Tag Archives: Mental Health

Helping clients build their life rafts

By Angela Frank June 5, 2017

How can you judge the value of a life raft if you can’t measure the impact of the waves, the harshness of the current or the depth of the water? For clients, being in the midst of chaos feels like being in the middle of the ocean with no vessel, flailing arms in hopes that someone might see and help.

It can be hard to determine where to start to get out of a bad situation. But with the help of professionals, clients learn how to slowly build their life rafts. Not all results are immediate. It can take years for a counselor’s impact to become apparent in a client.

When I was a client in counseling as a minor, I’m sure that the helping professionals in my life questioned whether they were making any impact on me. They would likely be surprised to find that not only did they have an impact, but that I have made it my mission to pass on what I learned from them.

I remember the first time a school counselor told me that I could not only graduate from high school but that I could also go on to college. I had assumed that opportunity was lost to me because I had previously dropped out of school. No one else had ever told me it was still a possibility. I still remember the way I felt when I heard this news. I was crying because, in that moment, I felt more hope than I had felt in a very long time.

I had been subjected to a life that was excessively chaotic. Between elementary and high school, I moved eight times, was interviewed by child protective services (CPS) social workers in two different states, had to stay with a stranger while my mother was in rehab and was fostered by two other families (being removed by court order from one of them).

Upon graduating from high school, I was floored to find out that children in similar situations do not often go to or finish college. After graduating with both my bachelor’s and master’s degrees and becoming licensed in counseling, I feel safe to say that I beat the odds and the expectations of many. I can’t stress enough that I could not have accomplished these goals if it wasn’t for the professionals in my life.

The list of coping skills presented in this article may be useful in working with adolescents and adults who have had childhood trauma, but they may not work as well for people who are still in the throes of chaos. This list is best used with clients who are at a place in their lives in which they are feeling safe and no longer feeling threatened by their attackers.

Many of the action points on this list are considered therapeutic techniques, but I used them before I knew they were taught as techniques to counselors. My hope is that this list will help other counselors who might feel lost in their practice or off course with a client to find direction once again.

The following skills constitute the foundation of my life raft.

 

1) Making a timeline

For someone who has had a chaotic childhood, time might seem like an abstract concept. Collecting documents can help these clients piece memories together, make past events feel more real and provide an outside, unbiased perspective into what was happening to and around them. Documents also can be used as a tool when confronting family members who deny or don’t want to face reality.

In Washington state, anyone can search online for court case files and request public records. I have been requesting my childhood records because I need help understanding what happened in my life. I collected as many records as I could find related to my past. These include court records, CPS records, police reports and mental health evaluations.

Obtaining records has been a struggle, but it has also been one of the most important steps in confronting my trauma. They serve as a concrete reminder that, as unbelievable as it all seems, what I remember from my childhood really happened. I was able to obtain one record from CPS but was informed a previous record had been destroyed before I even knew it existed. In many states, CPS doesn’t have to inform the subjects of records that the records exist before destroying them. The records told me about the abuse I remember and didn’t report when, as an adult, now I know I should have.

My mother let me know that anything left at her house from when I was a child is gone, so these records are all I have of my past. I haven’t talked to her in six years. I offered to show my younger sister the records because she was very young when the chaos ensued and doesn’t remember a lot. I believe this step has helped both of us.

2) Sharing my story

Listening is the most basic counseling technique any professional is taught, and talk therapy is the place where trauma victims really need to start. Listening is a tool that can be used to gain the trust of clients who normally keep their thoughts on lockdown. For me, having someone there literally just to listen — who didn’t know my family, wasn’t going to tell them what I was talking about and wasn’t going to judge me — was such a relief.

My counselor had to push me a little bit to get me to talk about the trauma. I brought my counselor a copy of my CPS records and let her look at them. It was easier than saying what had happened to me. I didn’t know how to bring it up myself. I had avoided telling her that I had a traumatic childhood because I had come to counseling (or so I thought) for a different reason. After she read my records, I felt she had a better understanding of why there were destructive patterns in my life.

3) Confronting the shame

After trust is gained, clients feel more comfortable talking about how they have treated others in response to what has happened to them. This is important because clients who come from dysfunctional families might fear backlash. Their family members may have tried to use these incidences against them for blackmail or as a “guilting” technique in the past. Just the thought of bringing this up and the potential resulting scrutiny can put clients on edge.

Talking about guilt in a therapeutic setting can help clients to see patterns of shaming and let go of their guilt little by little. Once clients can acknowledge that they have hurt others, it can open up conversation about how these clients are now different. They recognize that how they treated others was wrong and can reassure themselves that it won’t happen again.

This process gives clients back the power. Shame can no longer be used against them once they recognize that part of the reason they can talk about it now is because they have taken steps to change their destructive behaviors with others and are interested in constructive interactions.

It is really hard to acknowledge when you’ve wronged someone. I had memories of how I had wronged people that haunted me for years. When I finally was able to talk about these memories with my counselor, I never sensed that she judged me for what I had done. It was such a relief to finally be able to tell someone who wasn’t going to judge me for actions I had taken when I was a kid and was in a bad place.

4) Normalizing

As a counselor, normalizing is an essential technique, but there are appropriate and inappropriate ways to use it. It is appropriate to use normalizing to help clients recognize that they reacted harshly to a situation because that is how they grew up — as long as they are taught or have learned more constructive ways to handle tough situations. Children have little control, but adults are more responsible for their behavior. Discussing how destructive reactions are inappropriate as an adult is important.

After I told my counselor about what I was ashamed of and how I had treated people, she would normalize it for me, saying, “In this situation, it would be normal for you to have this reaction given your history.” When she told me that, it helped me put into perspective how the trauma affected me and why I would resort to taking certain actions instead of dealing with issues in a more functional manner. From this step, I have been able to deal with my anger, panic, and numbness in more constructive ways.

5) Practicing altruism

Clients may not always be in a position to help others financially, but there are plenty of other ways to help every day. Encourage clients to find those small but meaningful opportunities. It has been therapeutic for me to be there for my younger sister, both financially and emotionally, the way I would have liked someone to have been there for me. When I was removed by court order from a family member’s home, I didn’t get to see my sister for five years. Even though she doesn’t blame me and is understanding, this is how I am trying to make up for missing all that time watching her grow up.

6) Making amends

When clients tell their counselors about their guilt, they might feel depressed for a while after. Admitting that you hurt someone, even if it wasn’t on purpose, might not feel like enough. The next step might be apologizing in a way that feels fitting to the client. Not everyone gets a chance to face their victim and apologize, so writing a letter (which might be kept or sent to the victim, depending on whether the client feels the apology would benefit the other person) can be a very healing experience.

In dealing with my guilt, I apologized to family members because, in my agony, I hadn’t thought about their feelings or how I treated them. I offered that if they ever felt the need to confront me, I would be open to meeting with them. It has helped me to imagine these interactions beforehand. So far, none of my family members has felt the need to confront me. Instead they have told me either that I do not need to apologize or that they have forgiven me, which has brought me closure.

7) Discovering gratitude

For clients in the midst of depression or anxiety, it can be hard to elicit any positive feelings. It’s most important during these times to be grateful because the affect can snap a person out of the emotion. Making a list of what the clients have that they would be worse off without or the things they don’t want to change is a good place to start. This might also jog some really good memories, and clients might end up wanting to reach out to people. The internet is a useful tool for people searching and reaching out when the time comes.

Clients who haven’t been able to confront their past or who still feel guilt and shame might not be able to remember the people who helped them yet. Give it time — it’s a process.

I decided to use the internet to try to connect with people I remember showing me kindness when I was in despair. From becoming grateful, I was able to have more affectionate feelings toward my family and started recognizing the little things they had done to help me along the way.

Even though my mother was not in a position to care for me at times when I was a child, there are things she did that showed that she loved me and cared about me. When the time came, she gave me her tax information so I could fill out the Free Application for Federal Student Aid to finish college. She also told me I wasn’t crazy even when I was convinced I was. These actions don’t make me want to talk to her, but they do let me know that she wanted to keep me moving forward. I wasn’t able to be grateful for these little acts until I could fully accept all the trauma and stop trying to hide it from myself and everyone else.

8) Having faith

It’s well-known that possessing faith can literally keep someone alive. Being able to turn life circumstances over to a higher power can be a profoundly impactful internal resource. For me, this takes some of the pressure off regarding the goals I want to achieve. I keep working toward my goals, but it helps to have faith that forces are at work (even if I don’t understand them), giving me the power to push to get the things I want. When I’ve done all I can, that’s the time for me to just turn it over to the universe to let it take care of what I no longer have control over. I have stopped trying to maintain control of everything and have started to just let things happen.

It doesn’t matter if your faith is in a Christian God, Buddhism, Judaism, fate, Unitarian Universalism or some other system. Just having faith and truly believing that there is some bigger force out there that can’t be taken away can make a positive impact on an individual’s life.

9) Reconnecting with community

Everyone has days when he or she would rather just sit alone at home and watch TV or be on the computer. Over time, this can result in feeling disconnected and lonely. It can even be triggering, making clients feel more isolated than they actually are.

Tell clients that you understand that it can be hard to get out at times. But also remind them that simply being with others can provide a welcome distraction, result in meeting personal goals, and lead to positive feelings and new opportunities. For frugal clients, there are plenty of free events, but this might require some research.

For me, forcing myself to become part of a community and visit friends even when I didn’t feel like it made all the difference. I ended up being grateful I had made myself go. If clients tell you this same thing, talk extensively about what happened that made it a positive experience for them. This will encourage the new behavior.

10) Engaging in advocacy

There are plenty of marches going on in America right now as a way to advocate for what many believe in. Advocacy creates unity between people with similar goals, creates community, brings hope and empowers. Counselors can help by searching for groups or communities with a purpose that would help their clients move forward from their past.

I case manage children in foster care and get triggered at work sometimes because some of the stories I hear feel similar to mine. I can physically feel my heart hurt. To deal with this, I remember that there aren’t many professionals who can relate to what children in foster care go through the way I can, so I draw on my personal experience to advocate for and understand them.

11) Using a mantra

Having a reminder of what’s often forgotten or overlooked in the midst of chaos can be very comforting. This can help clients who feel stuck to keep going. When things are hard in my adult life, one thing that keeps me going is remembering that I survived much worse as a kid and have only grown stronger.

 

 

Conclusion

When people stop denying or minimizing their trauma and face their fears head-on, the resulting calm and insight are greater than the numbness brought on by burying the past. We all have our methods of coping; sometimes our coping strategies are so unique to us that we can’t even put a name to them.

Counselors have the ability to help clients find their strengths. The hard work results in feeling so empowered that clients may prefer to remember what they have already survived rather than trying to forget and feeling powerless over what they are experiencing now or will experience in the future.

Keep in mind that anyone who is sitting in front of you as a counselor has already survived a lot. Their arms are flailing for help, but they haven’t given up. There is still a chance for them. Using the techniques in this article, you have the power to help them build their life raft. You have the power to support them and be there for them as they look back on the chaos they survived, so that they can finally be free from it. Now that I have reevaluated my personal history, I want to help others recover from their own fears and trauma.

It took a long time to get to this place where I can finally face my past and not feel devastated. But now that I have, I would rather live in a cardboard box than ever deny myself again. When I tried to ignore my past, all it did was trigger me. It did not help me or those around me. I had so much anxiety that it was hard to function daily. I forgot why I was doing what I was doing and what my goals were in life. When I finally faced it head-on, I was able to reclaim myself, my confidence and my internal compass. Without the guidance I received from the helping professionals in my life, I would not be where I am today.

It might seem that some children are set up for failure, but counselors can help them find the strength within themselves to overcome. Take it from someone who knows. Anyone who is reading this possesses the power to change the course of someone’s life. Remember that.

 

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Angela Frank is a licensed mental health counselor in Washington state. She graduated from Washington State University with a Bachelor of Science in psychology and a Masters of Arts in education. She recently started a blog at highlymobilechildawareness.com and can be contacted at angela@highlymobilechildawareness.com.

 

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

Living with anxiety

By Bethany Bray May 24, 2017

Anxiety disorders are the most common mental illness in the United States, affecting 18 percent of the adult population, or more than 40 million people, according to the National Institutes of Health. Among adolescents the prevalence is even higher: 25 percent of youth ages 13 to 18 live with some type of anxiety disorder.

Anxiety disorders are often coupled with sleeplessness, depression, panic attacks, racing thoughts, headaches or other physical issues. Anxiety can run in families and be a lifelong challenge that spills over into all facets of life, from relationships and parenting to the workplace.

The good news is that anxiety disorders are manageable, and counselors have a plethora of tools to help clients lessen the impact of anxiety. Caitlyn McKinzie Bennett, a licensed mental health counselor, says she regularly talks this through with her clients at her private practice in Orlando, Florida. She often uses an analogy of ocean waves with clients: Anxiety comes in waves, and managing the disorder means learning coping tools and strategies to help surf those waves rather than expecting the waves to disappear entirely.

“Anxiety can be a long-term thing,” says Bennett, who is also a doctoral student in counselor education at the University of Central Florida. “With clients, I try and explain that [anxiety] is the body’s response that something’s not right — based off of what’s happened to you [such as past trauma] or what’s happening currently. Then we can work to accept it, cope and be happier in your life. Some things you can’t necessarily get rid of in their entirety, and that’s OK. It’s learning to be you and have a fulfilling life with anxiety, where you’re able to feel anxious and [still] be productive and be a mother, a student, a partner. I try and normalize that [anxiety is] going to come and go. It’s OK, and it’s human.”

Anxiety doesn’t happen in isolation

Everyone experiences anxiety from time to time, such as worry over an upcoming work responsibility, school exam or first date. Anxiety disorders, however, are marked by worry and racing thoughts that become debilitating and interfere with everyday functioning.

“It’s a normal part of life to experience occasional anxiety,” writes the Anxiety and Depression Association of America on its website (ADAA.org). “But you may experience anxiety that is persistent, seemingly uncontrollable and overwhelming. If it’s an excessive, irrational dread of everyday situations, it can be disabling. When anxiety interferes with daily activities, you may have an anxiety disorder.”

A number of related issues fall under the heading of anxiety disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), including specific phobia, panic disorder, separation anxiety disorder, social anxiety disorder, generalized anxiety disorder and others. According to the DSM-5, anxiety disorders “include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat.”

Racing thoughts, rumination and overthinking possibilities — from social interactions to decision-making — are central to anxiety. In addition, people with anxiety often struggle with insomnia or sleeplessness and physical symptoms such as a racing heart, sweaty palms and headaches, says Bennett, an American Counseling Association member who is currently leading a study for her doctoral dissertation on the effects of neurofeedback training on college students with anxiety. Adolescents sometimes turn to self-harming behaviors such as cutting or hair pulling to cope with anxiety. In adults and adolescents, anxiety can manifest in physiological issues such as stomachaches or irritable bowel syndrome. Although adults may channel their anxiety into physical problems, they’re also generally much more capable than adolescents and children of identifying and articulating the anxious thoughts, ruminations and social struggles that they’re facing, Bennett says.

Bennett worked with a 14-year-old female client whose anxiety had manifested as the behaviors of obsessive-compulsive disorder (OCD), including avoiding the number six, leaving her closet door open a certain way and struggling with crossing thresholds. Bennett worked with the client to identify her triggers and find coping mechanisms, such as connecting with friends and her Christian faith.

“A big part of her improvement was creating the awareness of what was happening,” Bennett says. “Typically there’s a large, irrational fear. With her, she was afraid that her mom was going to die. She would focus on it so much that it would cause her to start the [OCD] behavior. … For her, it felt so real. It was so scary for her that she felt compelled to do these behaviors to keep her mom alive, so to speak.”

Bennett worked with the young client to confront her fears in small doses through exposure therapy, such as listening to a song at volume level six and talking through how she felt afterward. This method allowed Bennett to first address the client’s OCD behaviors and then — once trust was built and the client had progressed — move on to work through the bigger, deeper issue of her fear of her mother’s death.

“It helped her to feel safe enough and have the confidence to work through some smaller things and move on to work on bigger things,” Bennett says. “For her it was talking it out, normalizing that for her and drawing attention to [her anxious behaviors].”

Christopher Pisarik is an associate professor in the Division of Academic Enhancement at the University of Georgia and a licensed professional counselor (LPC) who works with students in need of academic support. He says that stress and irregular sleep and eating patterns — which are often ubiquitous parts of college life — can go hand in hand with anxiety.

“Sleep is a big one — if they’re just not sleeping, or sleeping too much,” says Pisarik, who also treats many college-age clients at his private practice in Athens, Georgia. “This is really, really common — clients who can’t get to bed until 4 a.m., and then they can’t get to class, and it snowballs. Their thoughts just race with worry. … Sleep seems to be a big diagnostic indicator [for anxiety], and not being able to go to bed. [I ask clients,] ‘What are you thinking about, and can you stop thinking about this? Is that what’s keeping you from getting back to sleep?’ They get tired and fatigued, and it’s perpetuated.”

In addition, anxiety is often coupled with — or is an outgrowth of — other mental illnesses, most commonly depression. Counselors will need to treat a client’s anxiety alongside other diagnoses, Bennett says. For example, a client with schizophrenia will have hallucinations that provoke extreme anxiety. If the counselor doesn’t address the client’s anxiety, those symptoms will get worse, explains Bennett.

“Depression and anxiety are like brother and sister,” she adds. “They play off of each other and exacerbate the symptoms. You need to work through both. I don’t think I’ve ever worked with anyone who solely experienced anxiety.”

Stephanie Kuhn, an ACA member and LPC at the Anxiety Treatment Center of Greater Chicago, agrees. She regularly sees client anxiety paired with other issues such as specific phobias, insomnia, chronic pain issues, depression, panic disorders and OCD.

“It’s never really one thing,” Kuhn says. “It’s never just anxiety.”

Pumping the brakes on racing thoughts

The first step for many people who struggle with anxiety is to create awareness of their thoughts and then learn to manage those thoughts with a counselor’s help. Although the strategy of identifying negative self-talk and addressing one’s thoughts is old hat to most counselors, it may be an entirely new concept for some people, especially younger clients, says Pisarik, an ACA member who uses cognitive behavior therapy (CBT) in his private practice. Clients with anxiety often polarize, exaggerate or catastrophize details in their minds as they ruminate over them, he explains.

“Even being able to identify anxious thoughts is big,” Pisarik says. “They just assume it’s normal to walk around [feeling] anxious because of these thoughts. … It gives them a language and a real usable and rudimentary skill they can use in the moment when they’re walking in [to a stressful exam]. They can identify that their inner narrative isn’t healthy.”

For example, a college student might come to a counselor expressing worry about an upcoming exam in a class that he or she needs to pass for a major in pre-med. The student might have allowed negative and catastrophic thoughts to snowball: “If I get a C on this test, I will never get into medical school, which will derail my entire career plan and make my parents angry and disappointed.”

“For … a student who is 20 years old and [still] learning to think critically, it would be easy to blow everything out of proportion and catastrophize everything,” Pisarik says. “I am really big on helping them understand negative thinking and false cognitions, and getting them to self-monitor and renarrate [their unhealthy thoughts].”

Following the CBT approach, Pisarik says he would talk such clients through their thought patterns to identify and restructure their negative thoughts about the exam. He would also suggest that they focus on and remind themselves of prior successes, such as other exams or classes in which they earned A’s and B’s.

“I would try and systematically educate the client [about] what type of thinking that is,” Pisarik continues. “There are many doctors out there who got C’s and got into medical school, and probably [who] got C’s in medical school. I will explain that they are catastrophizing this … [and] try and get them to think about it in a different way, evaluate it carefully and create a different narrative about it. Are there people who have gotten C’s and gotten into medical school? If it stops you from getting into medical school, would that be the worst thing in the world?”

“It takes a consistent effort to practice and challenge one’s thinking,” adds Pisarik, who co-authored the article “A Phenomenological Study of Career Anxiety Among College Students.” The article will be published in the December issue of The Career Development Quarterly, the journal of the National Career Development Association, a division of ACA.

CBT works well for anxiety because “it lets people see that their own thinking and their behaviors are not productive for the way they want to live or the life they’re living right now,” says Kuhn, who uses both CBT and exposure therapy with her clients at the Anxiety Treatment Center of Greater Chicago. “It’s giving people an outside perspective — getting them to look at their own thoughts and behaviors objectively rather than letting those anxious thoughts take over everything, making it harder to function.”

One way Kuhn works with clients on challenging their unhealthy thoughts is by asking them to identify the best, worst and most likely outcomes of situations they are ruminating over. “I ask, ‘Would [the outcome] matter in a week, a month or a year from now?’ Typically the answer is no,” Kuhn says. “After we go through that, we reframe the original thought [and] transform it into something more rational, more realistic.”

Both Pisarik and Kuhn encourage their clients to keep thought logs to track anxious thoughts and the situations that triggered them. This exercise increases self-awareness, helps identify triggers and creates an opportunity to discuss how the client might change the negative narrative.

“Writing helps a lot because it slows people’s minds down, and they can go back and read about it,” Kuhn says. “Creating that awareness is the only way to understand yourself, understand what you’re worried about and be able to accept it and push it away.”

In addition to using thought logs, Pisarik gives his clients a list of automatic negative thoughts, or ANTs, to check themselves against. The collection lists the most common types of unhealthy, anxious thoughts and types of thinking, including catastrophizing and either-or thinking (polarizing).

Kuhn has a particular phrase that she often repeats with clients: “Handle it.” She acknowledges that it’s not the most empathic of mantras, but it does help to focus on the manageability of anxiety. With clients, she works toward a goal of “being able to sit with the uncomfortableness [of anxious thoughts] and tolerate the stress.”

Kuhn says her style when working with clients matches her personality: “Let’s go forward and hit our fears hard instead of tiptoeing around them.”

Exposure therapy, which introduces things in small, controlled increments in session that make a client anxious, is another good way to focus on handling anxiety, Kuhn adds. Whether the scenario is a fear of speaking up in class or a fear of being rejected by a loved one, exposure therapy can help clients learn to live with the issue and the anxious feelings that come with it.

“When I talk to people about ‘handling it,’ it’s creating that awareness and understanding [of] themselves that they’re able to manage or take on more than they think they can,” Kuhn says. “Anxiety a lot of the time makes us believe that we can’t handle the tiniest things. That’s why our body has created or learned how to respond to things in an overactive or hypersensitive way.” This is most commonly experienced in our fight-or-flight response, she says.

Managing worry and taming anxiety

From CBT and mindfulness to a focus on wellness and coping strategies, professional counselors have a wide range of tools to help clients who struggle with anxiety. Here are some ideas and techniques that can be particularly useful.

> Controlling the controllables. Kuhn says it can be helpful for clients to talk through and identify what is out of their control during situations that make them anxious. “A lot of times, anxious clients want control over everything, and that’s just not realistic,” Kuhn says. “It’s important to go over what’s controllable and what’s not. That creates awareness and a pathway to reevaluate [their] own thinking and behavior. I like to call it ‘controlling the controllables.’ I talk with clients about this a lot.”

Kuhn often uses an exercise with clients in which she draws a target with concentric circles. Things that clients can control, such as their own thoughts and behaviors, go in the center circle. Things that they partially control, such as their emotions or what they focus on sometimes, go in the middle ring. Things that are out of their control, such as what other people think or do, go in the outside circle. In a simpler alternative, Kuhn draws a center line down a piece of paper and works with clients to list what is and isn’t in their control in situations that make them anxious.

> Creating common ground. Kuhn says she also talks openly with clients about how common anxiety is, alerting them that they are among literally millions of Americans who are battling the same challenge. “I let them know they are not alone. It creates a universality,” Kuhn says. “To let people know that they’re not the only ones suffering like this can help. … It does create a common ground for people not to feel ashamed of [their anxiety] or feel like they can’t talk to someone about it. Just creating that education typically makes people feel a ton better.”

> Acknowledging and naming worry. Journaling and making lists to document anxious thoughts can help clients address and reframe the everyday rumination that accompanies anxiety. Kuhn offers two variations on this intervention: worry time and the worry tree.

With “worry time,” clients set aside a dedicated amount of time (Kuhn suggests 30 minutes) every day to write down any anxious thoughts that are troubling them. Clients don’t need to engage in long-form writing to complete this exercise, Kuhn says. Making a bulleted list or jotting thoughts down on sticky notes will work just as well. When the designated time is up, clients put all the notes in a box or container that they have set aside for this purpose. This action signifies that they are leaving those thoughts behind and can move on with the day.

“They have to leave those thoughts or sticky notes there and be done with them,” she says. “Obviously more [anxious] thoughts will come, but you have to remind yourself to leave them behind.”

With Kuhn’s “worry tree” intervention, clients create a flowchart of their anxious thoughts. With each item, clients ask themselves whether their worry is productive or unproductive (see image, below). “Is it something that you can actually do something about?” Kuhn asks. “If it’s unproductive, then you need to just let it go. Do something you enjoy or focus on something else to reset [your mind].”

 

> Mind-body focus and exercise. Mindfulness, meditation and other calming interventions can be particularly helpful for clients with anxiety. Kuhn recommends the smartphone app Pacifica, which prompts users with breathing, relaxation and mindfulness exercises, for both practitioners and clients. Kuhn, who has a background in sports counseling, and Pisarik, who is a runner himself, also prescribe exercise to anxious clients. Exercise boosts serotonin, a neurotransmitter connected to feelings of well-being, and comes with a host of other wellness benefits. In addition, exercise allows a person to get outdoors or disengage from work and home activities and other people for a brief period to “have time to hear your thoughts and challenge them,” Pisarik says. “You have to hear your thoughts if you’re going to challenge them.”

> The butterfly hug. Beth Patterson, an ACA member and LPC with a private practice in Denver, teaches deep breathing exercises to anxious clients to help them become grounded, focusing on the flow of energy through the body. She also recommends the “butterfly hug” technique. With this technique, clients cross their arms across their chests, just below the collarbone, with both feet planted firmly on the floor.

Clients tap themselves gently, alternating between their right and left hands. This motion introduces bilateral stimulation, the rhythmic left-right patterns that are used in eye movement desensitization and reprocessing. “It’s phenomenally self-soothing,” Patterson says. “Doing that with deep breathing really helps with anxiety. I love the idea that you’re hugging yourself. Even just doing that helps.”

> Walk it out. Along with deep breathing and grounding, Patterson also recommends walking and movement for clients who are feeling anxious. She instructs clients to focus on the feeling of each foot hitting the ground instead of their anxious thoughts. As with the butterfly hug, this action creates bilateral stimulation, Patterson notes.

Bennett also uses walking as a way to help clients refocus their thoughts. She will take clients out of the office during a session for a “mindful walk” up and down the block. During the walk, they talk about what they’re sensing, from the sunshine to the breeze to the smell of flowers. Bennett says this allows her to work with clients “in the moment,” recognizing and refocusing anxious thoughts as they come. Afterward, they process and talk through the experience back in the office.

“It’s a lesson that [anxious] thoughts are going to come up for you, and you can refocus on your sense of touch or hearing,” Bennett says. “Thoughts will come up, and it’s really easy to attach to those thoughts and become anxious, but we can acknowledge the thought, be accepting of it in the moment and refocus. Change and connection can come that way.”

> This is not that. Clients commonly transfer anxiety-provoking personal issues onto relationships or situations in other facets of life, including the workplace, Patterson says. For example, Patterson worked with a client who had a very domineering, controlling mother, and this client felt triggered by a female boss in her workplace. Patterson introduced the client to the mantra “this is not that,” and they worked on reframing the anxiety the client experienced when she felt her boss was being controlling.

“She had to work through it in a beneficial and compassionate way for herself and really remember ‘this is not that,’” Patterson says. “Our minds are brilliant, but they’re binary computers. When something happens, it will immediately associate it with something else it knows. If a co-worker is being overly competitive, it might trigger feelings about sibling rivalry. This [mantra] offers a great opportunity to work through family-of-origin issues [with clients] when you see them replicated in the workplace.”

> Abstain from negativity. Another empowering tool clients can use is to become conscious of and then avoid unhealthy or toxic situations and people who trigger their anxiety, Pisarik says. He advises clients to “stay away from groups of people or individuals who they know will engage in negative self-talk or negativity. If you’re feeling anxious already, the last thing you want to do is to go and talk to that toxic person.”

Similarly, he commonly advises anxious students to avoid waiting outside the room where they’re about to take a big exam, surrounded by 30 classmates who might be saying that they are going to fail, they didn’t study enough, they don’t feel prepared and so on. Counselors can coach anxious clients to think ahead and prepare ways to remove themselves from these types of situations, regroup and redirect their thinking, Pisarik says.

> Lifestyle choices. Counselors can also educate clients on the connection between anxiety and lifestyle choices such as sleep patterns, exercise and diet, Pisarik says. For young clients especially, this also includes social media use, he notes.

Pisarik says he frequently talks with his college-age clients about their alcohol consumption, drug use, irregular diet and other aspects of the modern university experience. “The lifestyle of a college student is absolutely conducive to generating anxiety,” he says. “While they are college students, I get that — their job is to have fun and sleep whenever [they] want. But building some sort of healthy routine is important, [including] getting enough sleep and making sure they eat well. I tell them to try and maintain the diet they had at home. … If you’re struggling with anxiety to begin with, any one of those [elements] can add to it, and those are really easy fixes.”

For Bennett, conversations with clients about lifestyle also include questions about smoking and caffeine use. Both tobacco and caffeine can make a person shaky or make his or her heart and mind race, which can trigger or exacerbate anxiety, she points out.

In addition to social media use, Pisarik also asks clients about their social engagement, such as participating in sports or other hobbies. Clients who struggle with anxiety often isolate themselves, he notes, so he works with them to identify social outlets, from volunteering to joining a school club. This sense of connection can reduce anxiety, he says.

> Narrative therapy and externalization. Patterson finds narrative therapy helpful when working with clients with anxiety because it allows them to externalize what they’re feeling. When clients uses phrases such as “I am worried” or “I am anxious,” Patterson will gently redirect them by saying, “No, you’re Susan, and you have a problem called worry.”

“Externalize the problem,” Patterson explains to clients. “Externalize it and dis-identify it. See it outside of yourself. … ‘I can deal with that because it’s not who I am.’ … If you’re carrying it around as if it’s you, you can’t do anything about it. The truth of the matter is, it’s not you.”

Counselors can also help clients with anxiety to focus on a time in their lives when they faced a similar challenge and got through it, Patterson says. She asks clients questions to help them probe deeper. For example: How did you handle that challenge? What worked, and what didn’t work?

 

Working with clients on medication

Anti-anxiety medications are commonly prescribed in the United States. Their prevalence means that counselors are likely to encounter clients who are taking medication to control their anxiety symptoms.

Regardless of their feelings about the use of psychotropic medications, practitioners must treat and support clients who are taking such medications the same as they would any other client, Kuhn says. “I never treat someone differently based on their medication. They get the same CBT therapy that anyone else would get,” she says, adding that the most important thing is to ensure that clients don’t feel judged by the counselor.

Kuhn has seen anti-anxiety medications work well for some clients. “It can take that little edge off that they need to get through the day and be able to function,” she says. At the same time, she also has clients who express a desire to be able to stop taking their medication eventually.

Pisarik notes that for anti-anxiety medication to work well, clients must remember to take it faithfully, keep track of how it makes them feel and schedule the repeated appointments needed to monitor and adjust dosage levels. Each of these elements can pose a challenge to college-age clients. “It’s a lot of work, and [college students] often lack the discipline and time to get it right,” Pisarik says.

Bennett agrees, suggesting that even though professional counselors are not the ones prescribing medications, they still need to discuss and explore medication use with their clients. She also stresses that practitioners should be knowledgeable about the different kinds of medications that clients may be taking and their possible side effects.

Bennett sometimes conducts conference calls with her clients and the medical professionals who are prescribing them medications so that she can help clients ask questions and otherwise be a support to them. “We [counselors] don’t prescribe, but at the same time it’s very important to collaborate with whoever is prescribing the [client’s] medication,” she says. “Be supportive and involve the client in conversations: How long have you taken it? Have you noticed any side effects? Has it been helping? Talk about how often they’re supposed to take it and if they’re adhering to that. There can be stigma about taking medications, so it’s important to normalize it. … It’s comforting too for the client to know that you’re on their side, and part of that is collaboration [about medication].”

 

See the person, not the anxiety

Given how common anxiety disorders are, it’s likely that any counselor’s caseload will be filled with clients presenting with symptoms of anxiety. It is important, however, for counselors to treat each client as an individual and to tailor the therapeutic approach to meet that client’s unique needs, Bennett emphasizes.

Building trust and a healthy therapeutic relationship are key in treating anxiety because clients can feel very vulnerable as they talk about what makes them anxious, Bennett points out. That is why it is critical to get to know these clients as individuals rather than through the lens of their anxiety.

“Don’t assume that because they’re anxious, they’re going to think and behave like other people with anxiety,” Bennett says. “Meet them where they are and find out what’s most effective for them based off of their interests. It can be empowering for clients to integrate their own interests and life experiences into the therapeutic process. Not only does this create buy-in for the client, but it can also help in creating a safe space to begin exploring the vulnerabilities that come along with anxiety. … Hear their story, find their strengths and give them a voice in the process. It’s important to honor them as individuals.”

 

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To contact the counselors interviewed for this article, email:

 

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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

 

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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.

Preparing for the mental health impact of climate change

By Debbie C. Sturm and Lennis G. Echterling May 10, 2017

Around the globe, coastlines are encroaching on communities, summer days are sweltering and reports of weather catastrophes often dominate the news media. These examples represent only a few of the monumental and pervasive environmental effects of our changing planet.

Climate change may be the most crucial issue confronting the inhabitants of our world today. The dramatic consequences that scientists have been predicting, such as rising sea levels, record-setting high temperatures and an increase in devastating natural disasters, are no longer theoretical. Although some still argue the point, climate change is now a grim reality, not a vague possibility in the distant future.

As devastating as these consequences are on our physical world, climate change also poses enormous threats to our psychological well-being. In a report released in 2012 by the National Wildlife Federation’s climate education program, with support from the Robert Wood Johnson Foundation, researchers predicted a sharp rise in mental health issues resulting from events related to climate change in the coming years. These issues include depression and anxiety, posttraumatic stress disorder, substance abuse, suicide and outbreaks of violence. The elderly, the poor, children and members of the military (and their families) were identified as being among those who will be most psychologically vulnerable.

We believe the counseling profession, which has its conceptual roots in the promotion of human growth and development, must play a more active role in addressing the mental health impact of climate change. For many decades, counselors have worked closely with countless individuals to help them achieve fulfilling careers, realize self-actualization, strengthen personal resilience and seek social justice. Recently, counselors have gained greater acceptance as valuable members of crisis and disaster response teams.

Our extensive training and experience in enhancing well-being enable us to serve as effective catalysts for positive change. Now more than ever, counselors are in a position to shape messaging and lead the way in effective prevention and intervention related to the psychological implications of climate change. This includes promoting climate resilience, strengthening disaster response programs and advocating for vulnerable populations.

Climate resilience and climate refugees

In January 2016, the Department of Housing and Urban Development announced a $48 million grant to move an entire indigenous community from Isle de Jean Charles, Louisiana, before the land disappears into the Gulf of Mexico. This marks the first allocation of federal dollars to permanently move an entire community impacted by climate change. These displaced people are now known as climate refugees. The main purpose of the grant is to work closely with the inhabitants of this community through a process that will honor their choices. By empowering the people and giving voice to their preferences, choice builds resilience.

Although this tribe is the first to be formally identified as climate refugees within the United States, climate refugee status is not a new phenomenon. The crisis in Syria, for example, has become so complex and tragic that it often eclipses the fact that a climate-related drought was the catalyst for mass migration to the cities, instigating intense cultural and economic conflicts.

Climate change threatens to become a tipping point in more and more areas of the world. Between 50 million and 200 million people could be displaced by 2050, according to the United Nations University Institute for Environment and Human Security. Populations that are economically and culturally vulnerable, such as those whose livelihoods depend on farming and fishing, will feel the impact most especially.

Climate resilience is the notion that we should not wait until there is no choice and people are traumatically displaced by the effects of climate change. Instead, we can help create resilience plans so that those who are impacted have both choice and voice in the matter. The International Red Cross has embraced the notion of climate resilience as a necessary element of preparation for what is to come, and as an opportunity to anticipate the physical, psychological and cultural needs ahead. Climate resilience, which is an integral component of disaster response within the International Red Cross, places significant emphasis on trauma and mental health response.

Place attachment

Consider again the people of Isle de Jean Charles. Although efforts are in place to help with the transition, residents still feel a deep attachment to their home. This isle holds their cultural and spiritual history. Their identity is deeply rooted to the story of this place.

Just as we are connected to our early attachment figures, we also share a deep and abiding attachment to our early places, both individually and culturally. In a 2016 article in The New York Times, Chief Albert Naquin of the Biloxi-Chitimacha-Choctaw tribe, the ancestral residents of Isle de Jean Charles, observed sadly, “We’re going to lose all our heritage, all our culture.”

Place attachment is the powerful bond that links a person to a place. It develops throughout one’s lifetime and even evolves over centuries throughout the history of a culture. This sense of connection to a specific place provides a profound source of meaning, belonging and sustenance. Simply put, this place is one’s home. Place attachment and sense of place are often interchangeable. Place identity considers attachment in terms of emotional or symbolic meanings, as internalized and integrated into a person’s identity.

Much like other aspects of attachment that we explore with clients struggling with any number of issues, place attachment is seated in a deep part of ourselves that connects to ancestry, early recollections, sensory experiences and story. It relates to the larger question of Who am I? — a question that can be partly answered through place identity.

In North Dakota, the Standing Rock Sioux Tribe recently engaged in a battle of culture and human rights against the Dakota Access pipeline, the construction of which threatens tribal land and clean water. Many have called Standing Rock a new civil rights moment encompassing a convergence of environmental rights, human rights and cultural rights. Tribal representatives from all over North America joined the Standing Rock Sioux in an empathic and familiar stand to protect culture and identity.

Journalist Rebecca Solnit, writing for The Guardian, spent time in Standing Rock to cover the movement. She gave eloquent voice to the tribe’s heartfelt commitment and place attachment: “Victors like to forget how they got their spoils, but the despoiled have long memories.” With a growing sense of awe, Solnit observed how the tribe relied on peace and prayer, valued humility and revered their ancestors.

Place matters as an integral piece of cultural, historical, existential and personal identity. The stories of people and their places, whether in Louisiana or the Dakotas, are as important as any other attachment issues or identity concerns that we consider when we counsel our clients.

Environmental justice as social justice

Issues that impact the planet also directly impact the people who live on the planet. At times, it seems as though conversations around environmental justice and social justice are happening with equal intensity and depth of passion but are taking place in two separate silos.

As the climate changes, families, communities and lives are affected. And as is true with so many other aspects of change, our most vulnerable neighbors — individuals with low incomes, communities of color, immigrants, indigenous peoples, children, pregnant women, older adults, people with disabilities and people with chronic medical conditions — are most subject to the impact. Understanding the issue and engaging in advocacy on behalf of the climate is also advocating on behalf of the people whose lives depend on a healthy planet. The global climate is interconnected — environmentally, psychologically, socially, culturally
and spiritually.

In 2010, the Council on Social Work Education declared sustainability and climate issues to be the social justice issues of the new century. In 2011, the American Psychological Association released a report highlighting the broad contributions that psychology could make, with continued research and advocacy, to understanding the power of the human-environment relationship. It included a call to action for scholars to bridge the gap between the science of environmental issues and the study and practice of psychology.

Our moral obligation

In a 2016 article on the ecoAffect website, psychiatrist Lise Van Susteren posed a challenge to those in the helping professions. She noted that we work with people who are faced with fears, traumas, unexpected changes and crises. We help our clients navigate this difficult terrain even as we view larger societal issues through a social justice and advocacy lens. She wonders, then, if we can ethically turn a blind eye to the approaching crises that our changing planet will bring. Do we have a duty to warn, to protect, or, at a minimum, to acknowledge that the changing climate is a significant variable in mental health?

The American Counseling Association has a long-established relationship with the American Red Cross as a model for and partner in disaster response. In 2002, the International Federation of Red Cross and Red Crescent Societies established the Red Cross/Red Crescent Climate Centre. This organization supports national Red Cross and Red Crescent Societies in their work to reduce loss of life and damage to livelihoods from climate change and extreme weather events. Goals include implementing information and education activities about climate change and extreme weather events; supporting the development of climate-adaptation activities and disaster-risk-reduction programs; and bringing concerns about the impacts of climate change on vulnerable people to the broader public. Considering the global movement toward acknowledging climate change in disaster response and preparedness, we believe it is vitally important for ACA to expand its vision for the future of disaster response.

As professionals who believe that all individuals deserve basic human and civil rights, we need to challenge ourselves to see the climate crisis as an imminent threat. Counselors are positioned to bring a trauma-informed and resilience-based perspective to the front lines of crisis and disaster response. We must recognize that environmental injustices and environmental racism — such as what we have witnessed in Flint, Michigan; with Hurricane Katrina; with the 2016 Louisiana floods; and with the standoff in Standing Rock — are enormous social justice issues.

Given our knowledge and skills as counselors, we have both the responsibility and the potential to contribute to environmental advocacy, disaster response and preparedness for building resilient communities. It is our basic duty to promote and deepen human beings’ most fundamental attachment to our natural world.

 

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Debbie C. Sturm is an associate professor at James Madison University in Virginia and a licensed professional counselor with more than 10 years’ experience in counseling survivors of trauma and community violence. She engages in research related to nature connectedness and mental health, sense of place, the psychology of sustainability and environmental justice as social justice. Contact her at sturmdc@jmu.edu.

Lennis G. Echterling is a professor at James Madison University with more than 30 years’ experience in crisis and disaster response, supporting first responders, and international stabilization and recovery in war-torn regions. As a doting grandfather to two young boys, he believes it is important that we give greater consideration to the health of our planet and our children.

Letters to the editor: ct@counseling.org

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

 

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

Becoming shameless

By Laurie Meyers April 25, 2017

You should be ashamed of yourself.” How many of us have heard — or perhaps even used — that phrase? Being on the receiving end of such a pronouncement is never pleasant. More important, experts firmly believe that attempting to wield shame as an instrument of change is both ineffective and harmful. In fact, many clinicians say that shame is intertwined with an abundance of issues that typically bring clients to counseling. Furthermore, it often stands as a significant barrier to healing.

In her book I Thought It Was Just Me (But It Isn’t), Brené Brown defines shame as “the intensely painful feeling or experience of believing we are flawed and therefore unworthy of acceptance and belonging.” The research professor at the University of Houston’s Graduate College of Social Work believes that shame has become a kind of silent epidemic in society that serves to isolate us and thus damages our sense of connection to others.

Thelma Duffey, the immediate past president of the American Counseling Association, agrees. One of her main initiatives as president focused on issues surrounding bullying and interpersonal violence, both of which can leave people struggling with a deep-seated sense of shame. “I see shame as a deeply painful feeling that people experience when they feel exposed, inadequate or especially vulnerable,” she says. “Unforgiving and powerful, shame can leave many people feeling unworthy and incapable.”

Bullied into shame

The practice of actively shaming others, particularly through bullying behaviors, is all too common in our culture, says Duffey, a practicing licensed professional counselor and licensed marriage and family therapist for more than 25 years.

“Bullying can trigger feelings of shame, leaving people feeling defenseless, embarrassed and confused,” she says. “Some feel such a strong sense of self-consciousness and become so preoccupied with avoiding shame-inducing situations that they withdraw from others, which can lead to an excruciating form of isolation.”

Without the consistent presence of love and support in a person’s life and the provision of a realistic viewpoint from others, there is no counterbalance to shame’s narrative.

“Imagine holding a broken mirror of yourself and believing that the distorted image is what you truly look like,” Duffey says. “Your perception would be off, wouldn’t it? Now imagine you are holding a broken mirror that reflects a distorted image of who you are as a person. If you believe this distortion, it won’t be easy to feel good about yourself or to connect with other people who love you. It will probably lead you to see the world as an unsafe place. In all likelihood, you’ll have to create ways of coping with these images just to survive. Too many times, these coping strategies ultimately keep us from the very connections we desire.”

Duffey says there is an antidote. “I believe that developing a sense of self-compassion is at the core of conquering shame,” she says. “Unfortunately, self-compassion is not always easy to come by, particularly when a person has been mistreated, publicly mocked or hurt, as is generally the case with any bullying situation. In fact, introducing the idea of self-compassion can actually make people wince when they live with feelings of shame, because it sheds light on their self-loathing perceptions.”

Counselors can use a variety of methods to help clients develop self-compassion, but a strong therapeutic bond is the most essential ingredient in that process, says Duffey, who is also a professor and chair of the counseling department at the University of Texas at San Antonio. One of the interventions she uses is Emotional Freedom Techniques (EFT).

“EFT has been described as a type of psychological acupressure that can help unblock distressing situations,” Duffey says. “The idea is to restore balance to the body’s energy field to move negative emotions that can keep us stuck. I also see it as a way for people to center themselves when they are in their uncomfortable emotions and to connect with themselves in a more soothing way.”

Duffey says that EFT in its traditional form has a sequence that involves identifying the problem — for example, shame — and then having clients ask themselves how they feel about the problem right now. Clients then rate the level of intensity of the problem, with 10 being most intense and zero being least intense. Next, the counselor and client come up with a “setup” statement that acknowledges the problem and follow that with an affirmation. Clients then repeat the statement and affirmation while performing a kind of “psychological acupuncture” that involves taking their hands and tapping five to seven times on the body’s “meridian” or energy points.

“A person experiencing shame and with memories of bullying might say something like, ‘Even though it is not always easy for me to see my own value, I deeply and completely love and accept myself,’” she says. “Or, ‘Even though I can still remember the horror of being made fun of, excluded and shunned, I can be on my own side now. And I am not alone. In fact, I am working on loving and accepting myself.’”

Once a person connects with the problem and the idea of loving, self-compassionate affirmations, he or she can use those affirmations to process all sorts of experiences, Duffey says. “The idea, of course, is not about thinking positively or practicing self-delusion,” she notes. “Rather, it is about really being honest about what hurts and confronting these feelings, [and then] offering affirmative statements of hope and compassion while tapping into the body’s energy using acupressure points.”

Duffey recommends the website thetappingsolution.com for those who would like to learn more about EFT.

The trauma-shame connection

At the ACA 2017 Conference & Expo in San Francisco this past March, licensed mental health counselor Thom Field presented “For Shame! The Neglected Emotion in PTSD.” In the session, he explained that shame is a significant component of posttraumatic stress disorder (PTSD), particularly in cases of interpersonal trauma, such as child abuse and intimate partner violence.

Because PTSD’s most common symptoms — hypervigilance, nightmares, flashbacks, intrusive memories and physiological hyperarousal — are all related to fear of external danger, experts in the trauma field have traditionally focused on fear as the primary emotion in PTSD, noted Field, a member of ACA. Using this assumption, therapy techniques for PTSD have focused on methods such as exposure therapy, he said. In exposure therapy, clients are asked to revisit the trauma multiple times because repetition has been shown to help lessen the physical and emotional effect of these memories.

However, new research suggests that trauma survivors often also fear being rejected and exposed as weak. This fear engenders a sense of shame, said Field, an associate professor and associate program director of the counseling master’s program at the City University of Seattle. He explained that the shame is fueled by a persistent negative self-appraisal in which clients who have experienced interpersonal trauma often berate themselves with statements such as “I am weak — an easy target”; “Something is wrong with me if I can’t prevent these things from happening”; or “Why didn’t I do something?” Trauma survivors often feel inadequate, inferior or powerless to affect their own environments, he added.

Field believes that counselors must understand the role of shame to help many of these individuals who are living with PTSD. “Shame is an emotion that arises when a person feels inadequate or corrupted by an irredeemable act or a contaminating event,” Field explained. “The person feels undesirable and unattractive and fears the perceived judgment of others.”

It is also important for counselors to differentiate shame from guilt, Field noted. He defined guilt as regret for a specific action that is bound to external circumstances. It is a feeling connected to what one has done rather than — in the case of shame — what one is, Field emphasized. Whereas guilt can motivate prosocial actions such as reparation, shame usually motivates self-protective actions such as withdrawal or lying to protect secrets, he pointed out.

Among the factors that increase feelings of shame in those who are experiencing PTSD or interpersonal trauma are the attribution of responsibility (such as the perception that having HIV or AIDS is that person’s “fault”); the level of visibility and an inability to “hide” (because of circumstances such as physical disability or disfigurement); and being marginalized, Field said.

Feelings of shame may prevent some people with PTSD from seeking counseling, and even those who do seek counseling may deny the presence or impact of trauma if a counselor asks them about it directly, Field said. Harboring a sense of shame may also make it difficult for clients to trust others, he added, so counselors must take care to proceed slowly and focus on developing the therapeutic alliance. These clients need to be made to feel safe enough to reveal their secrets and process their fear of rejection, humiliation and judgment by others, he emphasized.

An important step in the process is for counselors to facilitate client autonomy with what Field termed “pre-questions.” For instance, a counselor might say, “It seems like it might be helpful to revisit this event. How ready are you to face that?”

“If you dive in [yourself as the counselor], it feels [to the client] like it’s not voluntary,” Field explained. When counselors press the processing of shame before clients are ready, it can cause clients to, in essence, feel shame about their shame.

Counselors should also let clients know what to expect when they decide to share their trauma. For instance, Field said, “The client is going to feel physiological symptoms.”

Through client mirroring and active listening, counselors can help establish a sort of holding container for these clients’ emotions. This takes away the pressure of having to “do” anything with those emotions, allowing clients to feel safe simply “sitting” with their feelings until they are completely ready to process them, Field explained.

Like Duffey, Field thinks that self-compassion is essential to overcoming shame. The ultimate goal is to teach clients to accept their current and past experiences without self-judgment, he said. Field recommended that counselors use some of the exercises developed by psychologist and self-compassion researcher Kristin Neff. These include having clients imagine how they would treat a friend who was in the same circumstance, writing letters to themselves from a place of compassion, changing critical self-talk through reframing, keeping a self-compassion journal and practicing loving-kindness meditation.

The lasting shame of abuse

For clients who were sexually abused as children, the sense of shame is almost primal, says ACA member David Lawson, who has worked with trauma victims for more than 25 years. Time after time, women in their 30s and 40s have sat in Lawson’s office and insisted that it was somehow their fault that they were sexually abused as children.

“They say, ‘There must be something wrong with me.’ ‘I’m bad.’ ‘I’m contaminated,’” says Lawson, a counseling professor at Sam Houston State University in Texas who has conducted extensive research on trauma. “I’ve even had several people say, ‘I must be evil in some way for this to happen to me.’”

When parents are the perpetrators of sexual abuse, the abuse survivors’ sense of shame is particularly strong, Lawson says, because humans are wired to seek attachment with parental and other caregiving figures. To maintain this attachment, child victims must rationalize the abuse. As a result, these children often tell themselves that they are bad rather than accepting that the parent is not good, Lawson explains.

Another factor that contributes to these children’s feelings of shame is the perceived “benefits” they received from their abusers, Lawson says. He recounts the story of a female client in her 20s.

“She was abused from the ages of 5 to 16 by her father [until] her mother finally left the father. Years later she came into therapy, and I said, ‘Tell me about some of the best times in your life.’ She said that they were with her father: ‘At times I felt like I was my father’s girlfriend.’ There were benefits for her. He would buy her things and take her places, which he did not do with her siblings. Then, at night, the abuse would happen.”

The woman went on to confide to Lawson that the worst times in her life were also with her father. “He would tell her, ‘No one else will love you. You are worthless. No one will have you but me,’” Lawson says.

Abusers often use this technique, aware that if their victims feel there is nowhere else they can go and be accepted, there is a greater chance they will stay in the only place they seem welcome. This “acceptance” increases victims’ sense of connection to their abusers, Lawson says.

These patterns are distinct and specific to what Lawson calls the “trauma subculture.” The behaviors and beliefs of survivors of sexual trauma are so antithetical to most people’s expectations that outsiders — including many counselors — often find their reactions difficult to understand, he says.

“One of the hardest things for my students to get over is the way that [sexual trauma survivors] look at the world and the way they think about themselves,” Lawson says. “We just want to run over and hug them, but that just ramps up their shame because they don’t believe that they’re worthy.”

Early in his career, Lawson learned how premature sympathy and acceptance could backfire. He told a client that the abuse the client had suffered was not his fault, and the client got quite angry with Lawson, rejecting his help because he genuinely thought that Lawson didn’t know what he was doing.

What Lawson learned with that experience is that in immediately trying to correct clients’ beliefs about their abuse, counselors threaten to take away a major part of the identities that clients constructed as a way to survive. Today, Lawson urges counselors to move slowly with these clients and first work toward establishing a strong therapeutic bond.

“It may take many sessions just for them to feel comfortable,” he says. “These people don’t trust anyone, so to think that they’re going to trust in a few sessions is naïve and counterproductive.”

Start by accepting these clients where they are and reflecting on the dilemma they are facing, Lawson advises. “On the one hand, they feel an enormous amount of allegiance. On the other hand, they have strong feelings of hate,” he explains.

After counselors have established a relationship, they can introduce the idea of talking about the client’s experience. A counselor could say, “Talk to me about your relationship with your father and how you came to the conclusion that you’re not worthy of anyone else’s love,” Lawson suggests. He adds that counselors must give clients time to reflect and reconstruct how they came to their conclusions about self-worth.

Lawson says that once he asks those kinds of questions and lets clients unpack and narrate their experiences at their own pace, they are usually able to begin seeing how their erroneous, negative self-beliefs were shaped by what happened to them. He cautions, however, that intellectual understanding is not the same as emotional acceptance, which can take additional time. Lawson notes that some experts view this kind of shame as an annihilation of self. Survivors may feel that there is no part of themselves that is worth forgiving, he explains.

In the process of helping clients see themselves as redeemable, fully acknowledge the abuse that happened to them and grieve what was lost, counselors should be supportive, but they must also modulate their affirmation to a level that the client can handle, Lawson cautions. “If we’re too warm and nurturing, the client takes that and rejects it and sees us as incompetent because we don’t understand,” he says.

For that matter, trauma (and shame) may not be the stated concern that brings survivors of sexual abuse into counseling in the first place. Instead, the presenting issue may be depression, anxiety, relationship difficulties or something else, Lawson says. “I deal with whatever they present with and try to help them get some relief from those things,” he says.

But along the way, Lawson introduces the idea of addressing and processing the trauma with clients. He may approach it in a very general way at first, perhaps by asking clients to talk about the trauma as if it happened to someone else.

Lawson may also use a “lifetime line.” He starts by asking clients to pick a year of their lives and talk about everything they can remember about it — good and bad. By doing this, clients are not only processing trauma, but also remembering that there were positive events in their lives too, he says. Lawson also has clients write down all the positive memories to help remind them, as they construct their life narrative, that the abuse does not encompass their entire life.

Lawson says he finds narratives, either written or spoken, vital in treating clients’ shame. By showing compassion for their narratives, counselors can help clients start to feel compassion for themselves, he says.

Shame beliefs

Gray Otis, a licensed clinical mental health counselor in Cedar Hills, Utah, believes that shame is typically a component in traditional mental health disorders such as depression and anxiety. In fact, he says, shame likely underlies most issues for which clients come to counseling.

“Typically, the individuals who come for treatment have strongly held negative core beliefs about themselves,” says Otis, who has extensive postgraduate training in trauma treatment. These negative core beliefs are not just about behavior, he adds, but actually inform people’s sense of who they are.

Otis, whose counseling approach is centered on positive behavioral health, thinks that these beliefs stem from incidents that evoke a sense of shame in the person. Such events typically take place in childhood or adolescence, but adults can experience them too. These incidents may or may not be described as “traumatic.” Negative core beliefs can be caused by an accumulation of painful events, such as consistently being criticized as a child or going through a divorce. The resulting beliefs can take many forms, Otis says, but they generally revolve around reinforced themes — for instance, a person growing to believe that he or she is stupid, unworthy, undeserving and unlovable.

Otis believes the key to addressing clients’ mental health issues is uncovering and dispelling their shame-based negative core beliefs. The difficulty counselors may face in unraveling a client’s core beliefs will vary depending on the person and the complexity of his or her presenting issues. However, Otis says he finds it relatively straightforward to uncover many of these beliefs. When he asks clients to identify some of the things they believe about themselves that are not positive — Otis directs them to use “I am” statements — they can usually identify five or more negative beliefs, he says.

What is particularly potent about the beliefs underlying these “I am” statements is that people tend to perceive them as being inherent, unchangeable personal traits, Otis says. Many of these core beliefs are subconscious, he adds. By helping clients bring them to the surface and recognize that they are beliefs, not traits, counselors can assist clients in replacing negative beliefs with positive core beliefs.

Otis does this by having clients explore the origins of one of their negative beliefs, asking them when they started believing this internalized truth about themselves and what happened that contributed to that belief. Otis then asks clients to focus on one of their most distressful experiences and “freeze” it, as if it were a photograph. He then urges them to describe the emotional sense of the experience, identify their degree of distress and state the shame-based negative core belief (such as “I am never good enough”).

The next step is for clients to specify the positive core belief they desire. Otis then helps them identify life events that reinforce the new, positive core belief. He asks clients to remind themselves of these reinforcing events daily as a way to continue strengthening their positive belief. Next, Otis has clients revisit the experience that engendered the negative belief, and he talks with them about how the event was misinterpreted.

Otis says he also uses methods such as sand tray therapy, eye movement desensitization and reprocessing, and cognitive behavior therapy not only to help clients develop more positive beliefs but also to become more resilient. He emphasizes, however, that the most important factor when working with shame-based negative core beliefs is a strong therapeutic alliance.

Ultimately, he says, helping clients rid themselves of persistent shame is what opens the door to healing.

 

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

Letters to the editor: ct@counseling.org

 

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

Mental health implications of undocumented immigrant status

By Laura M. Gonzalez and Nathaniel N. Ivers April 6, 2017

The phrase undocumented immigrant, or its less charitable counterpart, illegal alien, tends to cause a stir in the media. The focus is on the paperwork, the lack of permission or legal status to be in the United States. However, for counselors to work effectively with this population, it is helpful to spend some time considering the second part of that phrase: immigrant.

For a person to decide to leave all that is known, familiar and comforting behind, he or she is likely in a state of considerable duress. Among the stressors that push immigrants to leave their homes are grinding poverty and starvation, threatened or actual violence, extortion from gangs, ethnic or religious discrimination and lack of hope that their situation will improve. Whether their journey involves hiding in a container in a cargo ship, clinging to the top of a moving train or walking through difficult terrain, it is not a decision to be taken lightly. Such a journey can last for months and be extremely perilous.

A person who decides to undertake such a journey as the “best available option” is already living in a state of physical, mental and emotional deprivation. We encourage counselors to consider the challenges posed by the pervasive stressors present in the person’s home country, the possible trauma encountered on the journey and the difficulty of living in the shadows in a new land where so much is strange and unfamiliar.

We have several goals with this article. We wish to clarify terminology and definitions to generate an accurate understanding of this population, describe some of the challenges facing families with undocumented members in the United States, outline some commonly occurring mental health issues among undocumented immigrants and provide counselors with some resources and ideas about how to respond to these clients. In addition to building individual capacity to respond among counselors, we hope to inspire advocates in our profession to consider systems-level responses or ways we can promote more equitable access to the support systems that undocumented immigrants often need. We are focusing on the undocumented portion of the immigrant population because of the severity of their needs and the relative scarcity of resources to meet those needs.

In terms of definitions, immigrants are people who leave their home country to live (temporarily or permanently) in a host country. They differ from refugees, which are defined as individuals fleeing persecution, war or natural disaster. The United Nations classifies refugees as a protected group, and if a host country offers these individuals asylum, it comes with automatic legal status. Immigrants can apply to receive temporary legal status based on a special function (such as a work visa or student visa), or they may become eligible for residency through a qualified family member who is a U.S. citizen. However, there are caps on each category (i.e., not every person who wishes to come to the U.S. to work or study may do so). Deferred Action for Childhood Arrivals (more commonly known as DACA) is a temporary permission to work that does not provide true legal standing in the U.S., and it can potentially be revoked by executive action.

It is important to have a trusted source for accurate information about immigration, especially when so much inaccurate information abounds in other public sources. In particular, counselors may wish to become familiar with eligibility for health and human services for undocumented immigrants. A helpful source for this information is the National Immigration Law Center website (nilc.org), which provides details about eligibility for health care services, education, workers’ rights, driver’s licenses, economic support programs and so on.

It also is important for counselors to be aware that differences exist between federal and state immigration policies and practices. Some states have created restrictive laws to govern activities such as enrolling an undocumented child in school, presenting for services in an emergency room and applying for a driver’s license. Thus, it is incumbent upon counselors to understand the climate and laws within their states and local communities. The current policy climate is changing rapidly, so staying up to date is essential.

Common challenges

Each immigrant family with at least one undocumented member is unique, but some typical challenges do exist. For adult immigrants who are undocumented, there are daily concerns about detection by the authorities, potential deportation and separation from other family members. Even an act as simple as driving to the grocery store can be perilous without a driver’s license, so undocumented immigrants may adopt the mantra “trust no one” and try to live in the shadows, undetected. The newest guidelines from the Department of Homeland Security (dhs.gov/executive-orders-protecting-homeland) include a broader definition of priorities for deportation. This change has generated enormous fear in the immigrant community.

Many undocumented immigrants must work jobs in which they are paid as part of the underground economy. Thus, they are not able to speak out against unsafe workplace conditions or unfair or discriminatory practices for fear of retribution. These jobs often pay poverty-level wages and involve hard manual labor. Some undocumented immigrants work more than one job to make ends meet.

Adults who are undocumented are also unlikely to have access to needed services such as health, legal, educational and other social support services, so they have unmet needs in terms of physical and mental health. In addition, it is common for these adults to have experienced some form of trauma — physical or sexual assault, robbery, threats, extortion, bearing witness to murder — during their journey to the U.S., so there is an accumulation of stressors that can become quite profound.

Youth living in a family with at least one undocumented member experience some of the same stressors — concerns about deportation of a family member, poverty, lack of services, etc. But some of their concerns are different. In most cases, these youth will have access to basic K-12 education, so they often acculturate to U.S. language and culture norms more quickly than do their parents. This can be difficult in the early phases of adjustment, but it does bring some benefit in terms of language proficiency, educational opportunity and socialization.

However, when their friends start moving through rites of passage such as getting a driver’s license, landing a first job or applying to college, youth who are undocumented or who have an undocumented parent have a strikingly divergent experience. Some are already aware of their legal status, but other youth first learn about their lack of documentation when they ask their parents to assist with these normative tasks. At this point, some youth become disillusioned and depressed, believing that all of their dreams and aspirations are now beyond their reach. Without a socially sanctioned way to participate in society, these youth may become involved in maladaptive coping strategies (e.g., gang involvement, substance abuse). Other undocumented youth become more determined and start fighting to achieve their goals, even if they have to create new systems outside of the defined legal structures.

In both cases, it is unlikely that their parents will be able to provide much assistance, so undocumented youth will almost always need advocates or champions from outside of their group to assist them. It is risky to identify oneself as undocumented in today’s hostile political climate, so finding an advocate is not a straightforward process. Adults who are familiar with the signs and signals that a youth (or a youth’s family member) may be undocumented — for example, not driving, not applying to college even with a good academic record, having many absences from school that are not typical — may find ways to reach out and indirectly inquire about the youth’s circumstances or offer resources. Counselors might wish to review websites such as the Department of Education’s Resource Guide: Supporting Undocumented Youth (www2.ed.gov/about/overview/focus/supporting-undocumented-youth.pdf) and the UCLA clearinghouse of resources on undocumented youth (smhp.psych.ucla.edu/qf/undoc.html).

Using ecological systems theory 

It is important that counselors understand the singular environmental factors and societal barriers that have the potential to affect the development and mental health of undocumented youth and families. This understanding can prepare counselors to apply more effective strategies when working with undocumented clients or families.

Urie Bronfenbrenner’s ecological systems theory may be a particularly helpful tool for counselors in this regard. Bronfenbrenner’s theory describes human development in terms of interactions between individuals’ personal characteristics and their environmental systems. The five environmental systems are the microsystem, mesosystem, exosystem, macrosystem and chronosystem.

The microsystem is the most immediate environment in which an individual interacts. For children, microsystems commonly consist of a small group of people, such as parents, siblings, schoolteachers, friends and classmates. The mesosystem is the interaction between microsystems, such as the communications between parents and teachers.

The exosystem is outside of one’s direct interaction but still has the potential to impact one’s mental health and development because it directly influences members of one’s microsystem. This might include a parent’s relationship with his or her boss or co-workers, or a teacher’s relationship with his or her principal. A common example of the influence of the exosystem on someone is that of a parent who feels unappreciated and disrespected at work and then displaces that anger and frustration onto his or her children.

The macrosystem is the largest ecological system. It includes cultural values and beliefs, and political and economic systems. The chronosystem, which includes constancy and change, reflects the influence of time on one’s development.

Undocumented immigrant status can influence all aspects of a person’s ecological system. In the microsystem, immigration may affect the relationships among and between family members. The combination of fewer community and financial resources plus the need to stay obscure or in the shadows may reduce the number of microsystems that undocumented youth and families have. For example, documented youth may engage in more extracurricular activities than do undocumented youth. This expands the microsystems of documented youth to include additional people, such as teammates, music teachers and coaches.

Immigration, and particularly undocumented immigration, may also change traditionally microsystemic relationships into exosystemic relationships. For example, it is common for undocumented families to immigrate to the United States in waves, with a parent initially leaving children with extended family members. This can lead to parents becoming part of their children’s exosystem for a period of time. Later, when children are able to immigrate to the United States to reunite with their parents, the relationship rapidly shifts back to one that is microsystemic. These sudden shifts in interactions can require an adjustment period and strain the relationships between undocumented youth and their parents. Changes in microsystems can also occur as the result of other factors such as deportation.

Undocumented immigration may also influence the mesosystem, or interactions between microsystems, particularly in reference to the quality and frequency of such interactions. One example is the relationship between a child’s schoolteacher and parents. Language differences between parents and teachers can affect the strength of this relationship, which can in turn reduce the ability of undocumented parents to be fully involved in their child’s school. This can prove particularly challenging when difficult and complicated situations such as discrimination or bullying occur.

The indirect aspect of the exosystem may be particularly pronounced with undocumented youth and families. Parents who are trying to make ends meet but who are not legally allowed to work in the United States may work long hours at very low-paying jobs and experience exploitation, prejudice and discrimination. Parents who experience financial stress and fear of potential deportation may inadvertently displace their preoccupations onto their children in the form of irritation and frustration. This can negatively impact the mental health and development of these youth.

The macrosystem also may have a profound effect on mental health and development. In particular, marginalized groups such as undocumented youth and families are particularly vulnerable to economic and political trends. This is certainly true in reference to the legislation and execution of laws associated with undocumented immigration. As previously mentioned, undocumented youth who learn of their undocumented status and the barriers associated with that status in terms of securing education, employment, a driver’s license and so on may be particularly susceptible to feelings of despair, hopelessness, helplessness, anxiety and fear.

Unique factors associated with the chronosystem also may be in play with individuals and families who are undocumented. In particular, the possibility of change, such as deportation, may constantly be on the minds of undocumented youth or members of their microsystems. Changes (or a lack thereof) in immigration policies and laws may also affect the mental health of undocumented individuals. For example, in 2010, Dreamers anxiously awaited the prospect of gaining citizenship through federal legislation (known as the Dream Act). However, this legislation was met with barriers and did not pass Congress. This was a huge blow to many who were leaning on this legislation for the prospect of stability, opportunities for education and careers, and other privileges of full citizenship.

More recently, political rhetoric and actions associated with securing the U.S. border and enforcing immigration laws more strictly have created a great deal of uncertainty and fear in undocumented immigrant communities.

Strategies for working with undocumented clients 

Counselors can do a number of things to help undocumented individuals and their families. With respect to the microsystem, counselors can provide a space for undocumented youth and families to vent their frustrations, fears, mistrust and sadness associated with their experiences of discrimination, exploitation and barriers. Helping parents to express their frustrations may reduce the chances of them displacing anger and frustration onto other members of the family unit. Counselors can also help parents problem-solve and cope with challenging aspects of their lives, such as dealing with disrespectful co-workers or prejudicial bosses. In addition, counselors can help parents prepare for worst-case scenarios, such as steps they could take in the event that one or both parents were detained or deported.

Concerning the mesosystem, counselors can help youth and families develop their relationships with other microsystems, such as teachers and other school personnel. In particular, it is important for counselors to help undocumented youth and parents brainstorm ways to respond to school personnel about school issues such as academic struggles, behavioral challenges, discrimination and bullying. With clients’ permission, counselors working with undocumented youth and families may also consider taking on an advocacy role with school systems, particularly when discrimination and unresolved bullying are occurring.

With respect to the macrosystem, counselors may consider advocating for changes in the law regarding illegal immigration. This may include advocating for pathways to citizenship, better access to community resources and so on. It also may take the form of advocating against movements or legislation that would be harmful to undocumented youth and their families.

Counselors can also help youth and families draw upon and cultivate resilience. This may take the form of helping clients to remember the struggles and obstacles they have already been through and rediscover the strengths they possess that have helped them navigate these trials.

Case study

The following is a brief case study of a counseling experience that one of the article authors had with an undocumented family. Specific names and circumstances have been changed to protect the family’s identity. Many of the details of this case are common experiences that undocumented families face.

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Marcus, an undocumented immigrant who is 14 and speaks Spanish, was referred to you by the school social worker. Marcus attends the first session with his 45-year-old mother, Elizabeth, who also speaks Spanish and is undocumented. Elizabeth shares with you that she immigrated alone to the United States 10 years ago. Because of financial difficulties, she had to leave Marcus with her parents in her country of origin. A few months before this first session, Marcus was able to join his mother in the U.S. Elizabeth shares that Marcus refuses to call her “mom” and acts very standoffish toward her.

Marcus shares that he doesn’t know why he had to come to the United States. He says that he was happy in his country of origin and misses his friends, grandparents and cousins. He also says that he doesn’t like school, that English is difficult for him to learn and that students at the school pick on him. He says he can understand the names the other kids call him and the mean things they say. He doesn’t have enough command of English to fight back with his words, however, so he uses his fists. Marcus has used his fists to fend off verbal attacks a number of times and, on each occasion, he has been suspended from school.

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In this case example, Marcus’ microsystem changed suddenly. He was uprooted from the only life he had known, where he had friends and close connections to extended family. Using Bronfenbrenner’s model as a reference, we see that Marcus was separated from his ecological system — a system in which he knew the explicit and implicit cultural beliefs, values and rules and interacted with people who looked like him and shared his language. His microsystem changed from that of friends, grandparents, uncles, aunts and cousins to that of his mother and a schoolteacher.

Furthermore, Marcus’ mother, who for many years had been part of his exosystem — someone who influenced his life indirectly but didn’t interact with him outside of an occasional phone call and letter — became his primary microsystem. Elizabeth, who missed her son dearly and felt guilty for not being there to raise him, wanted desperately to pick up where they had left off before she immigrated to the United States. Marcus was not able to reciprocate her feelings, which hurt Elizabeth deeply.

Although Elizabeth had lived in the United States for a decade, she had interacted primarily with other Spanish speakers and largely remained in the shadows to avoid detection. Therefore, she struggled to communicate with school personnel at Marcus’ school and did not know how to help her son deal with the bullying that he experienced.

The counselor should take into account a number of factors when conceptualizing and treating this family. Systemically, it is important to recognize the changes (chronosystem) that have occurred in the lives of both Elizabeth and Marcus and how they are adjusting to those changes. The counselor might help Elizabeth recognize the adjustments that Marcus is experiencing and assist her in developing realistic expectations regarding their relationship. It also would be beneficial to further assess her relationship and interactions with Marcus’ school (mesosystem) and co-construct strategies to help her figure out what is going on in school and how to advocate for her son. The counselor also might consider ways that he or she can advocate appropriately on behalf of the family.

The counselor also might assess Marcus’ exosystem by understanding the stressors that Elizabeth faces in her daily life. These include working multiple jobs, experiencing pressure from family members in her country of origin to help out financially and dealing with ongoing fears of deportation. If Elizabeth is facing a great deal of stress and anxiety, the counselor could take care to validate Elizabeth’s emotions and provide her with stress-reduction tools.

The counselor can work with Marcus to develop healthy strategies for dealing with the verbal abuse he reports experiencing at school. The counselor also might work to broaden Marcus’ microsystem by looking into community programs in which Marcus might be interested, including sports programs, after-school programs or a mentorship program.

Conclusion and resources

Seemingly insurmountable barriers exist for undocumented children and families, but counselors can take a number of steps to facilitate the mental health of these clients. It can be particularly helpful to conceptualize undocumented families’ circumstances from a systemic perspective, such as Bronfenbrenner’s ecological systems theory. It also is helpful to validate clients’ experiences while drawing upon their resources, including the resilience and skills they have used to overcome past trials and struggles.

Finally, it is important for counselors to be aware of the resources that exist to help undocumented families. The following resources will get you started.

In addition, we recommend the following books for those who wish to deepen their personal understanding of the narratives of undocumented immigrants:

  • Enrique’s Journey: The Story of a Boy’s Dangerous Odyssey to Reunite With His Mother by Sonia Nazario
  • Underground America: Narratives of Undocumented Lives compiled and edited by Peter Orner

 

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

Laura M. Gonzalez is an associate professor in the School of Education at the University of North Carolina at Greensboro, having received a Ph.D. in counselor education from North Carolina State University and an M.Ed. in college counseling from the University of Delaware. In addition, she has conducted research and outreach to the Latino immigrant community with the goal of enhancing educational access. Contact her at lmgonza2@uncg.edu.

Nathaniel N. Ivers is an assistant professor in the Department of Counseling at Wake Forest University. He received his master’s in counseling from Wake Forest University and a Ph.D. in counseling and counselor education from the University of North Carolina at Greensboro. He has published research and conceptual papers related to Latino immigrants and has provided counseling to the Spanish-speaking immigrant population in North Carolina. Contact him at iversnn@wfu.edu.

Letters to the editor: ct@counseling.org

 

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