Tag Archives: Mental Health

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.

Digging into the numbers

By Scott Rasmus February 9, 2017

It has been relatively well-publicized in the media that mental illness typically affects 20 percent of the U.S. population, or about 1 in 5 people, yet the source of this statistic is rarely disclosed. Furthermore, media sources typically discuss mental illness in general terms and don’t address its susceptibility by age or present statistics on the prevalence of mental illness over time. For instance, a basic comparison of mental illness prevalence statistics between children and adults, or in any given year versus over a person’s lifetime, is rarely offered.

Therefore, I wanted to offer a web-based meta-analysis of prevalence statistics for mental illness by including as many reputable sources of mental health information as I could identify. These sources include the Centers for Disease Control and Prevention, the National Alliance on Mental Illness, the American Psychological Association, the American Psychiatric Association, the National Institute of Mental Health (NIMH), the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of the Surgeon General. The focus of my research was on the most current web research available, spanning the years 2011 to 2015.

Prevalence data

What are the generally accepted definitions of one-year prevalence and lifetime prevalence for mental illness? The NIMH defines one-year prevalence as the proportion of people who have experienced a mental illness in the past year, whereas lifetime prevalence reflects how many people have experienced an incidence of mental illness at any point in their lives up until the point of assessment. These numbers are typically reported as a percentage of the population. It is important to note that these statistics do not necessarily reflect new cases of mental illness, but rather those individuals who have experienced an instance of mental illness — new, ongoing or otherwise — in a given time period. With these definitions in mind, let’s look at the prevalence numbers.

In reviewing the prevalence statistics from various sources, my web research indicated that the average one-year prevalence for adults with mental illness was 22.2 percent (see Table 1), ranging from 14.5 to 26.2 percent over eight well-accepted sources. The average number trends higher than the general prevalence statistic that is often cited in the media, indicating that mental illness is somewhat more common than what is typically reported. With this in mind, one-year prevalence statistics should be revised and presented to the public to reflect that mental illness affects between 20 and 25 percent of adults in any given year.

For youths, I found data only for those ages 8-18. My research indicated that the average one-year prevalence number for mental illness among youths supported the number that is typically reported in the media — 20 percent (see Table 1). However, whereas I identified eight reputable sources of statistics for prevalence of mental illness among adults, I could identify no more than two such sources for youths. This discrepancy in viable sources suggests that a need exists for better research to identify the prevalence of mental illness among our children and adolescents.

I next refined the study to look at the one-year prevalence statistics for severe mental illness (see Table 2). When investigating this special population that is rarely reported in the media, my research indicated that the one-year prevalence average of severe mental illness among adults was 5.7 percent, ranging from 4 to 9.5 percent over seven sources. For youths ages 8-18, the one-year prevalence for severe mental illness averaged about 14 percent over just two sources, with a wide range from 9 to 20 percent.

Putting these numbers in the context of general mental illness, it implies that among adults, severe mental illness constitutes about a quarter of all cases, whereas among youths, severe mental illness makes up more than two-thirds of cases in any given year. This highlights an interesting difference, but we may infer from these numbers that the prevalence of severe mental illness can differ widely based on the definitions applied to it.

My experience suggests that these definitions tend to be more ambiguous and often are termed “severe mental illness,” “severe mental disorder” or “severe emotional disturbance,” to name a few. In my work over the past several years, I have noticed that the interpretation of the definition for severe mental illness can vary so greatly that it may include as few as five mental illness diagnoses or more than 100. SAMHSA’s National Registry of Evidence-based Programs and Practices identifies 17 related terms for severe mental illness. These terms can vary by state and with the inclusion or exclusion of childhood mental disorders and functional impairment criteria. On top of this variance, mental health professionals understand that there is some subjectivity involved in the diagnosis of mental disorders to begin with, even before the classification of the mental illness is determined as severe or not.

Next, I looked at the lifetime prevalence of mental illness for both adults and youths (see Table 3). Interestingly, I found the number of credible sources for these statistics much more limited than those for one-year prevalence, with only two sources apiece for both adults and youths. For adults, the lifetime prevalence statistics averaged 48.2 percent, with a range from 46.4 to 50 percent. For youths, the lifetime prevalence of mental illness ranged from 13 percent (ages 8-15) to 46 percent (ages 13-18), averaging about 30 percent over the full 8-18 age range. Given that youths have had fewer years to experience mental illness, it makes sense that their lifetime prevalence rates are lower than the lifetime prevalence rates of adults.

Finally, when considering the lifetime prevalence of severe mental illness (see Table 4), I could find reliable statistics only for youths, with an average prevalence of approximately 21 percent over two sources. I didn’t find enough credible information about the lifetime prevalence of severe mental illness in adults to even report here. Given the scarcity of statistics for both youths and adults related to lifetime prevalence of severe mental illness, this appears to represent a large gap in the research.

Concerning numbers

After reviewing the prevalence data for mental illness, it makes sense to me to consider current research statistics related to how many individuals with mental illness actually receive treatment for their disorders in a given year. My research indicates that the statistics for both youths and adults seem very consistent with age, averaging about 45 percent overall, and ranging over four sources from 39 to 50 percent.

These numbers shocked me somewhat and were very concerning. Such statistics indicate that regardless of age, less than half of the people who experience an episode of mental illness receive the mental health treatment that they need. This statistic begs the question: Why is this the case?

I can only hypothesize about the answer, which likely has many facets, including a general lack of awareness about mental illness, the need for education around it and the powerful influence of stigma related to mental illness. The media associates mental illness with a number of negative outcomes, particularly highlighting its relationship to violence, which in reality is very rare. To better address this misperception, the board for which I serve as the executive director — the Mental Health and Addiction Recovery Services Board in Butler County, Ohio — has adopted a position statement based on multiple sources indicating that only 3 to 5 percent of those with mental illness are violent. Still, let me offer a practical example of how the prevalence numbers and treatment statistics can be applied to the county where I live and work.

Based on the 2010 census numbers, Butler County has a population of about 370,000 residents. Applying the one-year prevalence statistics for mental illness of 20 to 25 percent, this implies that between 74,000 and 93,000 residents in our county experience an incidence of mental illness in a given year. Of those residents, upward of half don’t receive the mental health treatment services that they need. Potentially, that’s more than 46,000 county residents who may not be living their lives in as fulfilling and productive a manner as they otherwise could, especially when we know that mental health treatment largely works. People recover through modalities such as talk therapy, medications, lifestyle changes and other treatment approaches, which often are incorporated in an integrated way. What a challenge we face in addressing the mental health needs not only in my county but in our entire country and beyond. There are so many lives affected and so much productivity lost to what are very treatable illnesses.

Compiling the information I have shared in this article on the prevalence of mental illness related to time, age and treatment has really impressed on me how much work remains to be done to obtain better estimates of the general incidence of mental illness in our country and the world. We especially need more detailed statistics related to the cultural and demographic aspects of mental illness. The bible of mental illness, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, contains some valuable information related to prevalence and cultural data for specific diagnoses. There remains, however, a need for better research via large random studies that look at mental illness in general, including developmental disabilities and substance use disorders. I often wonder if the published mental health statistics that I review include these categories of mental illness.

Furthermore, as better statistics are researched and reported, mental health prevalence numbers need to be compared with those of well-known physical illnesses such as cancer, heart disease, diabetes, obesity and hypertension. In this way, I believe we can better demonstrate and publicize how common mental illness truly is in our society. Taking these actions will go a long way toward educating the public about its incidence, thus normalizing mental illness and, I hope, reducing the stigma with which it is often associated.

 

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

Scott Rasmus is the executive director of the Butler County (Ohio) Mental Health and Addiction Recovery Services Board. He received his doctorate in counselor education from the University of Central Florida. He is dually licensed in Ohio as a licensed professional clinical counselor-supervisor and as an independent marriage and family therapist. He has presented internationally on mental health topics. Contact him at RasmusSD@bcmhars.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.

The (misguided) pursuit of happiness

By Laurie Meyers February 1, 2017

Happiness. Most Americans seem to believe that it is something to which we are entitled. After all, happiness — or at least the pursuit of it — is enshrined in our nation’s Declaration of Independence.

As a result, we invest a significant amount of time, money and effort looking for that magical thing/place/person/experience that will ultimately deliver the promise of happiness. We play the lottery, hoping for the big payoff that will make everything better. We buy books that promise us happiness in X number of steps. We go to spas and wellness retreats hoping to meditate, stretch or massage our way to happiness. There is even a whole school of psychological thought — positive psychology — that has devoted much of its time to the study of happiness.

But what is happiness? Is it a state of being? A process? A transient emotion? And whatever it is, can counselors help clients find or achieve it?

“I think our culture defines happiness as a relative emotional state of bliss or euphoria that comes and goes,” says licensed professional counselor Ryan Thomas Neace, the founder of Change Inc., a counseling practice in St. Louis that focuses on holistic practices to help clients achieve biological, psychological, social and spiritual wellness. “The great irony being that we tend to ignore that relative ‘coming and going’ and demand that happiness stick around permanently. It doesn’t end very well that way.”

Reaching for the wrong goal

Perhaps happiness isn’t exactly what most people are looking for after all.

“I think we struggle with the fleeting nature of happiness because our culture is so consumeristic,” says Neace, an American Counseling Association member who also blogs about spirituality and religion on The Huffington Post website. “Happiness, we think, like everything else, ought to be something we can obtain on a permanent basis if we just put together the right combination of life factors — a nice body, a good partner, a strong education, a large salary, etc. If we’re unhappy, we work out more and eat less, end a relationship and/or start a new one, change schools or jobs, etc.”

But none of those things can deliver lasting happiness, Neace asserts. “Even if some of these things are related to happiness, they don’t change its fundamental nature as fleeting and elusive,” he says.

People sometimes seek happiness by avoiding reality, Neace observes. “Anything that helps us to avoid reality on a relatively permanent basis cannot ultimately lead to happiness and is eventually — if not immediately — destructive,” he says. “I’m not talking about the person who has had a rough day and decides to smoke a joint or have a glass of wine to relax a little, and I’m not talking about people who use fantasy playfully in recreation or to spice up their sex lives.

“Instead, I’m talking about the clients I’ve had who plow through their lives doing anything they can to avoid facing up to their mismatched occupations, their wayward teenagers, their sexual identities, etc. I’m talking about the person who avoids looking at his or her failing marriage because they don’t want to be unhappy. It sounds so illogical from an outside, third-party perspective, but it happens all the time. What really happens isn’t that the person doing the avoiding somehow magically becomes happy; [it’s] that their unhappiness shifts locations, usually to someplace outside their conscious awareness. So the person in an unhappy marriage compulsively spends money or works excessively to avoid being at home. It’s like squeezing one end of a balloon — it just makes the other end swell.”

Even some of the most prominent voices in happiness research are rethinking happiness as a goal. For instance, Martin Seligman, the founder of positive psychology and author of the 2002 book Authentic Happiness, eventually rejected happiness as the ultimate goal. In his 2011 book Flourish: A Visionary New Understanding of Happiness and Well-being, Seligman discussed the limitations of happiness as the key to life satisfaction. This is because happiness is too based on mood, he said, so Seligman redefined positive psychology to focus on “well-being.”

True satisfaction

If happiness is not necessarily to be the stated goal in counseling, what is? “In therapy, I try to contrast that for clients with something that is probably more akin to contentment, which I define as a quality of ‘OK-ness’ that is nonrelative –— present for the most part without regard to circumstance or situation,” Neace says. “Contentment can include moments of happiness, but it doesn’t demand that those feelings, or any others for that matter, stick around. Contentment transcends happiness and allows it to actually be what we already know it is — sometimes fleeting and elusive, prone to slip away when the wind changes direction.”

Maya Georgieva, a national certified counselor whose counseling approach emphasizes wellness and focuses on the effects of emotional strain on the body, prefers to concentrate on helping clients live richer, fuller lives. Rather than helping clients strive for happiness, Georgieva views her goal as helping them to grow — a process that is unique to each individual. Instead of focusing on attaining some ephemeral state of being, she believes it is more important to find out what the client wants to achieve and what he or she wants to change.

Georgieva encourages “self-actualization” for clients. “We’re born with the ability and desire … to grow,” she says. Growth involves removing any barriers that hinder clients from learning and creating new relationships and accomplishments.

When clients show up to counseling looking for “happiness,” Neace emphasizes the importance of telling them that contentment should be the goal instead. “There’s typically a ton of work to be done there simply around insight and helping people recognize the problem underneath the problem,” he says. “In other words, clients typically come in and tell us that some relationship or job or situation is unsatisfactory and must change. [In their eyes], it is the problem. … It is our job to point out to them that perhaps it is their approach — trying to squeeze happiness out of every situation — that actually causes the real trouble and is, in fact, the problem underneath the problem.”

“The key here for counselors is helping clients understand that reality can actually be a decent source upon which to base their existence,” he continues. Reality might not always be happy, but it can serve as the basis for contentment, Neace observes.

The leisure perspective 

ACA member Rodney Dieser believes leisure is very important for overall well-being. As such, he is a proponent of the “serious leisure perspective,” which was developed by sociologist Robert Stebbins.

As explained by Dieser, a professor of leisure, youth and human services at the University of Northern Iowa, the serious leisure perspective has three components.

1) Serious leisure involves spending a large amount of time to master skills as a hobby. An example would be learning to play an instrument over time and participating in the community orchestra.

2) Casual leisure is what most people think of as leisure. Examples include relaxing, going to a restaurant, resting on a hammock or going to the beach.

3) Project-based leisure involves taking on a project that is somewhat complicated but that doesn’t involve more “serious skills.” Examples include planning a family vacation, engaging in fundraising for a local community project or participating in other kinds of volunteer efforts.

In addition to allowing the body to relax, leisure can help clients build and strengthen relationships, achieve a sense of purpose and establish a sense of community, Dieser says. For example, Dieser once worked with a middle-aged man who had stage 4 renal disease that rendered him unable to work. He was home on disability and depressed. Part of his distress involved his identity as a traditional male who viewed himself as the primary provider for the family. Now, because of renal disease, his wife had to work and provide financial support for the family instead.

“One of the things I did was ask him to reflect back on his life. Was there anything he did in his free time that he enjoyed?” Dieser recalls. “He said that he used to fish a lot and was a serious angler and fly fisherman. He still had the rods and tackle box, but all the gear hadn’t been out in 10 years.”

Dieser suggested that because the man now had extra time on his hands and already owned all the gear, he might consider taking up fishing again. The man started going out regularly and even taught his daughter how to fish. The father and daughter bonded over these experiences, which ultimately made their relationship stronger.

“When I first met him in assessment, his role/purpose in life was his family,” Dieser says. “So now he is fishing regularly with his daughter, which is fulfilling his existential purpose. One of the benefits of this terrible development is he gets to do things he wouldn’t have gotten to do [otherwise].”

In another case, Dieser was working with a single father in his 40s who had medical issues, depression and anxiety. His family was struggling financially, and the client felt isolated. During a counseling session, he talked to Dieser about the possibility of buying a Jet Ski. The man felt guilty about even considering the possibility because of the family’s finances, but operating a personal watercraft was something he had loved previously, and he wanted to share this activity with his two daughters.

“I let the guy talk about it and work through it out loud, [evaluating] the pros and cons,” Dieser says. When viewing it from a financial standpoint, the client thought his priority should be to pay some bills that were past due. But Dieser also had him look at it from a relationship perspective: Could he really put a price tag on spending time with his daughters? Was it possible for him to pay most of his bills and still buy the Jet Ski as an act of self-care?

The client decided to buy a used Jet Ski and started taking his daughters out with him as part of their family time. He also developed friendships with other owners of personal watercraft and ended up on a boating committee, which allowed him to contribute and provided a sense of purpose. Dieser says that all of these developments helped ease the client’s depression.

Final thoughts

Unfortunately, Dieser says, many Americans operate under the belief that they can buy happiness. In addition, he thinks that the individual nature of American culture often leads to isolation.

“The U.S. is the most individualist country in the world,” he says. “We are constantly not paying attention to relationships and belongingness. We are so focused on ourselves that we get lonely and there is no one there to provide a safety net when we fall.”

“The leisure-happiness connection is there, but it hasn’t really been defined,” Dieser says. “Leisure creates meaning, belonging, fulfillment and purpose. I think those are the same things that create happiness. Most people think of leisure as just doing nothing but relaxing. They don’t see it as about energy and engagement.”

“The real power of leisure is actually giving meaning in life,” he says. “I really see leisure connected to existential counseling.”

“It’s possible that any number of additional constructs are related to the search for happiness but, ultimately, no source outside ourselves can produce it,” Neace says. “Don’t get me wrong — we need a ton of support, encouragement, guidance, wisdom, friendship, etc., from outside of ourselves. But the ultimate goal isn’t just that we have a bunch of external sources of validation and satisfaction, but that we learn to internalize those sources into a united, inner chorus that helps us know we are enough, that things are OK — even if they aren’t OK right now — and that we’re going to make it. Perhaps that’s the key difference between happiness and contentment — the movement from an external to internal source of strength and resilience.”

 

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

Letters to the editorct@counseling.org

 

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

The value of contemporary psychoanalysis in conceptualizing clients

By Whitney Keefner, Hilary Burt and Nicholas Grudev October 5, 2016

branding-_sigmundAs students in the University of Vermont’s graduate counseling program, our professors have stressed both the benefits and critiques of Sigmund Freud’s psychoanalytic theory. We grew curious about how Freud’s pioneering ideas have evolved over time and how they can be applied to clients today. We think that contemporary psychoanalytic theory provides a great foundation for understanding human development, and this article allowed us to explore its progression.

Freud’s psychoanalytic theory has received widespread criticism since its establishment in the late 19th century. However, Freud’s original theories have undergone numerous evolutions, resulting in the de-emphasis of antiquated ideas pertaining to psychosexual fixation and a modern emphasis on the influence of early life family dynamics on later life relational patterns. This shift from examining repressed libidinal urges to the intrapersonal/interpersonal etiology of relational patterns allows counselors to place problems into an addressable context — namely, the bolstering of intrapersonal resources (i.e., ego strength) and the formation and maintenance of quality attachment relationships. These two branches of psychoanalytic thought are known respectively as ego psychology and object relations.

Ego psychology

From a contemporary psychoanalytic perspective, an individual’s mental health is dependent on the regulatory abilities of the ego. The ego is the contemporary psychoanalytic term for the psychological mechanism that governs the processing of reality and the regulation of instinctual urges and moral rigidity. The ego has many significant roles, including perceiving and adapting to reality, maintaining behavioral control over the id and defending the individual from undue anxiety. The undeveloped (or overstressed) ego can lead to a wide span of threats to a person’s wellness.

Mental health issues arise when the ego has not developed properly and its regulatory functions are either immature or absent. The Psychodynamic Diagnostic Manual (a psychoanalytic “companion” to the Diagnostic and Statistical Manual of Mental Disorders that is used by many practitioners of contemporary psychoanalytic theory) outlines several functions of ego health. These functions (collectively referred to in the Psychodynamic Diagnostic Manual as the Personality Axis, or P Axis) include:

  • The maintenance of a realistic and stable view of self and others
  • The ability to maintain stable relationships
  • The ability to experience and regulate a full range of emotions
  • The ability to integrate a regulated sense of morality into day-to-day life

Counselors might use these functions collectively as a guide to conceptualize the health of a client’s ego, while simultaneously considering specific aspects of ego function as possible starting points for counseling interventions. It is also worth considering how clients may defend their sense of self through the use of defense mechanisms.

Considering ego and relationships: Object relations

Whereas ego psychology represents contemporary psychoanalytic views on the development and regulation of the self, a separate yet related branch of contemporary psychoanalysis focuses on the self in relationship with others. Many theorists within the psychoanalytic school of thought place significant emphasis on the association between intrapersonal and interpersonal wellness.

From an object relations perspective, counselors may view barriers to client wellness as stemming from the quality of early interactions between the client and his or her caregivers and how the client internalized these early relational experiences. When an infant is first born, it is undifferentiated from the mother. Thus, the self has not yet formed. The self is composed of the ego, the internal objects (i.e., structures formed due to early experiences with a caretaker) and the affect that binds the ego and internal objects together.

The development of internal objects and ego is crucial to one’s functioning in later life because impaired object relations may result in the development of abnormal behaviors, cognitions or emotions. To elaborate, when an individual experiences negative relational experiences in the caretaker-child dyad, healthy object relations fail to formulate. These relational blunders occur after ego-relatedness (i.e., the phase of absolute dependence on the mother). When the child is not provided with an ego-supportive environment, growth of the ego is inhibited.

Fragmented ego strength during childhood may contribute to later issues in adulthood. Object relations bears a strong theoretical resemblance to attachment theory in that the relational experience between a caretaker and an infant carries implications for functioning across the life span. For example, the relationships that individuals hold with others (caregivers, friends, romantic partners, etc.) shape the development and regulatory ability of the ego. Individuals with fragmented ego strength are therefore at a disadvantage because they developed a faulty foundation for both self-regulatory abilities and social interactions later in life.

Defense mechanisms

In her book Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2011), Nancy McWilliams conceptualizes a person’s capacity to acknowledge reality — even when that reality is unpleasant — in terms of ego strength. Ego strength, like other aspects of wellness, is constantly in flux and can be eroded temporarily by the stresses of day-to-day life. When ego strength is compromised by anxiety-provoking circumstances, or even by mental fatigue (we note, for example, that our egos begin to feel considerably less sturdy by the end of the semester), ego defense mechanisms serve as a kind of respite from perceived threats. When sensitive topics are broached in the context of counseling, client defense mechanisms may present themselves. Because these same defenses likely arise in other contexts that are interpersonally challenging for clients, acknowledging and discussing these defensive processes may prove to be a generative pathway to change.

According to McWilliams, when clients use a defense mechanism, they are generally trying unconsciously to avoid the management of some powerful, threatening feeling (e.g., anxiety, grief, shame, envy). In the same way that fabled knights used shields to deflect the fiery breath of a dragon, clients may use defense mechanisms to ward off potential threats while attempting to maintain safety and stability in their stances.

It is important to note that the use of defense mechanisms is a common, if not daily, occurrence in the lives of most people. Indeed, the use of defense mechanisms is considered by most mental health professionals to be adaptive and necessary for sound mental health. George Vaillant (1994) described how defense mechanisms help people to regulate internal and external reality, and decrease conflict and cognitive dissonance. However, it is also important to note that defense mechanisms can be used in ways that are more adaptive or less adaptive. The degree to which an architecture of defenses might be considered adaptive pertains to the frequency and rigidity with which the defenses are used and the types of defenses employed.

In broad terms, defense mechanisms might be defined as primary or secondary defensive processes. McWilliams considers primary defenses to be less adaptive because they contain a greater degree of distortion in the boundary between the self and the outer world relative to secondary defenses. Primary defense mechanisms are characterized by the avoidance or radical distortion of disturbing facts of life.

For example, McWilliams explains how the primary defense mechanism of introjection involves substituting the perceived qualities, values, behaviors or beliefs of another person for one’s own identity. In effect, these individuals are uncritically adopting the attitudes, values or feelings that they perceive a valued other wants them to have. McWilliams suggests that such global distortions of self and reality likely have their origins in early developmental stress and the lack of developmental opportunities to cultivate a coherent and stable ego or a differentiated sense of self.

McWilliams considers secondary defenses to be “more mature” because they allow an uncompromised sense of self to remain relatively intact, even as an uncomfortable reality is held at bay. Secondary defenses allow for greater accommodation of reality and a stable sense of self. For example, counseling students may occasionally employ “gallows humor” (humor is one of numerous secondary defenses that McWilliams describes) before taking tests such as the National Counselor Examination. Humor in such cases helps to ease the tension by distracting from the reality of the situation without engaging in significant denial or distortion of the situation itself.

The degree to which developmental opportunities have allowed for the establishment of the aforementioned ego domains and the type of defensive architecture generally used (i.e., primary vs. secondary) contribute significantly to how clients perceive difficulties in their lives.

Ego dystonic vs. ego syntonic

An essential aspect of understanding an individual’s mental health is the presence or absence of an observing ego. According to McWilliams, an observing ego enables clients to see their problems as inconsistent with the other parts of their personalities. Such problems are termed ego dystonic. In terms of counseling individuals with ego dystonic problems, the client’s and the therapist’s understanding of the problems are likely to align because both parties recognize the problems to be undesirable. Thus, the observing ego allows for identification of unwanted problems and helps the client bring his or her personality back to a desirable level of functioning.

Problems that are unrecognizable by an individual are termed ego syntonic. According to McWilliams, such problems are likely to be rooted deep in the individual’s personality and often develop during early childhood. Because ego syntonic problems are intertwined in the person’s character, addressing these problems can be perceived to be a direct assault on the individual’s personality.

Taking away an adult representation of an adaptation from childhood could compromise an individual’s entire way of being. It is therefore important for counselors to handle ego syntonic problems slowly and delicately. For example, counselors could validate and empathize with a client’s ego syntonic experience while subsequently offering an alternative perspective. Establishing rapport and trust in the counseling relationship is perhaps the strongest tool when working with individuals whose maladaptive behaviors are intertwined in their personalities.

Substantial time is required for ego syntonic problems to become ego dystonic, and treatment is not possible until an individual can recognize his or her problems as such. The presence or absence of an observing ego determines whether an individual’s problems are neurotic or entwined in his or her character. Ego syntonic problems are telling of a dysregulated ego because the ego lacks the ability to acknowledge, understand and accept reality. Individuals who are capable of recognizing their problems likely have a better sense of self and a more developed ego.

Summary

Contemporary psychoanalytic thought emphasizes the impact of the ego on an individual’s well-being. Whether development is viewed from an object relations lens or an ego psychological lens, the ego is at the core of healthy development. The ego’s ability to balance the id and the superego, and process reality and emotions, can be learned only if an individual’s social relationships throughout his or her lifetime foster healthy ego development. Unhealthy development or underdevelopment of the ego can cause psychopathological problems because an individual’s abilities to process reality and emotions are likely to be impaired.

According to McWilliams, all of us have powerful childhood fears and yearnings. We handle them with the best defense strategies available to us at the time and maintain these methods of coping as other demands replace the early scenarios of our lives. Thus, defense mechanisms are useful in protecting the ego, but when used in excess, they may cause psychopathological problems. In this way, ego defense mechanisms are like sugar. When needed, sugar provides valuable energy that prevents the body’s systems from malfunctioning. But when consumed in excess, sugar can cause disease and negatively affect an individual’s well-being.

Conceptualizing clients through a contemporary psychoanalytic lens can provide counselors with a deep understanding of the past and present factors that are shaping clients’ lives. This approach illuminates how adaptations formed during childhood can present as maladaptive behaviors or cognitions in adulthood. Unlike classic psychoanalysis, contemporary psychoanalytic theory considers the social factors that contribute to ego health, therefore giving counselors a more comprehensive and applicable understanding of the client.

 

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The authors would like to extend a special thank you to Aaron Kindsvatter for his contributions and supervision.

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Whitney Keefner is a second-year student pursuing a dual master’s degree in clinical mental health counseling and school counseling at the University of Vermont. She is currently interning at Spectrum Youth and Family Services in Burlington, providing integrated co-occurring treatment for mental health and substance abuse issues. Upon completing her degree, she hopes to continue working with individuals struggling with substance abuse in a community mental health setting. Contact her at wkeefner@uvm.edu.

Hilary Burt is a second-year graduate student in clinical mental health counseling at the University of Vermont. She is interning at UVM Counseling and Psychiatry Services. After she completes her degree, she hopes to work with children and adolescents in a community mental health setting. Contact her at hburt@uvm.edu.

Nicholas Grudev is a second-year graduate student interning at the MindBody Clinic at the University of Vermont Medical Center. Upon completing his master’s degree, he plans to enroll in a doctoral program to study counseling psychology. Contact him at ngrudev@uvm.edu.

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