
  • Keep an eye open for enmeshment. What might initially appear as a healthy parent-child relationship could be extremely unhealthy. For instance, there may be a lack of community or family support.
  • Recognize that children generally benefit from the involvement of parents, absence abuse or neglect. Realize that some rejected parents may have personality disorders and continue to instigate court hearings or defy court orders.

 

The do’s and don’ts

• Do not recommend a change in custody if one parent is behaving badly. Custody reversal may be necessary in some cases, but it is not the role of the counselor to make that determination.

• Do not align with one parent over the other.

• Do cooperate with parenting coordinators and the courts.

• Do recognize that parents in litigation are likely to be working toward an adult-oriented outcome — namely to prevail in court.

• Do consider a variety of explanations when working with a child or teenager who irrationally rejects a parent.

• Do not discard information that is inconsistent with the counselor’s viewpoint.

 

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Monika Logan is a licensed professional counselor living in Dallas who specializes in troubled parent-child relationships and sexual behavior problems. In addition to maintaining a private practice and doing court-connected work, she recently developed a program to help youth in the criminal justice system maintain boundaries both offline and online and stay connected with their families. Contact her at mlogan@texaspcs.org.

 

Retaining family focus

By Laurie Meyers September 23, 2015

“Rose” and “Steve” came to American Counseling Association member Laura Marshak for couples counseling because they felt they had been growing further and further apart ever since their son, “Sammy,” who was now in elementary school, had been born with cerebral palsy. Out of necessity, Retaining-family-focusSteve had become the primary breadwinner for the family, while Rose left her job to provide the extensive care that Sammy required.

Over time, Steve buried himself in his work, while Rose handled Sammy’s daily needs. She shuttled Sammy to his appointments for speech therapy, physical therapy and other specialized services and also took on the task of petitioning Sammy’s school for an Individualized Education Program. Rose felt she was doing all the heavy lifting and resented Steve because she thought he wasn’t helping enough with Sammy’s care. Steve, on the other hand, thought Rose didn’t appreciate how hard he was working to secure their financial future. Angry and resentful, they rarely spent time together as a couple, says Marshak, whose specialties include counseling parents of children with special needs as part of a group practice in Pittsburgh.

“They said it was too hard to find a qualified baby sitter who could handle their son’s medical complications,” recounts Marshak, who is also a counseling professor at Indiana University of Pennsylvania. “In reality, they did not have much to say to each other anymore and had lost an intimate connection.”

According to Marshak, the author of the recently published book Going Solo While Raising Children With Disabilities, Rose and Steve’s story is not unusual. Instead, it is an all-too-common experience shared by many other couples who have children with special needs.

As loved and wanted as these children may be, the unavoidable extra care they require can take a toll not just on parents but also on siblings and the family as a whole. When a child has special needs — whether physical, medical, intellectual, emotional or educational — parents may find it necessary to alter virtually every facet of family life. For these families, it can sometimes seem as if every resource, from time to money to even patience, are continually at risk of being exhausted. Depending on the severity of the child’s disability or special circumstance, the family may need access to intensive medical, health or other services such as occupational or speech therapy; specialized education and possibly job training; and help with daily tasks that other families may take for granted, from basic hygiene to learning and applying social skills.

Because efforts are understandably focused on navigating the day-to-day and moment-to-moment challenges of addressing their child’s special needs, another very important need can often get pushed to the side: maintaining the overall health and well-being of the individual family members and the family unit as a whole. Parents can struggle to take time for themselves while caring for their children. Marriages and partnerships can be tested or neglected. Siblings might struggle to cope with disparate levels of parental attention, feeling they have been left to face life’s challenges on their own. That’s why counselors can play such an important role in helping these families not just meet the special needs of their children, but also attain a better sense of equilibrium.

Addressing behavioral issues

Charmaine Solomon, a licensed professional counselor (LPC) and sole practitioner in Plano, Texas, says that when families of children with special needs come to see her, they are generally looking for help with the day-to-day issues. One issue that comes up frequently is discipline.

“Families with special needs children struggle to discipline in an appropriate manner,” Solomon says. “Because the child has special needs, they [the families] feel like they can’t hold them accountable.”

Solomon, a member of the Texas Counseling Association, a branch of ACA, has a now-grown son who suffered a traumatic brain injury as a child that left him disabled. This personal experience has informed her counseling practice. One of Solomon’s areas of focus is working with children and adults who have special needs such as autism and intellectual disabilities. She is also one of the founding members of My Possibilities, a continuing education day program for adults with special needs located in Plano.

Considering everything else that the parents may be struggling to manage, a child’s acting-out behaviors may seem like a relatively minor problem, particularly when the child is young, Solomon says. However, as the child gets older, this lack of discipline may become virtually unmanageable or, in some cases, even lead to violence, she notes.

Parents who focus on punishment when their child with special needs is acting out or showing aggression may find themselves locked in an escalating punishment cycle until seemingly the only solution left is to ground the child for life, says Erik Young, an LPC in West Chester, Pennsylvania. He has worked with individuals with special needs and their families for the past 20 years, including in a rehabilitation center, a life-skills training organization, a behavioral health care organization and, for the past four years, as a private practitioner. Young and his wife have also provided foster care for several children with special needs.

When parents come to Young for assistance with their children’s behavioral problems, he helps them develop a behavioral plan, which will vary according to the child’s problem behavior and capabilities. For example, many children with intellectual disabilities possess poor verbal communication skills, and their inability to communicate effectively may be part of the behavior problem, he says. Young frequently works on communication skills with the child and parents, giving the child a book or tablet device with pictures that the child can use to indicate what he or she wants.

Discipline strategies will vary from child to child, says Solomon, but should typically focus on reward and reinforcement rather than exclusively punitive measures. For example, parents should focus on what the child really enjoys, such as spending time on an iPad, and start by setting a time limit on the activity, Solomon explains. If the child displays the desired behavior, the limit will be increased, but problematic behavior will result in decreased time with the pleasurable activity, she says.

When appropriate, Young likes to use cognitive behavior therapy (CBT) to uncover what the trigger or cause of the child’s behavior problem might be. Conversely, it may be that a child’s behavior is not truly problematic but is simply angering or frustrating to the parent for some reason, so he will also use CBT to help the parent understand why. Young will then develop a behavioral plan that may include teaching the child and parents strategies for anger management, emotional regulation and so on.

Robert Jason Grant, an LPC and sole practitioner in Nixa, Missouri, also works with both the child (mainly children who are on the autism spectrum) and the child’s parents to explore factors that contribute to behavioral issues. For instance, he explains, punishment for certain behaviors isn’t successful with children who have autism because these children engage in impulsive behavior.

“[The behavior] is not thought out and may even be a surprise to the child,” says Grant, a member of ACA. “They may not even have time to think about consequences.”

Instead, Grant says, behavioral work should focus on what is causing or contributing to the problem. Because children with autism typically possess little or no ability to regulate emotions or process sensory input, emotional and sensory dysregulation are often the main contributing factors to these children’s discipline problems, he says.

“What tends to create dysregulation, and how do we change that?” Grant asks. “Is it environmental? Do we need to provide sensory breaks? … A sensory break could be something as simple and basic as a private quiet room, let’s say in school, where the child can go to be by [himself or herself], with no other people and no one coming to talk.”

Sometimes, all these children need is to “reset,” Grant says, and that can take as little as 10 minutes.

Grant also works with children and parents to tackle the dysfunction head on. He has designed a specific approach that he calls AutPlay, which is a combination of behavior and play therapy for children who have autism. The play therapy tools he uses include objects such as weighted vests, weighted balls and other sensory toys because children who are on the autism spectrum find these items soothing, he says. Parents can use these toys at home to continue the therapy, and that is important because dysregulation requires constant maintenance, he says.

The benefits of effective discipline go beyond managing specific behavioral issues, Solomon says. When parents discipline a child who has special needs, they are teaching him or her how to tell right from wrong and also how to accept instruction, she asserts. Knowing how to make decisions and how to follow instructions contribute to a child’s sense of independence, adds Solomon, who believes that parents should always be working toward increasing the child’s level of independence.

For instance, some children with special needs may require help feeding or dressing themselves beyond the age that is typical for completing those activities independently, Solomon says. Although it is often easier to continue to dress and feed a child who has difficulties, parents should keep working toward teaching the child to do these things on his or her own, she asserts. Solomon acknowledges that this process can take a little — or a lot — longer, but in many cases, she says, the child will eventually have the capability to do it. The same holds true for many other self-care and independent activities that will ultimately benefit the child, she says.

Letting children with special needs do everything they are able to do can also bolster their self-image, says Susan Stuntzner, an assistant professor in the School of Rehabilitation Services and Counseling at the University of Texas, Rio Grande Valley. On the flip side, automatically doing everything for a child who has a disability can send negative messages about his or her capabilities and value and also create a sense of learned helplessness, she says.

Family needs

As children become more self-sufficient, this generally eases the pressure on parents. But parents of children with special needs sometimes come to believe that they are the only ones who can — or should — provide adequate care for their child, Solomon says. Unfortunately, being constantly on call, and with no relief in sight, tends to only cause more problems, she says.

Young says that although families may initially come to counseling for help with a specific problem such as discipline, he also probes for any other stressors with which the family is having difficulty coping, either as a group or individually.

There really is no way to fully prepare for the needs of a child with a disability until you have to do it, he says. Families are suddenly faced with the need to obtain — among other things — health, medical and disability services, Young explains. Further complicating matters is the fact that there is no one central place to obtain services. Disability and educational assistance vary from state to state, and health and medical services are usually secured through insurance plans with varying levels of benefits, Young and Solomon point out.

In addition to coordinating outside services, parents must come up with a plan for meeting the child’s daily needs, Young says. Children with special needs may require additional help with daily activities such as getting dressed or even eating. Children with disabilities may need constant care, meaning someone has to be watching them at all times, Young adds. This means spouses and families may have to engage in tough discussions and make significant compromises. For instance, who stays home to provide care to the child? Who will be on call to take the child to any therapy that he or she might require? To address these needs, one parent will often stop working, which can creates an additional source of stress: money and finances.

Caring for a child with special needs can be a 24-hour job that many families assume they can and should engage in alone, Solomon says. But if all of the family’s time and attention is spent on taking care of the child, who is taking care of the family?

“Oftentimes, families are trying to figure out how to tend to their family member’s needs and concerns to the point that they forget they have their own set of needs,” says Stuntzner, an ACA member who also writes and speaks about living with a disability. “As a result, families … may experience personal or caregiver burnout.” In fact, if parents consistently ignore their own needs, they may eventually grow resentful of how much help their child requires, she warns.

Young works with families who are dealing with a child’s special needs or circumstances to help them recognize that they don’t have to do it alone and that resources are available to them. He points out that he, or any other counselor, can offer the family a neutral source of support — someone to talk to who doesn’t have any kind of emotional attachment or agenda but understands what the family is going through. Because Young also has connections (from his time working in a rehabilitation center and a behavioral health care organization) to state and local agencies that help provide services, he can point these families in the right direction. He even keeps a binder of business cards that he has gathered over time, based on personal or client experience, for tradespeople such as plumbers and handymen who are used to coming to homes with children with special needs and who won’t be disturbed by outbursts or other behaviors that might be regarded as outside the norm.

A system of support

When Grant works with parents of children with autism or other special needs, he always emphasizes the importance of self-care. He teaches parents how to conduct a self-care inventory so they will start actively thinking about caring for themselves.

Encouraging family members to engage in self-care sometimes requires a shift in perspective. For instance, self-care can mean something as small as taking a few moments during the day to indulge in something the individual really enjoys, Young notes. “Instead of a week on the beach — because that’s probably not going to happen — what can they do during the day? [It’s] just little moments that can be refreshing,” he says.

When a child is born with special needs, becomes disabled or is diagnosed with a disorder, Young says, it is common for extended family members and friends to draw back at first, often because they feel like outsiders and aren’t sure what they can do to help. So Young encourages families who have a child with special needs to actively reach out to others, explaining that maintaining a solid social network is crucial for both emotional and practical support.

“I often take my clients through the process of listing all potential resource people — no matter how disconnected — and talk about what they might be able to contribute,” he explains. “Then we go about ‘recruiting’ them so to speak. Find ways to utilize their talents and, thus, spread the stress. People generally want to help when they can. They may just need guidance.”

That’s why Young tells these families to let their networks know what they need specifically. “Take an executive role. You are president,” Young urges his clients. “These people are your Cabinet, your advisers. Make sure you’re getting them to do what you want.”

With a support network, parents can also build a system of respite care. Once a child is used to being with a caregiver, the parents can take breaks, possibly even getting away for a day trip or weekend vacation, Solomon says.

Sometimes families won’t seek any kind of support because they feel ashamed of their struggles, Solomon says. Rather than isolate themselves further, she encourages these clients to seek out others families of children with special needs. She suggests that parents contact local mental health agencies to find support networks.

Young says that lately he has been providing more couples counseling than family counseling because the primary issue for many of his families who are dealing with special needs is actually a problem with the parents’ marriage or partnership. The stress of caring for a child with special needs can take a particular toll on a couple’s relationship, he points out.

Solomon agrees, noting that respite care isn’t just important for parents as individuals but also as a couple. When providing focused care to a child with special needs, it can be particularly challenging to find the time or the energy to just be a couple, she says. Identifying someone who can provide caregiver support can allow couples to take much-needed time for date nights or even a short trip, she adds.

Parenting styles can also drive a wedge between couples who are caring for a child with special needs, says Young, who uses talk therapy with couples. If parents can’t agree on how best to care for or discipline their child, it creates a continual source of conflict, he says. Young helps couples learn to communicate with each other about what they want and need and how best to compromise, if needed.

“I like to use a variety of techniques that hone active listening and clear communication skills and trust,” he says. “One favorite technique I learned at an attachment therapy conference is to have the couple sit in chairs facing each other. One person communicates a brief statement, then the other person has to repeat it back. Then they switch roles. Even this simple exercise can highlight when assumptions are being made and communication is being blocked.”

Young also specifically addresses differing parenting styles with couples, such as when one partner is more authoritarian and the other is more nurturing. He works with these couples to develop a joint parenting style that is balanced — both authoritative and nurturing.

Young also works with the parents in session to practice planning for specific concerns. He asks them to think about how they were raised and how that influences the way they parent today. This exercise helps to spur conversations that can uncover differences in the way they view parenting, he says. Young then helps the couple to negotiate these differences.

Sometimes it’s not parenting style — but substance — that causes the problem. Solomon says disparate distribution of parental responsibility is often a source of tension in families managing special needs. She regularly sees mothers who take all the responsibility for caregiving — either by choice or necessity — which leaves little time for other relationships. Solomon tells her clients that parents need to share responsibility. For example, when possible, fathers should take a turn accompanying the child to therapy. If the mother is the sole caregiver during the day, the father should give her a break by taking on extra duties at night.

Marshak’s couple, Rose and Steve, offered an example of disparate responsibilities — or at least that was how it appeared to Rose. With Marshak’s help, the couple began to discuss the underlying tensions and motivations that had led them to their crisis point.

When Sammy was first born, Rose was deeply depressed and wanted to talk about her grief with Steve, explains Marshak, who co-authored the 2007 book Married With Special Needs Children: A Couple’s Guide to Keeping Connected with Fran Prezant, a speech and language pathologist and researcher on disability issues. Steve, however, preferred to avoid discussion and bury himself in his work. Rose thought Steve’s silence meant that he didn’t care about her or Sammy, but focusing on work and providing for his family was actually Steve’s coping mechanism to deal with his grief. As time passed, Rose spent her time learning as much as she could about cerebral palsy and seeking support through a network of other mothers who had children with the disease. Steve worried constantly about how to financially support his family in the present and how to make sure there would be money for his son in the future in case Sammy couldn’t support himself. So Steve worked even harder.

Guided by Marshak, the couple discussed all of these issues in counseling. Rose began to understand that work was Steve’s way of coping with his feelings of grief and worry and that even though he wasn’t sharing his grief verbally, that didn’t mean he wasn’t hurting. Steve learned to become more expressive with his feelings.

Rose and Steve also worked to re-establish their romantic connection by going out as a couple again and trying to view each other as the individuals with whom they had fallen in love — not just as Sammy’s parents, Marshak says. Over time, as they re-established their bond as a couple, they also started to adjust their roles, including sharing more of the responsibilities related to Sammy’s educational and medical needs. Rose even resumed some of the leisure activities she had given up when she felt she was solely responsible for Sammy’s care.

Speaking to siblings

When working with a family who has a child with special needs, it is also important for counselors to take time to focus on the needs of family members who may get overlooked, or at least feel like they are overlooked — siblings.

Grant sometimes works with siblings on their own so they will know they have an outlet for their struggles and frustrations. “One of the biggest challenges [for siblings of a child with special needs] is the feeling of having to take a step back, of giving up things for their sibling,” he says.

Out of necessity, the child with special needs is the family’s biggest area of focus. To the child’s siblings, this circumstance can seem not only unfair but also as if the parents are choosing to favor the child with the disability or special needs, Grant adds.

When Solomon’s son who is disabled was a child, his siblings struggled with feeling forgotten. “I had to teach my [other] sons the difference between ‘have to’ and ‘want to,’” she recalls. Solomon sat down with her sons and explained that it wasn’t a matter of wanting to spend less time with them but rather that their brother needed more of her time.

As the siblings of a child with special needs get older, they may also start to worry about or feel responsible for their brother or sister, Grant says. He regularly teaches siblings games that they can play with their brother or sister who has special needs that will help the child to cultivate specific skills. One such game is called Social Skills Fortune Tellers.

Grant teaches the “neurotypical” sibling — the fortune teller — how to make an origami structure with tented triangles that can be manipulated with the fingers so that different sides or flaps of the triangle show. Each flap holds a social skill to practice. The fortune teller manipulates the origami and reveals a skill, which the siblings then practice, Grant explains. As an alternative, the origami can also be used for emotions, he says. When a particular emotion is revealed, both the neurotypical sibling and the sibling with special needs can share a time when they felt that particular emotion or make a face that demonstrates that feeling.

Grant also uses family play therapy techniques to allow siblings — and all family members — to express how they are feeling or what they are thinking about issues such as how autism is affecting the family or how the parents are parenting. One technique is called “color my feelings.” Each family member uses a white piece of paper with a heart drawn on it. The family members color the hearts with whatever color best represents their feelings, he explains. The family members then share their hearts, allowing everyone an opportunity to talk about the feelings they are having and why they are experiencing those feelings.

Lifelong support

It is painful to contemplate, but there will come a time when the parents are no longer there to help their child with special needs, Solomon says. That is why she is adamant about encouraging her clients to plan for that future now.

Solomon tells parents that they need to consider questions such as: Who will take care of the child? What services will the child need? Where will the child live? Where will the money to pay for the child’s needs come from?

She helps parents learn what guardianship is and urges them to start planning immediately for the lifelong financial needs related to providing for someone with a disability. Solomon also notes that it is important for parents to apply for disability services well ahead of time. Once a child graduates, he or she loses any benefits, such as ongoing speech therapy, that the child’s school provides, she points out. Solomon adds that in Texas, there is currently a 12-year waiting list for state services.

Young also helps families come to grips with the reality of planning for a child’s ongoing support once the parents are gone or are no longer able, for health or other reasons, to continue providing care. Although he acknowledges it is a difficult conversation to have, he sits down with families and helps them develop a long-term plan by investigating options such as sheltered workshops and group homes. Young also emphasizes the wisdom of financial planning with insurance agencies that specialize in estate planning and special needs trusts.

From Solomon’s perspective, this planning process also comes back to encouraging children with special needs to develop as much independence as possible and teaching them skills to help prepare them for the future, just as parents do with any child.

“Just like with another child [without special needs], you ask, ‘Have you done your homework? Practiced your instrument?’ With the child with special needs it’s, ‘Did you practice doing your buttons? Did you take a shower?’” she says. It’s still homework, she adds, but homework of a different sort.

Young says it is important for counselors to empathize with parents about the challenges of raising a child with special needs. At the same time, he encourages parents to let go of the idea of what “could have been” and instead embrace the child that they have because each child with special needs also has his or her own beautiful gifts.

Stuntzner, who is also a member of the American Rehabilitation Counseling Association, agrees. “Coping well does not mean the family has not felt or experienced negatives or difficulties,” she says. “Rather, it is an indication that through the experience of a loved one’s disability, they have found a way to work with the situation so that it brings the family together instead of pulling it apart.”

 

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Additional resources

The American Rehabilitation Counseling Association, a division of the American Counseling Association, is an organization of rehabilitation counseling practitioners, educators and students who are concerned with enhancing the development of people with disabilities throughout their life span and in promoting excellence in the rehabilitation counseling profession’s practice, research, consultation and professional development. To learn more, go to the ARCA website at arcaweb.org.

The International Association of Marriage and Family Counselors, also a division of ACA, is an organization whose members help develop healthy family systems through prevention, education and therapy. For more information, visit iamfconline.org.

Other resources include:

  • “Disability Awareness,” an ACA podcast presented by Robbin Miller. To access the podcast, go to the Knowledge Center section of ACA’s website (counseling.org) and click on “Podcasts.”
  • Yes You Can!: Art-Centered Therapy for People With Disabilities, an ACA DVD presented by Judith A. Rubin. To purchase the DVD, go to the ACA bookstore (counseling.org/publications/bookstore).
  • “Autism Spectrum Disorder,” an ACA Practice Brief written by Carl J. Sheperis, Darrel Mohr and Rachael Ammons. To access this brief, go to the Knowledge Center section of ACA’s website (counseling.org), click on the “Center for Counseling Practice, Policy and Research” and then “Practice Briefs.”

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To contact the individuals interviewed for this article, email:

 

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

Letters to the editor: ct@counseling.org

Empty crib, broken heart

By Bethany Bray September 22, 2015

This past summer, Facebook CEO Mark Zuckerberg and his wife, pediatrician Priscilla Chan, announced that they are expecting a baby. This celebrity baby news grabbed headlines for a different reason than most, however. The couple’s announcement included a candid acknowledgment that they had been trying to have a baby for several years and had suffered three miscarriages along the way.

“It’s a lonely experience,” Zuckerberg wrote in a July Facebook post. “Most people don’t discuss miscarriages because you worry your problems will distance you or reflect upon you — as if you’re defective or did something to cause this. So you struggle on your own. … We hope that sharing our Empty-crib-broken-heartexperience will give more people the same hope we felt and will help more people feel comfortable sharing their stories as well.”

Zuckerberg and Chan’s post resonated with millions of people (witness the post’s 1.7 million “likes,” nearly 112,000 comments and 49,000-plus shares as of the end of August) and helped raise the curtain on some painful yet common issues that are rarely talked about openly.

Although many people who face miscarriage and infertility feel alone or isolated, statistics show the circumstances are much more common than people may think. Miscarriage, defined as the loss of a pregnancy before 20 weeks, occurs in 15 percent of known pregnancies, according to the American Congress of Obstetricians and Gynecologists. The U.S. Centers for Disease Control and Prevention reports that about 12 percent of women ages 15 to 44 have “difficulty getting pregnant or carrying a pregnancy to term,” while an estimated 7.4 million women in that same age bracket have used fertility services.

“Trying to make sense of it all is really, really challenging. The depth of the pain and the challenges you go through are hard to put into words,” says Kristin Douglas, a licensed professional clinical counselor and American Counseling Association member in Kentucky who has personal experience with infertility and multiple miscarriage losses. “You don’t ‘get over’ these kinds of losses. You work through them, but you don’t get over them.”

Mourning what might have been

A person or couple can’t help but think about the future, even if cautiously, after a fertility treatment or positive pregnancy test. Considerations from possible baby names to how the mother might be “showing” by a certain month naturally spring to mind.

“When that is taken away” — either through miscarriage or an unsuccessful fertility treatment — “you’re not grieving the past, you’re grieving what was going to be. You’re grieving the future,” says Valorie Thomas, a licensed marriage and family therapist and licensed mental health counselor in Florida. “With pregnancy loss and infertility, each time it doesn’t happen, you’re grieving … for all the ways you were thinking it was going to be. Helping the client to see that can be eye-opening — acknowledging that it’s real, it’s a loss [and] it’s gut-wrenchingly painful.”

Thomas knows this pain firsthand. She has been pregnant 10 times, but only one — her sixth pregnancy, a now 16-year-old son — was carried full term. Thomas and her husband also have a 7-year-old daughter whom they adopted.

Unlike when other family members, friends or acquaintances die, miscarriage and infertility can leave clients without memories to grieve. Often, people don’t even realize that they have the right to grieve, says Thomas, an ACA member who has a small private practice and is an adjunct professor at Rollins College in Winter Park, Florida. It’s the type of loss “that’s hard to understand,” she says. “You [typically] think of a loss as something that was already here, and you’re grieving it [no longer being here].”

With fertility treatment, she says, “You get the call from the doctors saying, ‘The pregnancy test was negative, we’ll see you next month,’ and they hang up,” leaving the individual or couple reeling with a flood of emotions, from anger and frustration to sadness and embarrassment.

Clients who are struggling with infertility or grieving a miscarriage can present with a range of issues in a counselor’s office. Depression, anxiety and intense stress are very common, Douglas says, as are feelings of guilt, anger, disappointment, frustration and fear. It is also possible for these clients to wrestle with trauma symptoms associated with their loss, she says.

It is not uncommon for couples or individuals to have experienced both infertility and miscarriage. Miscarriage, or “the inability to carry a pregnancy to term,” may be part of the infertility experience, Thomas says. But even when there is no overlap, couples who experience a miscarriage may share some of the same emotional responses as those who are having difficulty conceiving, she says, including a sense of helplessness, desperation and loss of control.

Because miscarriage and infertility can be taboo subjects, clients may not realize that they can — and should — acknowledge a pregnancy loss. For example, Thomas says, perhaps a client feels “down” every autumn but doesn’t know why. It could be that she experienced a miscarriage years or even decades ago during the fall that she never processed.

Professional counselors can provide help and support in a variety of ways to those who have experienced infertility or miscarriage. This might include helping clients work through the pain and stress of disappointment, self-doubt and even family or cultural expectations. It might also encompass encouraging these clients to practice self-care and teaching them coping mechanisms to help them get through the bad days.

Above all, counselors must familiarize themselves with infertility and reproductive issues if they are going to be sensitive and effective helpers for these clients, says Ebru Buluc-Halper, a mental health counseling graduate student at Pace University who runs a support group for couples and individuals going through infertility.

“If [a counselor] doesn’t know what they’re talking about, it’s a huge turnoff,” says Buluc-Halper, an ACA member who led a poster session on multicultural considerations in infertility counseling at ACA’s 2015 Conference & Expo in Orlando, Florida. She has friends “who were very frustrated by [a therapist’s] lack of knowledge and were turned off from therapy because they wanted to be understood. It doesn’t happen to everyone, but it does happen.”

“People want to be heard and want someone to talk to,” says Buluc-Halper, who has personal experience with miscarriage and fertility treatment. “They are deeply in need of empathy and understanding, which they’re not getting from the people around them, sometimes even from their partners.”

Counselors who don’t understand miscarriage and infertility — at the very least possessing a basic knowledge of the processes, terminology and biological factors surrounding these issues — risk reinjuring and alienating clients, agrees Douglas, an assistant professor of counselor education and coordinator of the counseling clinic at Murray State University in Kentucky. People who disclose their miscarriage or infertility struggles are often subject to the well-meaning but hurtful comments and assumptions of others, she says. Among the statements that are common: “If you just relax and de-stress, you’ll get pregnant”; “Just give it time, it will happen”; “At least you weren’t that far along to get attached”; “Maybe you should just adopt”; and “Maybe it’s not in your cards.” Comments such as these are often completely untrue and very upsetting to the receiver, says Douglas, who wrote her doctoral dissertation on miscarriage at the University of Wyoming.

“The last thing a person wants is to talk to a counselor who is going to say some insensitive and hurtful things in response to what that person experienced,” Douglas says. “There is a fear of what a counselor might say. Are they going to say the insensitive things that everyone else says? Things that are so hurtful or that minimize the loss?”

Handle with care

One of the most important things counselors can keep in mind is that no two clients’ experiences are the same, says Courtney Armstrong, an ACA member with a private practice in Chattanooga, Tennessee. Each client will attach a different meaning to what she or he is going through.

“Everyone’s experience with infertility is different. You can’t just make assumptions,” says Armstrong, a licensed professional counselor who accepts client referrals from a fertility clinic in her area. “You have to respect that it’s a process for people to come to terms with their infertility. It’s not something you can help them reason their way out of. You have to treat each person individually because every person is going to respond in a different way.”

Counseling and therapy must also be individualized in cases of miscarriage. Douglas says she finds it much easier to talk about her first miscarriage, which involved triplets, than her second, which was a single baby. “People would never compare the death of a sibling or a parent to that of an uncle or other relative,” Douglas says, “but somehow, [people] just lump all the miscarriages together. Each failed fertility treatment is not the same either.”

There is no one-size-fits-all way to address a client’s infertility or miscarriage in counseling, agrees Thomas. “It’s important that the counselor be aware [of] spirituality and traditions and culture. Your clients are bringing all of that to you,” she says. “You can’t just [use] a cookie-cutter approach.”

Thomas terms miscarriage a “silent sorrow,” saying that the loss typically goes unacknowledged by society. Too often, she says, the message that women who have experienced miscarriage receive is: “Get over it. You’ll be fine. Don’t worry about it.”

“But depending on your spiritual beliefs, depending on what that meant to you at the time, what it signified, what does family mean to you, what does creating a family [mean to you], how bad you wanted it — all those things play into your reaction,” Thomas says.

Paying careful attention to the language the client uses can provide counselors clues about how the person is processing the loss, she says. For example, does the client say, “I was 10 weeks pregnant, and I lost the baby,” or does she use another word? If the client or couple isn’t ready to use the word “baby,” the counselor shouldn’t refer to the pregnancy that way either, Thomas advises.

After going through pregnancy loss and several rounds of in vitro fertilization, Armstrong and her husband made the choice to be child free. Making that conscious decision was empowering, she says. “The choice piece is the really important part — deciding if this is the best and right thing for me,” she explains.

Likewise, Armstrong says, in counseling it can be empowering for clients to find meaning and realize they still have the ability to make choices in an unwanted situation. Wanting to be a parent and wanting to be pregnant are two different things, and helping clients to uncouple those two concepts in their mind can be helpful, she says.

“If they’re going to explore infertility treatment, adoption or other options, is this about having a child or having a child that’s biologically connected to you? The most important thing is that they feel they have the freedom to make a choice,” she says.

Thomas’ experience with infertility caused her to rethink the assumptions she’d held growing up in a Catholic family with nine brothers and sisters. “In my family, it was just assumed we’d all have large families,” she says. “When that didn’t happen for me, I had to revisit [that] and ask myself if I’d be OK if that didn’t happen. Then I came to grips [with the realization] that you can create family in different ways. It was OK that I had other parts of myself to be a whole person. I realized that it may be different for me.”

How to help

Heartbreak can accompany miscarriage and infertility. But so can hope and healing. Here are a few ways counselors can help clients who are processing these experiences.

Storytelling and narrative therapy: Two of the most important things counselors can provide to these clients are a listening ear and empathy. “It’s just so important to listen to their story, really listen to their story,” Thomas says. “Every one of them is so different. Each one has a different journey. Listen compassionately and really be present.”

Douglas recommends inviting clients, but not pressuring them, to talk about their loss experiences, such as where they were and how they felt when they learned they were pregnant, what it was like to be pregnant, what happened during their miscarriage and what feelings they had when they learned their pregnancy was over.

“Just like with other types of trauma, you want to be sensitive to not retraumatize clients by having them share their story over and over again,” she says. “But at the same time, if clients feel it would be healing to share their story, invite them to share it and process it as many times as they feel they need to. It can be healing to remember, to talk it through, to process these things with other people, especially if clients did not feel their loss was acknowledged or if they did not have the opportunity to share their story in full with anyone.”

This hit home for Douglas as she wrote the narrative of her first miscarriage for her doctoral dissertation. It was the first time she had written out the entire story, start to finish, she says. Afterward, she read the four-page narrative aloud to her own counselor in a therapy session. “It was such a powerful moment. I just sobbed and sobbed as I read it,” Douglas says. “It was then that I realized I had shared my story with lots of different people but never the whole thing beginning to end — only parts. That was huge for me. I had a further glimpse into the power of story, the power of vulnerability, the power of giving voice to nebulous experiences and the power of validation. Sharing my story beginning to end was emotional but very healing.”

The empty chair approach: This Gestalt technique can be helpful for processing “unfinished business” — something all too common for those who have had a miscarriage, according to Douglas. Counselors might ask clients to speak to an empty chair as if their child who was miscarried were sitting there. Or use the empty chair to have clients speak to whomever they need to — perhaps a co-worker who made an insensitive comment or a doctor who came across as callous, sterile or impersonal. The empty chair can also provide a means for clients to speak to their deity, even venting frustration or another emotion.

“This can be a way to give the client a voice or provide a degree of closure,” Douglas says. “It not only helps clients work through complex feelings as they process lost hopes, dreams and frustrations, but also helps them have an important, needed voice.”

Journaling and letter writing: Writing a letter can provide clients an outlet to tell their miscarried baby that they miss and love the child. Similarly, clients can write themselves a letter from the baby, Thomas says.

“At some point when they’re ready, have the client write a letter from the baby to the parents. They can say, ‘I’m still here. I love you.’ That’s very healing, but it shouldn’t be done right away,” Thomas warns. “It takes time. [The parents] have to be ready for that.”

Creating a journal can also help clients process a pregnancy loss by encouraging them to explore the loss and what it meant to them, Thomas says. Each experience will be different, whether it is the client’s first miscarriage or third, whether the client already has children at home, whether it was an unplanned pregnancy and so on.

Expressive arts and other creative therapies: Douglas displayed copies of some of the pastel chalk drawings she created as part of her own way of coping with her miscarriage loss when she co-presented a session at the ACA Conference in Charlotte, North Carolina, in 2009.

She advises counselors to pay attention to their clients’ creative interests and incorporate those interests into the therapeutic process, if appropriate. For example, if the client likes to garden, planting a tree in honor of a child who was miscarried might be healing for the client. If the client has a flair for design, perhaps she could design a bracelet with charms that represent the pregnancy. Douglas finds that expressive arts or other creative therapies not only help clients work through challenges associated with their loss, but also assist in making the intangible tangible.

Douglas had one client who enjoyed scrapbooking. Creating scrapbook pages became her version of a journal and helped her find meaning in the miscarriage she had suffered. Scrapbooks or other creative projects can include ultrasound images, hospital bracelets, photos of baby gifts that were received or a narrative written by the client about what it felt like to find out she was pregnant.

“One of the challenges of miscarriage is the intangibility,” Douglas says. “When you have such few items, those ‘artifacts’ such as an ultrasound photo become very important in validating your experience and your loss. You cling to those things.”

Mind-body and wellness approaches: Thomas says mind-body approaches such as yoga, relaxation techniques, meditation, deep breathing, guided imagery and repeated prayer can be helpful to clients who have experienced miscarriage or infertility. In one case, Thomas used guided imagery with a client before her fertility treatment, instructing her to envision that her grandfather, who had passed away, would be with her to support her throughout the procedure.

In addition, encouraging clients to pursue a wellness lifestyle, including eating healthy food, exercising regularly and getting enough sleep, can be helpful, both because of the health benefits provided and because it gives clients a new area of focus. Spending time on healthy cooking, for example, can divert a client’s energy and focus away from frustrated or anxious thoughts. Assure clients that they are working to be “in the best place they can be to ride this roller coaster,” Thomas says. The thought becomes: “I am doing the best I can to make my body healthy so I have a chance of conceiving.”

Encouraging clients in the practice of self-nurturance, such as taking 30 minutes each day to do something they really enjoy, can also help refocus their energy away from the stress of fertility treatments. Thomas instructs clients to think of 10 things that they enjoy doing and that make them happy. Then she asks clients, “How many of these things are you doing? You’re allowed to enjoy things during this time. Look for ways to enjoy yourself.”

Developing signals: Sometimes social situations can be overwhelming for individuals who are going through infertility or who have experienced a miscarriage. Buluc-Halper and Douglas both suggest that counselors have these clients develop a signal to let their partners or trusted friends know when they need to change the subject or take a break during social gatherings.

But clients also need to be realistic about what they can and cannot handle, Buluc-Halper says. “Going through this experience is a good time in your life to put yourself first,” she says. “[When] you’re expected to show up at a dinner or a baby shower and you emotionally, truly, cannot handle it, it’s OK to put yourself first and say, ‘It’s not a good day for me.’ Put yourself in touch with what you’re feeling. You’re in such a fragile state. There are days when you wake up and you know that you can’t go, and others when you are strong enough.”

Externalize the problem: Buluc-Halper suggests that counselors help clients remove the word infertile from their vocabulary. Infertility is not their identity, she explains. “We don’t say, ‘I’m cancer.’ We say, ‘I have cancer,’” she says. “Infertility doesn’t define them. It’s just part of their journey. Finding a way to externalize that does make it easier to go to the dinner, the family gathering, the baby shower, [knowing] this is just part of my journey. Everybody will go through something in their lives, and this [infertility] is one of the things that we just happen to be going through. … Everybody will find some sort of resolution, whatever that may be. As in every experience, there will be a resolution. It might not be the resolution you envision, but you will find some kind of closure.”

The trusted friend: When clients are hesitant to tell family and friends about what they are going through, Buluc-Halper suggests that they pick one person, such as their mother or a favorite sister or cousin, to confide in. Ideally that person should be able to serve as a buffer when awkward or painful subjects or questions are raised at family or social gatherings. In Douglas’ case, she had a trusted friend who would intercept baby shower invitations for her, knowing she wasn’t ready to face such a baby-focused event.

A cultural perspective: A client’s cultural background can play a huge role in how that person views and deals with miscarriage or infertility. At the same time, counselors should never assume that individual clients will experience these issues within the cultural norms of their respective backgrounds, Buluc-Halper says. Doing a cultural genogram with clients can help counselors get a better idea of the role that cultural background plays in a person’s life, she says.

Thomas agrees, noting that she asks clients about their spirituality and family of origin at intake.

“The very, very important part for all counselors to remember when working with infertility clients from a cultural perspective is to be very aware of their own cultural biases,” Buluc-Halper says. “Be cognizant not to distort the couple’s experience based on how you assume that culture perceives infertility in terms of its ideologies, in terms of its experiences or in terms of the resolution. … They might not be experiencing infertility the same way you might expect them to based on their cultural background.”

Taking a break: For clients who are going through fertility treatments, each stage brings a series of decisions and procedures that can be exhausting, Armstrong says. Counselors can offer their clients reassurance that if they decide to take a break from treatments, it doesn’t mean they are giving up,Empty-crib-broken-heart-small she says. “Maybe take a month off, regroup and then go on to the next stage [of fertility treatment]. Tell them, ‘You’re not giving up. You’re just backing off for a minute to get some perspective and come back,’” Armstrong says.

Internet forums: Numerous websites and online forums are available for people going through infertility and reproductive issues. Although these sites provide helpful information and a way to connect with and find support from other people facing similar issues, the sites can also cause clients to spend more time focusing on issues that cause them anxiety, stress or sadness.

In Armstrong’s case, she stopped visiting online forums while she was undergoing in vitro fertilization because they were provoking her anxiety. Although such forums can offer support in many situations, Armstrong found they could also act as a platform to swap “horror stories” or misinformation. “Some people find them very helpful, while others find it makes them feel worse,” she says. “It helps them know that they’re not alone, but there can also be a risk because it can make them more worried.”

If online forums don’t appear to be serving clients’ best interests, counselors can suggest that they take a break and attend in-person support groups instead. Support groups, whether online or in person, can play an integral role in breaking through the isolation that often accompanies experiences of miscarriage and infertility, Buluc-Halper adds.

Grief: Douglas theorizes that women grieve miscarriage loss developmentally. “This is a life that would have been,” she explains, “and you will most likely grieve in different ways and different stages for what that child would have been like [as it aged]” — such as when the child would have started walking and talking or when the child would have started kindergarten. Missed milestones may be extra emotional as time passes. As a result, grief may resurface over and over again, but in different ways, complicating the healing process, Douglas says.

Anniversaries: In cases of miscarriage, multiple dates can be painful, such as the day the couple found out they were expecting, the baby’s due date, the date they lost the pregnancy and so on. Counselors might suggest that clients engage in extra self-care on those anniversaries or commemorate the dates with rituals such as playing a meaningful song, lighting a candle or sending up a helium balloon with a letter inside to their miscarried child, Douglas says.

Control: One of the most difficult aspects of dealing with infertility or miscarriage for clients is accepting that what has happened or is happening is largely out of their control. “A lot of people blame themselves and think, ‘I’m not doing enough or could be doing things differently,’” Armstrong says.

In cases of infertility, some clients will do things to try to take control of the situation, such as cutting gluten out of their diets or taking their temperature daily. Counselors need to be sensitive to the fact that these clients may have devoted a lot of time and energy to finding different methods that might increase their chances of conception, Armstrong says. If the methods are giving them more confidence or security about their situation, that can be good, Armstrong says, but if the methods are only serving to make clients blame themselves further, that can be harmful. “Be mindful and aware of helping clients find what makes sense and what may not be influencing whether or not they get pregnant,” she says.

In cases of miscarriage, Armstrong says she most often points to biology with clients. The human body is designed to abort a pregnancy that could be harmful, she says. “I really try and bring it back [to the fact] that we don’t understand all the reasons why [women miscarry], but it’s purely biological,” she says.

Offering hope: Individuals receive very straightforward — and sometimes upsetting — information from medical doctors about their infertility, including the slim percentage they may have of getting pregnant or the complications that could happen as a result, Thomas says.

On the other side of that coin, a counselor’s focus on the positive can provide clients an antidote to discouragement, she says. “Hope is such a big factor. … Put [clients] back in charge of their life,” she advises. “Offer hope that there are some coping strategies [available and that the client is] a normal person responding to the struggles of creating a family. [Tell them], ‘You need to give yourself permission to be angry and cry. … Keep the faith. If you want a family, it will happen. It may just not be the way you envisioned.’”

Couples: It takes two

Spouses or significant others will naturally deal with miscarriage or infertility in different ways and process things at different rates. In fact, it is common for a counselor to see relationship partners who are in two very different states emotionally, Armstrong says. One partner may have already accepted what has happened, while the other is still in a bargaining stage, thinking, “Surely there is something we can do” to change the situation, Armstrong says.

Counselors can help by educating couples that the grief that accompanies a miscarriage or infertility will come in waves and that each partner is likely to be at a different point along the grief spectrum. Once couples understand that it is natural to feel differently about what they are experiencing, they often express a sense of solace, Armstrong says.

“They’re relieved [because] they don’t see themselves in conflict, just at different stages in the process. Then they can understand and be more patient with each other,” she says. “Help them understand that they’re in different stages and how to communicate and best support each other” wherever they are in the process.

Differences in spirituality level or religious background can threaten to divide a couple during a miscarriage, notes Thomas. For example, one partner may consider a miscarried baby to have a soul, while the other does not.

“Spirituality can be very healing or create a lot of conflict if they’re coming from different perspectives,” Thomas says. “One may feel it’s ridiculous to grieve, while the other feels it’s necessary. Work with them to be respectful of each [other’s perspective].”

It can be helpful for counselors to suggest that a female client bring her partner to medical and therapy appointments when possible, Buluc-Halper says. It is important that the client learn to rely on her partner for support throughout the entire process, not just during times of extreme anxiety, she points out.

“Partners don’t always understand how all-consuming this [infertility] experience is,” Buluc-Halper says. “You’re the one that is doing blood work, and your arm is purple from all the injections. It’s not to diminish the male experience of this, but they don’t always understand why the female can’t really detach herself from the issue.”

As important as empathy is for counselors, it is equally important to teach that skill to couples, Thomas says. She often has couples hold hands as they tell each other what the miscarriage journey has been like for them. The counselor is there to assure both partners that whatever they are feeling is valid, real and quite possibly intense, Thomas says.

“Give them a safe place to explore what this has been like for them — sometimes for the first time,” Thomas says. “What does that loss mean to them? [They are] really seeing each other describe what happened and how they’re feeling right now. Because they grieve differently, it’s important to validate their experience and [explain] that it may trigger some previous losses and intensity that might scare them.”

“With infertility, they can get stuck and not want to move on if they’ve had a pregnancy loss and not really grieved it,” she says. “They need to slow down and experience what they need to experience before they go on to the next step.”

Breaking the silence

By inviting conversations about miscarriage and infertility, counselors can play an important role in removing the stigma and isolation that surround these issues. Douglas cites the example of breast cancer, a once-taboo subject that is now openly talked about and advocated for with well-publicized campaigns and fundraisers.

“Invite the conversation and break the silence,” Douglas says. “Help give women and men permission to grieve miscarriage losses and give voice to those losses. Give them a safe, nonjudgmental place to share their stories. Invite those stories. Take time to listen to those stories over and over again, as many times as people need.”

 

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For more information

  • Valorie Thomas will be presenting two sessions on these topics at the 2016 ACA Conference & Expo in Montréal. Thomas’ sessions are titled “Creating Rituals for Couples Experiencing Early Pregnancy Loss” and “A Mind/Body Approach for Struggling With Infertility.” See counseling.org/conference for session and registration information.
  • Oct. 15 is Pregnancy and Infant Loss Remembrance Day. Visit october15th.com for information and events, such as remembrance walks, listed by state.
  • The National Infertility Association (resolve.org) offers a wealth of information and resources, including online support communities and a hotline, 1-866-NOTALONE.
  • The American Pregnancy Association has resources on infertility and pregnancy loss at its website: americanpregnancy.org
  • An ACA Practice Brief titled “Counseling People Experiencing Infertility,” by Donna M. Gibson and Jennifer M. Gerlach, is available to ACA members on counseling.org. (Practice Briefs are listed at the Center for Counseling Practice, Policy and Research page, which is under the “Knowledge Center” tab on the homepage.)

 

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Bibliotherapy resources for clients and practitioners

  • Jaffe, Janet and Diamond, Martha (2011). Reproductive Trauma: Psychotherapy with Infertility and Pregnancy Loss Clients
  • Kohn, I. and Moffit, P. L. (2000). A silent sorrow: Pregnancy loss: Guidance and support for you and your family. New York: Routledge. Doubleday Dell Publishing Group, Inc.
  • Kushner, H. (1981). When bad things happen to good people. New York: Avon Books.
  • Domar, A. D. and Kelly, A. L. (2004). Conquering infertility: Dr. Alice Domar’s mind/body guide to enhancing fertility and coping with infertility. New York: Penguin Books.
  • Jones, C. F. (2009). Hopeful heart, Peaceful mind: Managing Fertility. Fraser Davis Press.

 

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

Letters to the editor: ct@counseling.org