Tag Archives: mindfulness

Volcanic adolescence

By Chris Warren-Dickins January 14, 2019

In the early days, Caroline, a 14-year-old girl, started each session with a chin thrust indignantly at her counselor. She wanted to be seen as a warrior, and she offered answers that were blunt as a sledgehammer.

And why should she drop her defenses? She had seen too many adults — teachers, social workers, friends of the family — try to engage with her at first, and then seemingly lose interest. In the end, she felt that she was just an inconvenience to everyone around her. Why should Caroline believe that this counselor would offer a different type of relationship?

With any new client comes the challenge of forming a therapeutic relationship, but when that new client is an adolescent, there are additional factors to consider. Aside from the legal issues of capacity and consent, I discuss 10 of those therapeutic factors below.

 

1) A holistic assessment: It is important to adopt a strengths-based approach to assessment of adolescents. In addition, it is worth reviewing that assessment more regularly than with an adult client because more things are likely to change with a growing adolescent. As Urie Bronfenbrenner pointed out, a young person’s development is the result of a complex system of relationships that constitute the child’s environment. Therefore, assessments of young clients will include their developmental needs, the extent to which caregivers are meeting their needs, and their family and environmental contexts, including the influence that their school and peers have on them. The assessment should also gauge the influence of technology in the young person’s life.

2) Emotional “distance” from problems: As an adolescent, Caroline needs her counselor to appreciate that she does not have the same “distance” as adults experience from their problems. Adolescents have little control over their lives. They have to stay in the same home or school, even if these things might be the source of their depression, anxiety or other presenting issue.

3) Grasp of emotional language: As a 14-year-old, Caroline still has not developed her emotional language, so volcanic eruptions of anger or shoulder shrugs of apparent indifference are her only means of expressing how she feels. We have to see past the shoulder shrugging, which can easily be interpreted as nonchalance, and open ourselves to the possibility that young clients want to express themselves but just don’t know how to yet.

Images are a useful starting point, even if it is just looking at a series of facial expressions to try and help these clients identify the emotions they are experiencing.

4) The dominance of transition: Transition features heavily in adolescents’ lives. Each year, they are at a different stage of educational development and, each year, they experience bodily changes. On top of all of this, their ideas about who they are and how they fit in with their peers and wider society are in a constant state of flux.

At this level of fluidity, a counselor can offer Caroline some sort of stability. One source of this stability can be the therapist’s professional boundaries. The counselor can also offer Caroline the benefit of his or her life experiences, providing a deeper context than Caroline’s young perspective. But the counselor’s older years and life experience do not provide complete insight, no matter what the client’s presenting issues is, so a person-centered approach is crucial. We, as counselors, do not know Caroline’s worldview until we explore it with her, and we have to be careful not to make too many assumptions.

5) Disruption tenfold: It is hard for adolescents to experience so much transition, but it is even harder to manage at the same time as dealing with mental or physical health challenges, a chaotic home life or a sudden major change experienced by the adolescent’s parents (e.g., job loss, divorce, bereavement).

Because of the volcanic eruptions of adolescence, there is a danger that adolescents will become scapegoats in these situations. Just because adolescents may shout the loudest does not mean they are the source of the problems. Often, parents bring their adolescents for therapy, and these adults are completely unwilling to consider that the need for change might also rest on their own shoulders, rather than expecting just the adolescent to change and the whole family dynamic to become settled.

6) Discrimination experienced by minority adolescents: If an adolescent client is a member of the LGBTQ community or is an ethnic minority, it is likely that they have endured some sort of discrimination. If adolescents have to make sense of this — in addition to the transitions they are experiencing in their bodies, at school and at home — it can be challenging to deal with.

Is it any wonder that we sometimes see volcanic behavior in adolescents in the form of outbursts and defiance, screamed at us in a burning rage? If we are to help these youngsters, we have to see past the behavior that spews out like lava. We must dare to imagine what unmet needs might be fueling this volcano.

To help us, we can consider Abraham Maslow’s hierarchy of needs, and we can assess to what extent our adolescent clients may be getting their basic physiological needs met. Perhaps they are hungry, or there is the constant threat of homelessness hanging over them. Or perhaps their basic safety needs aren’t being met because domestic violence is present in the home. We can continue working our way up Maslow’s hierarchy (love/belonging, esteem and, ultimately, self-actualization) to understand what unmet needs may be fueling what appears on the surface to be irrational and unacceptable behavior.

7) Trauma-informed care: If the adolescent has a history of trauma, it is especially important to see past his or her volcanic eruptions of anger. In a 2017 article in Counseling Today about young clients in foster care (“Fostering a brighter future”), Stephanie Eberts states that therapists need to “help these children heal” by acting as a “translator” of the child’s behavior: “This includes explaining what a child’s behavior means and what motivates it, and then equipping both the child and the parents … with tools to redirect the behavior and better cope with tough emotions.”

8) Testing (to discover and take reassurance from) the boundaries: Adolescents may test boundaries more than adult clients do. Modeling behavior is important, and this is where congruence comes into play. If young clients are constantly pushing the boundaries by turning up late to sessions or missing them entirely, you can communicate the resulting emotion you are experiencing as a result of their behavior.

I like to think of this like a sonar device: Young clients are checking to see if you are still emotionally there and whether they are also still present in the interaction. You can share this with young clients, showing that certain behavior has consequences. Then you can jointly look for a way to resolve the matter.

Psychotherapist Rozsika Parker wrote about parents’ relationships with their children, but the following statements could apply equally to counselors and their young clients. Young clients “need to learn that they have an impact, that it’s possible to hurt” an adult, but it is also possible to “make it up with them.” Parker encourages adults to “show joy, hate, love, satisfaction — the full range of emotions — that will help the child to know themselves.” Parker wrote that she “heard the same note of reproach in their wails when they teethed, as in the studied criticism of me they could launch as teenagers.”

9) The resistant adolescent: As with any resistant client, adolescents need to feel that they are choosing to be in the sessions. But what happens if they are given no choice? If a therapist is working with a young client and the client’s family, and the young client chooses to leave the session early, what should the approach be?

I have heard some therapists adopt the following approach: They tell young clients that they are free to return to the session at any time but that the session will continue with the other family members. I quite like this approach because it avoids sessions becoming hijacked and held hostage by young clients, which might be a parallel process to other times in which these young clients have held more power than they knew how to handle. For example, they might have been forced to adopt a parental role with a younger sibling, or even a neglectful parent, at an inappropriately young age.

10) Mindfulness and meditation: I have seen and heard some of the criticisms of mindfulness and meditation. I struggle with this because, when I was starting out in this profession, my mentors raved about mindfulness and meditation. I need to see where this debate goes, but in the meantime, I cannot help but believe that there might be some value in mindfulness and meditation in our work with young clients.

Everything we offer our clients involves a balancing act between thoughts, feelings and bodily sensations. Society is built to engage the thinking side of our awareness, and this casts a shadow over our feelings and bodily sensations. Yet all three are important sources of information. If we focus solely on our thoughts, we are arguably functioning at only a third of our capacity. Short and simple mindfulness or meditation exercises can help young clients tap all sources of information, while also giving them a moment of relief from the constant demands of life.

 

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Chris Warren-Dickins is a licensed professional counselor in Ridgewood, New Jersey. Contact him through his website at exploretransform.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.

Five pragmatic tools to become a nonanxious presence: Tips and tricks for being a mindful counselor

By John Wheeler June 26, 2018

One of the most uplifting and powerful things counselors can do for their clients is to become a “nonanxious presence.” The term, originally coined by Jewish Rabbi and family therapist Edwin Friedman, is used to describe an individual who provides a calm, cool, focused and collected environment that empowers others to be relaxed.

This can be especially helpful for clients who have varying levels of anxiety, are in crisis or share information that could be traumatizing. By being a nonanxious presence, the counselor can model emotional regulation and invite clients to see that there is more than the anxiety or other feelings they may be experiencing.

As a counselor-in-training and certified empowerment coach, here are the five pragmatic tools that I use in my own practice.

 

1) Don’t buy in to the story; it only makes your client a victim. Everyone has a story about life. They use this story to determine who they are, where they are from, who they hope to become and all the difficulties they have overcome. As counselors, we must acknowledge the stories our clients share and the significance they assign to these stories. However, we must further consider how clients may use these stories to limit themselves and give up control in their life. If, as counselors, we allow ourselves to be swept into the story, we do a disservice to our clients and allow them to serve in the role of victim.

How does that apply to being a nonanxious presence? By not buying into the story and the role your clients have assigned themselves, you invite them to see the story from a different perspective. When you resist the urge to emotionally join their story, you are able to see all the ways in which their story is playing out in their daily lives. You, as counselor, are then free to identify patterns of behavior and gain insight into clients’ lives, thus empowering them to create something greater than they currently have.

2) Be you and trust your training. As a counselor-in-training myself, it seems the hardest thing to remember is to be yourself and to trust your training. Many times, we can be swept up in what we must “do” as counselors and fail to connect with the client. If we get caught up in the information we must gather, the treatment goals we are measuring and the skills or techniques we plan to implement, we may miss the opportunity to make a true connection, which so many people are missing in their lives.

The most influential measure of success in counseling is the client-counselor relationship. Have you ever noticed that some of your best sessions take place when you are willing to simply be present with your clients and let go of using a specific technique? How different might your practice be if you were willing to just be you, had faith that you possess the training you need and allowed yourself to meet the client in the here and now? Truly being present with yourself also invites your clients to be with themselves and to lower their barriers. In the process, you become the nonanxious presence that allows for greater change in clients’ lives.

3) Empower your clients to know that nothing is personal. Take a moment and consider a time when you experienced difficulty in a relationship, either romantically or otherwise. How differently might you have reacted to the event if you had known it wasn’t personal? This is another tool I use as a nonanxious presence with my clients. I empower them to know that nothing they have experienced or believe was done to them is personal.

This approach can be particularly helpful when dealing with abuse, trauma or relationship problems that arise in session. Clients can sometimes use their abuse or trauma as a coping skill to ensure that no one is able to get that close to them again. It is a means for them to know they have control and will not allow more abuse in the future. Reframing your clients’ perspective to “it wasn’t personal” invites them to see where they were a convenient target for the other person to release what they were experiencing. When individuals choose to abuse someone, they seldom consider who the other person is; quite frankly, they are just looking to relieve whatever level of stress, anxiety or other feeling they are experiencing.

When using this tool with your clients, it is important to have a strong rapport and relationship with them because challenging someone’s view on abuse can be difficult for the person to accept. If you are able to empower your clients to see that nothing is personal, however, it opens the door for them to separate themselves from the abuse or trauma and to begin the healing process.

4) Practice having an interesting point of view about everything. The greatest tool I have learned from my training with Access Consciousness is to practice having an interesting point of view about everything. An interesting point of view is the place where you can hear, see or become aware of anything without judgment.

As counselors, we receive training in cultural competency and learn the importance of maintaining an environment of nonjudgment with our clients. This is exactly what invites our clients to trust, share and be present with us in session.

How many times have you been judged? How did that make you feel or react? Now imagine if you were sharing the most intimate parts of your life and became aware that someone had a point of view about you? I am not saying that counselors should not be observant and make notice of things taking place in session, but we must be willing to put our points of view aside and be with our clients.

Another way to use this tool is to teach our clients that they can also have an interesting point of view in any area of their own life. This can help them detach from the high level of emotions that prevent them from going beyond the problem. What might this approach add to your daily life inside and outside of your counseling practice?

5) Ask questions, never give answers. As counselors, we can fall into the habit of dispensing advice. As someone who studied for a few years as a life coach, one of the greatest tools I used was to always ask questions and never to give answers. As a nonanxious presence, you can empower your clients by asking questions that allow them to see what is true in their lives.

Depending on your clients’ level of cognition, the use of this tool can lead to greater levels of healing and insight into their choices in life. It also helps to eliminate the possibility of setting up the counselor as the “power” in the relationship and prevents clients from developing a high level of dependency. As counselors, we must allow our clients to see their difficulties from a different light and empower them to trust in themselves.

Questions always empower clients, whereas providing “answers” disempowers clients. Acknowledge that your clients are the experts in their own lives; we, as counselors, are simply a resource they can use to gain new information.

 

Many of us who choose this profession believe we are called to serve others or have the ability to make a difference in the world. If you truly embrace your role as a nonanxious presence in the lives of your clients and the power this can have to create change, I firmly believe that you will have a rewarding career. What if you were willing to not simply diagnose and treat your clients but to empower them to live their best lives? What if you were willing to acknowledge the gift that you are and the ability you have to invite something greater to exist on the planet? We often hear that “human beings are messy.” What if you being you, as a nonanxious presence, is exactly what is required to begin untangling the mess?

 

 

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John Wheeler is a graduate student at the University of Dayton and a counselor-in-training at Riverscape Counseling in Dayton, Ohio. His focus in therapy is helping to address people’s unique needs while also assisting in facilitating a healthy, self-sustaining outlook on life. He encourages clients to take a proactive approach in fostering a lifestyle that promotes mental, emotional and physical well-being. Contact him at wheelerj7@udayton.edu.

 

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Related reading, from the Counseling Today archives: “When help isn’t helpful: Overfunctioning for clients

 

 

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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.

Differentiation of self through the lens of mindfulness

By Kevin Foose and Maria Cicio February 7, 2018

A few years ago, while teaching a course in family therapy, a particularly bright and insightful student named Maria lingered after class one day and asked, “Isn’t differentiation of self similar to mindfulness?” I hadn’t quite thought of it like that before, but it certainly seemed plausible. “Let’s set aside some time to talk,” I suggested. With that single question began many months of conversations.

In 2015, a continuation of those hours of exploration transformed into an “anti-presentation” that was awarded “Best of Show” at the Louisiana Counseling Association Annual Conference. The examination continued the following spring at the American Counseling Association Conference & Expo in Montréal. In the end, it was inquiry rather than answers that animated our informal lyceum. Quest and question are born of a common root. And teaching is thin soup if only the student grows. The current work is an attempt to extend the spirit and tone of those many fruitful hours of meeting.

Attempting to define differentiation

Differentiation of self (DoS), since first being introduced by Murray Bowen in the early years of the family therapy movement, has remained a lofty, elusive and often misunderstood concept. As Bowen’s colleague, Michael Kerr, pointed out, differentiation contains so many unique conceptual facets that it defies simple definition.

Bowen himself, persistently mystified by the consistent misinterpretation of differentiation, noted late in his life in one of his more cantankerous moments that he wished he’d never “discovered” it in the first place. Anthropologist Gregory Bateson once said of Charles Darwin that he didn’t discover evolution, he made it up. The same may be said of DoS. Viewed through this lens, DoS becomes a story (the point of which is to communicate its creator’s intent) steeped in a deep faith in science and the relatively recent emergence of the Western nuclear family.

If we are to accept the premise that differentiation does indeed defy simple definition, or at the very least is so subtle and nuanced that it is open to numerous interpretations, the initial question that emerges is: What in the world are we actually talking about when we talk about differentiation?

Michael Cowen, one of my colleagues at Loyola University New Orleans, provides a useful foundation from which to launch this conceptual ship with his interpretation of differentiation as “the capacity to be aware of one’s own unique pattern of feeling, valuing and thinking, and to decide and act in ways that remain faithful to that awareness.” Cowen’s definition shifts the focus of differentiation away from some thing that one is or has or even does, toward a description of understanding and action. It is a process that, at its core, allows individuals to make distinctions between thoughts and feelings and to remain calm in highly emotional situations. It is the ability to be both a part of and apart from significant relationships, and it places a high premium on the ability to behave rationally. It is not, however, a call for a Spock-like hyper-rationality nor a ringing endorsement of the ruggedly individualistic American mythology.

For the sake of moving forward with consensus, nebulous as it may be, I (Kevin) am inclined to give Bowen the final say in the construction of a working definition of differentiation as “a way of thinking that translates into a way of being.” So the story goes.

If that description of differentiation is to be accepted, the question then becomes, how is one to cultivate such “a way of thinking?” And who might act as a reliable translator? This is the point at which the teaching of the Buddha, in general, and mindfulness, specifically, can offer a helpful perspective from which to view perceptions and human experience.

At first glance, Bowen and Buddha may seem to be a strange pairing. After all, Bowen’s search for understanding led him back to the tumult of his family of origin, whereas Buddha left home seeking transcendence and never returned. Logistically, Buddha’s eightfold path provides a different road map toward liberation and understanding than does Bowen’s eight interlocking theoretical concepts. But the wisdom gained beneath the Bodhi tree may not be as divergent from the family tree as one might think. When differentiation is examined through the prism of mindfulness, significant conceptual convergences begin to emerge. The potential implications for personal growth, insight and clinical practice merit a pause, perhaps a deep breath, and further contemplation.

Mindfulness

Mindfulness is essentially the act of being present. Anchored in continuous awareness of each emerging moment, it is the cultivation of a calm, dispassionate state in which experience can be examined with acceptance and nonjudgment. Mindfulness, not unlike DoS, is a process that provides the possibility of escaping the trappings of emotional reactivity.

In an excellent article examining mindfulness (“Mindfulness: A Proposed Operational Definition” in the September 2004 issue of Clinical Psychology: Science and Practice), a group of Canadian academics, led by Scott R. Bishop, pointed out that the insight that emerges through disciplined contemplative practice creates an open “space between one’s perception and response, ultimately making it possible to respond and interact more reflectively (as opposed to reflexively).” Rather than becoming tangled up in “ruminative, elaborative thought streams about one’s experience and its origins, implications and associations, mindfulness involves a direct experience of events in the mind and body,” wrote Bishop and his colleagues

In other words, we are able to stay tethered in the present, experiencing our life with courage and composure as it actually unfolds in our midst. In this awakened state, our mind is freed from anger, attachment to desire and misperception. Providing an alternative to being swept away in a flood of emotionality and elaborate misinterpretation, we are able to resist the urge to flee into ideations of the imagined future clouded by the residue of the past, or compulsively bend reality to meet idiosyncratic needs.

Mindfulness is the antidote to fear, confusion and anxiety. It is a practice and process that tethers us to the immediacy of our lives with the insight to see “relationships between thoughts, feelings and actions and to discern the meaning and causes of experience and behavior” (as described in “Mindfulness: A Proposed Operational Definition”). Essentially, mindfulness cultivates the ability to interact rather than react.

The greatest hurdle in defining a self or sustaining mindful attention is emotional reactivity. When emotions escalate beyond a critical threshold, a state of mind emerges in which rational thinking evaporates and agitation hijacks the cognitive process. It is impossible to differentiate in such an agitated state. We become prisoners to automatic emotional responses saturated in fear.

Buddha referred to this reactive state as “monkey mind,” in which fear becomes much like a loud, drunken monkey frantically screeching the alarm bells of danger in our brains. The ability to quickly regain composure and quiet the monkey mind is the cornerstone of both differentiation and mindfulness.

The quiet mind is fertile ground for exploring what Buddha called “store consciousness.” Long before Sigmund Freud proposed his theory of the unconscious (again, see Bateson above) or Bowen began his examination of psychobiological cognitive-emotional processes, Buddha was wandering about preaching the Dharma, teaching practices aimed at liberating people from misperception and attachment to mental formations that seemed to be just beyond the reach of everyday awareness.

Vietnamese Buddhist monk Thich Nhat Hanh writes in the introduction of Cultivating the Mind of Love: “In our store consciousness are buried all the seeds, representing everything we have ever done, experienced or perceived. When a seed is watered, it manifests in our mind consciousness. … The work of meditation is to cultivate the garden of our store consciousness.”

Getting back into harmony with our lives

Whatever we “attend” to will grow. And what we don’t attend to will tend to grow out of control without insight into content and coping strategies buried deep in our store consciousness. For multigenerational family systems theory, the seeds in the soil are the early experiences in the family of origin. Differentiation allows for a bit of psychic “weeding” to occur so that intimacy and integrity may grow.

Buddha, too, was attuned to the influence that family members have on one another. Perhaps more poetic, but no less prophetic, a Buddhist teaching examines the importance of the emotional climate of filial bonds, invoking the image of the garden again: “A family is a place where minds come in contact with one another. If these minds love one another, the home will be as beautiful as a flower garden. But if these minds get out of harmony with one another, it is like a storm that plays havoc with the garden.”

It is precisely in those moments when one finds oneself in the “I” of the storm where mindful intention allows the well-differentiated self to stay calm and sift through frenetic cognition that often causes impairment in our lives. The ability to sit in the midst of the tempest and remain present, self-aware and in close emotional contact with others is the essence of what Soto Zen monk Shunryu Suzuki calls “imperturbable composure.”

The well-differentiated self exhibits radical acceptance to what Jon Kabat-Zinn calls the “full catastrophe of living.” In this way, we remain open and curious to the actual events of our lives as they unfold, freeing ourselves from endless cycles of suffering and automatic reactivity. Whether we call this mindfulness or differentiation becomes an exercise in semantics.

Through work and practice, we become available to the full reality of our lives, with the insight and courage to quietly slip through the cracks of our conditioning and allow our ego-cramped consciousness to release its grip on our battered psyche. Quite simply, DoS and mindfulness bring us back into harmony with our lives.

For Buddha, the ultimate act of enlightenment is to wake up. The Dharma teaches that it is possible for any of us to awaken at any moment in our lives. Much like achieving a fully mindful present state, people often find embarking on the path of defining a self to be a daunting task.

Bowen was clear and consistent in his insistence that the fully differentiated self is a theoretical concept that is practically unattainable. It is a guiding light rather than prescription. However, with much work and practice, it is possible to increase one’s level of differentiation. Bowen pointed out that if we can “control the anxiety and the reactiveness to anxiety, the functional level will improve.” The task at hand becomes “getting beyond anger and blaming to a level of objectivity that is far more than an intellectual activity. … The overall goal is to be constantly in contact” with emotional issues involving ourselves and others.

A common thread

Although Bowen and Buddha’s conceptualization of the “self” superficially seems to be the point at which the Venn in the Zen between DoS and mindfulness begins to diverge, it is through interdependence that the deepest synthesis actually occurs. Whether one adopts a scientific or a spiritual perspective, the influence that each of us has upon the other is the thread that ties mindfulness and differentiation together.

Bowen was certain that the self exists. Buddha sent his disciples out into the world in search of the self and sat patiently waiting for the report back. Ralph Waldo Emerson, with his ever-present, transcendental wisdom, offered this: “All that is said of the wise man by Stoic or Oriental or modern essayist … describes his unattained but attainable self.”

Both Buddha’s and Bowen’s philosophical views were undergirded by a belief in the profound effect that each of us has upon one another. Bowen believed that successfully differentiating oneself within the system could have significant influence on all others in that system. He noted that if one is able to successfully define a solid sense of self and defend against requests from others to change back to old ways of being, then the entire system can catapult forward into higher levels of functioning.

The Dharma teaches that when one is awakened with compassion and wisdom, all are touched by the light. In Cultivating the Mind of Love, Hanh examines Buddha’s teachings, exploring the ways in which the Dharma opens each of us to the possibility of deeper understanding and more intimate connection. In his introduction, Hanh invites us to become fully present, and “the rain of the Dharma will water the deepest seeds of your store consciousness. If the seed of understanding is watered … the fruits of love and understanding will grow.”

Examining the teaching of interbeing and the delusion of separateness falsely constructed in the mind, Hanh concludes: “We must vow to practice for everyone, not just for ourselves. … Because of our ignorance and habit energies, we usually perceive things incorrectly. We are caught in our mental categories, especially our notions of self, person, living being and life span. We discriminate between self and nonself. … When we see things this way, our behavior will be based on wrong perceptions. Our mind is like a sword cutting reality into pieces, and then we act as though each piece of reality is independent from other pieces. If we look deeply, we will remove these barriers between our mental categories and see the one in the many and the many in the one, which is the true nature of interbeing. … Everything is touching everything else. … To bring relief to one person is to bring relief to everyone, including ourselves. This insight brings about the kinds of actions that are truly helpful.”

These are hopeful thoughts for troubled times. What is called for in this moment, if one is to view differentiation through the lens of mindfulness, is a “way of thinking that translates into a way of being in the world” that accurately perceives the deep connection that we have with the world surrounding us and the profound effect that each of us has upon one another. So the story goes.

Compassionate listening

Counseling is a reciprocal process of story and interpretation. As a conversational intervention, much attention has been given to the narrative telling of the tale — the “talk” in talk therapy. Often lost in the reciprocity is the transformative power of listening. As Hanh points out, when we listen to another deeply and compassionately, we help that person to suffer less. “One hour like that can bring transformation and healing,” he teaches.

If listening in this way does indeed, as we believe, lead to the alleviation of suffering, the question becomes, how does one engage in the process of compassionate listening?

The calm that accompanies the differentiated self, and a mindful stance tethered in the present, provide a helpful perspective from which to enter into another’s story. It allows one to avoid judgment without abandoning discernment and concern. This way of being allows the counselor to bear witness to the tumultuous content of clients’ troubled narratives without becoming overwhelmed. We can tolerate intense emotion without needing to flee for safety and care without getting carried away.

Deep listening contains the seeds of empathy. The calm that accompanies a well-differentiated presence opens up the space to create the distance necessary to examine problem-saturated narratives. The practice of active listening artfully folds the story continuously back upon itself, returning the client to present-moment awareness. The acceptance that accompanies awareness invites the client to slow down, resist the impulse to avoid the suffering and instead examine the story with compassion. The wisdom to accept that which is beyond our control paradoxically generates the flexibility necessary for transformation to occur.

Pragmatically speaking, compassionate listening is rooted in language. To listen in this manner, it is essential to remain firmly planted in the present, gathering content without getting lost in the labyrinth of past suffering or anxious projections of the future. When listening to stories of suffering, it can be easy to lose sight of the fact that the actual experience is the retelling of the tale here and now, not what occurred there and then. It is imperative to honor our clients’ suffering while also uncovering their strength.

The task is to attend to the content of the client’s story while staying deeply connected to the person. Listening in this way allows us to wonder what the client is trying to communicate about his or her struggle through the story. What meaning is seeking to be understood? What are the relational and emotional elements recurring in the client’s words? Compassionate listening is the conduit into the deepest sense of clients’ experiences. It asks, how can we be present to the struggle and help our clients confront the frustrating and most frightening moments of their lives?

At its core, compassionate listening holds the therapeutic space. It widens the client’s interpretation just a bit. It uses the client’s language, symbols and metaphors. It sees as well as hears, deconstructing the story, searching the margins for what has been edited out, pulling the thread of seemingly disjointed pieces and reflecting it back in recognizable form. This way of listening is ultimately a path toward healing that allows for safe passage through suffering. As American Buddhist nun Pema Chödrön points out, mindfulness allows us to choose an alternative course for our lives. A process such as DoS requires us to first notice the true nature of our experience, then disrupt our habitual patterns and do things differently and, finally, practice again and again, one moment at a time.

A client suffers and a change is necessary. The struggle often comes with not knowing how to manifest a healthy change. The client has likely been avoiding, wrestling with and running away from anxiety for years, creating deeply ingrained habits. In the space created by deep listening, the client can experience something different. Clients may be able to look at their anxiety for the first time with compassion and understanding. The paradox is that once they are able to sit with their struggle instead of avoiding it, anxiety loosens its grip on their lives.

DoS, viewed through the lens of mindfulness, creates the clarity and compassion for transformation to occur. Mindfulness aids in the process by creating awareness of our mind-body interaction so that we can become more skillful in our interpersonal, and intrapersonal, relationship(s).

Just as the counseling process makes space for emotions, thoughts, ideas and stories in session, mindfulness creates a similar space for our internal experience to occur. This is the “deep listening” to our own process. Mindful awareness allows for attunement, not only with our clients but with ourselves. It creates systemic and intrapsychic awareness to the ways that we get hooked into metanarratives and mental confines. Emotions no longer run amok, and we are available to be in relationship with others. As clinicians, we must first listen deeply to the mystery and history of our own stories before making contact with someone else’s.

The Beat Zen of Richard Brautigan leads us to a quiet place to begin in his poem “Karma Repair Kit: Items 1-4”:

1. Get enough food to eat,/ and eat it.

2. Find a place to sleep where it is quiet,/ and sleep there.

3. Reduce intellectual and emotional noise/ until you arrive at the silence of yourself,/ and listen to it.

4. ???

 

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

Kevin Foose is an assistant professor in the Department of Counseling at Loyola University New Orleans. He maintains a private practice that focuses on couples and adult individuals. Contact him at kjfoose@loyno.edu.

Maria Cicio is a graduate of the Loyola University New Orleans master’s in counseling program, class of 2015. A licensed professional counselor, she is currently working in community mental health in rural Oklahoma.

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.

Talking through the pain

By Laurie Meyers January 30, 2018

By the time the 43-year-old man, a victim of an industrial accident, limped into American Counseling Association member David Engstrom’s office, he’d been experiencing lower back pain for 10 years and taking OxyContin for six. The client, whose pain was written in the grimace on his face as he sat down, was a referral from a local orthopedic surgeon, who was concerned about the man’s rapidly increasing tolerance to the drug.

“He often took twice the prescribed dose, and the effect on his pain was diminishing,” says Engstrom, a health psychologist who works in integrated care centers.

The man’s story is, unfortunately, not unusual. According to the National Institutes of Health, 8 out of 10 adults will experience lower back pain at some point in their lives. As the more than 76 million baby boomers continue to age, many of them will increasingly face the aches and pains that come with chronic health issues. And as professional counselors are aware, mental health issues such as depression, anxiety and addiction can also cause or heighten physical pain.

Those who suffer from chronic pain are often in desperate need of some succor, but in many cases, prescription drug treatments or surgery may be ineffective or undesirable. Fortunately, professional counselors can often help provide some relief.

Treating chronic pain

At first, the client had only one question for Engstrom: “I’m not crazy, so why am I here?”

Although the man’s physician did not think that the pain was all in the man’s head, it is not uncommon for sufferers of chronic pain to encounter skepticism about what they are experiencing. “It was important … to defuse the idea that I might think he was imagining his pain,” Engstrom says. “So I [told him] that I accepted that his pain was real and that all pain is experienced from both body and mind. I told him that we would be a team and work on this together.”

Engstrom and the client worked together for five months. As they followed the treatment plan, the man’s physician slowly eased him off of the OxyContin.

Engstrom began by teaching the client relaxation exercises such as progressive muscle relaxation. “When in pain, the natural inclination of the body is to contract muscles,” Engstrom explains. “In the long term, this reduces blood flow to the painful area and slows the healing process. Contracted muscles can be a direct source of pain.”

Engstrom also began using biofeedback to promote further relaxation. In biofeedback sessions, sensors are attached to the body and connected to a monitoring device that measures bodily functions such as breathing, perspiration, skin temperature, blood pressure, muscle tension and heartbeat.

“When you relax, clear your mind and breathe deeply, your breathing slows and your heart rate dips correspondingly,” Engstrom explains. “As the signals change on the monitors, you begin to learn how to consciously control body functions that are normally unconscious. For many clients, this sense of control can be a powerful, liberating experience.”

As Engstrom’s client learned to control his responses, he began reporting a decrease in pain following the relaxation exercises.

Engstrom also used cognitive behavior therapy (CBT) methods, including asking the man to keep a daily journal recording his pain level at different times of the day, along with his activity and mood. Through the journal, the man started recognizing that his pain level wasn’t constant. Instead, it varied and was influenced by what he was doing and thinking at the time.

Engstrom highly recommends CBT for pain treatment because it helps provide pain relief in several ways. “First, it changes the way people view their pain,” he says. “CBT can change the thoughts, emotions and behaviors related to pain, improve coping strategies and put the discomfort in a better context. You recognize that the pain interferes less with your quality of life and, therefore, you can function better.”

In this case, the client was trapped by thoughts that “the pain will never go away” and “I’ll end up a cripple,” Engstrom says. He and the client worked on CBT exercises for several months, keeping track of and questioning the validity of such negative future thoughts. They also practiced substituting more helpful thoughts, including “I will take each day as it comes” and “I will focus on doing the best I can today.”

Chronic pain often engenders a sense of helplessness among those who experience it, Engstrom says, so CBT also helps by producing a problem-solving mindset. When clients take action, they typically feel more in control of their pain, he says.

CBT also fosters new coping skills, giving clients tools that they can use in other parts of their lives. “The tactics a client learns for pain control can help with other problems they may encounter in the future, such as depression, anxiety or stress,” Engstrom says.

Because clients can engage in CBT exercises on their own, it also fosters a sense of autonomy. Engstrom often gives clients worksheets or book chapters to review at home, allowing them to practice controlling their pain independently.

Engstrom notes that CBT can also change the physical response in the brain that makes pain worse. “Pain causes stress, and stress affects pain-control chemicals in the brain, such as norepinephrine and serotonin,” he explains. “By reducing arousal that impacts these chemicals, the body’s natural pain-relief responses may become more powerful.”

Although Engstrom acknowledges that he could not completely banish the discomfort his client felt, he was able to lessen both the sensation and perception of the man’s pain and give him tools to better manage it.

Taking away pain’s power

Mindfulness is another powerful tool for lessening the perception of pain, says licensed professional counselor (LPC) Russ Curtis, co-leader of ACA’s Interest Network for Integrated Care.

Mindfulness teaches the art of awareness without judgment, meaning that we are aware of our thoughts and feelings but can choose the ones we focus on, Curtis continues. He gives an example of how a client might learn to regard pain: “This is pain. Pain is a sensation. And sensations tend to ebb and flow and may eventually subside, even if just for a little while. I’ll breathe and get back to doing what is meaningful to me.”

Engstrom agrees. Unlike traditional painkillers, mindfulness is not intended to dull or eliminate the pain. Instead, when managing pain through the use of mindfulness-based practices, the goal is to change clients’ perception of the pain so that they suffer less, he explains.

“Suffering is not always related to pain,” Engstrom continues. “A big unsolved puzzle is how some clients can tolerate a great deal of pain without suffering, while others suffer with relatively smaller degrees of pain.”

According to Engstrom, the way that people experience pain is related not just to its intensity but also to other variables. Some of these variable include:

  • Emotional state: “I am angry that I am feeling this way.”
  • Beliefs about pain: “This pain means there’s something seriously wrong with me.”
  • Expectations: “These painkillers aren’t going to work.”
  • Environment: “I don’t have anyone to talk to about how I feel.”

By helping people separate the physical sensation of pain from its other less tangible factors, mindfulness can reduce the suffering associated with pain, even if it is not possible to lessen its severity, Engstrom says.

According to Engstrom, mindfulness may also improve the psychological experience of pain by:

  • Decreasing repetitive thinking and reactivity
  • Increasing a sense of acceptance of unpleasant sensations
  • Improving emotional flexibility
  • Reducing rumination and avoidant behaviors
  • Increasing a sense of acceptance of the present moment
  • Increasing the relaxation response and decreasing stress

Curtis, an associate professor of counseling at Western Carolina University in North Carolina, suggests acceptance and commitment therapy (ACT) as another technique to help guide clients’ focus away from their pain.

“ACT can help people revisit what their true values are, whether it’s being of service, having a great family life or creating art,” he notes. Encouraging clients to identify and pursue what is most important to them helps ensure that despite the pain they feel, they are still engaging in the things that give their lives meaning and not waiting for a cure before moving forward, Curtis explains.

Teamwork and support

In helping clients confront chronic pain, Curtis says, counselors should not forget their most effective weapon — the therapeutic relationship. Because living with chronic pain can be very isolating, simply sitting with clients and listening to their stories with empathy is very powerful, he says.

Counselors have the opportunity to provide the validation and support that clients with chronic pain may not be getting from the other people in their lives, says Christopher Yadron, an LPC and former private practitioner who specialized in pain management and substance abuse treatment. The sense of shame that often accompanies the experience of chronic pain can add to clients’ isolation, he says. According to Yadron, who is currently an administrator at the Betty Ford Center in Rancho Mirage, California, clients with chronic pain often fear that others will question the legitimacy of their pain — for instance, whether it is truly “bad enough” for them to need extended time off from work or to miss social occasions.

Curtis says it is important for counselors to ensure that these clients understand that the therapeutic relationship is collaborative and equal. That means that rather than simply throwing out solutions, counselors need to truly listen to these clients. This includes asking them what other methods of pain relief they have tried — such as supplements, over-the-counter painkillers, physical therapy, yoga or swimming — and what worked best for them, Curtis says.

The U.S. health care system has led many people to believe that there is a pill or surgery for every ailment, Curtis observes. This makes the provision of psychoeducation essential for clients with chronic pain. “Let them know there’s no magic bullet,” he says. Instead, he advises that counselors help clients see that relief will be incremental and that it will be delivered via multiple techniques, usually in conjunction with a team of other health professionals such as physicians and physical therapists.

Curtis, Yadron and Engstrom all agree that counselors should work in conjunction with clients’ other health care providers when trying to address the issue of chronic pain. Ultimately, however, it may be up to the counselor to put the “whole picture” together.

A 60-something female client with severe depression was referred to Engstrom from a pain clinic, where she had been diagnosed and treated for fibromyalgia. After an assessment, Engstrom could see that the woman’s depression was related to continuing pain, combined with social isolation and poor sleep patterns. The woman was unemployed, lived alone and spent most of her day worrying about whether her pain would get any better. Some of her previous doctors had not believed that fibromyalgia was a real medical concern and thus simply had dismissed her as being lonely and depressed. Despite finally receiving treatment for her fibromyalgia, the woman was still in a lot of pain when she was referred to Engstrom.

Engstrom treated the woman’s depression with CBT and taught her to practice mindfulness through breathing exercises and being present. Addressing her mood and sleep problems played a crucial role in improving her pain (insomnia is common in fibromyalgia). By dismissing the woman’s fibromyalgia diagnosis, discounting the importance of mood and not even considering the quality of her sleep, multiple doctors had failed to treat her pain.

Engstrom points out that in this case and the case of his client with lower back pain, successful treatment hinged on cognitive and behavioral factors — manifestations of pain that medical professionals often overlook.

 

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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.

 

Integrating mindfulness interventions in counseling courses

By Allison Buller October 2, 2017

As a professor of counseling, I am invested in helping students develop the necessary and sufficient skills to become effective psychotherapists. There is a plethora of evidence to support mindfulness as a tool for fostering these skills. Integrating mindfulness training can:

  • Improve how counselors-in-training relate to self and others with more acceptance, genuineness and empathy
  • Help counseling students develop a deeper connection to clients’ experiences and be more present to clients’ suffering
  • Help decrease stress, negative affect, rumination, and state and trait anxiety, and increase positive affect and self-compassion
  • Help students become more aware, patient, mentally focused, empathic, compassionate, attentive, responsive and able to handle strong emotions
  • Help students cultivate therapeutic presence

With all of the good data to support mindfulness in counselor education, I chose to describe a few of my favorite mindful interventions and how I implement them in my counseling courses.

 

Mindfulness interventions

Breathing techniques and guided mindfulness practices are among the key interventions I include in all of my counseling classes. The interventions are secular; therefore, I do not use terminology that would be considered religious or unusual for the university context. I ask students to close their eyes while I guide them through a mindfulness practice of attending to a specific focus for several minutes, such as paying attention to each breath or sending out positive energy to self or others (i.e., stress breath and compassion meditation).

The movement, breathing and mindfulness components of the class are designed to enhance the students’ capacities for sustained attention, promoting greater awareness of cognitive, physiologic and bodily states and how to regulate those states. In addition, I include a brief period of discussion prior to the guided mindfulness practice in which I offer didactic information about such topics as identifying stressful events, using mindfulness techniques to respond to difficult people, cultivating positive relationships with others and keeping one’s mind and body healthy. This information is often woven into subsequent guided mindfulness practices (e.g., using the breath to relax if something stressful has happened). Students are encouraged to practice these skills outside of class and reflect on their experiences in writing.

I often receive positive feedback from students participating in mindfulness practice. Among the reflections I have received are:

  • “I felt relaxed.”
  • “Calming … I wish we could do this every time.”
  • “Tired in a good way.”
  • “It helped me to feel something different.”

In some cases, students may experience open displays of emotion during meditation (i.e., crying, runny nose, shortness of breath). The generalizability for students happens when they can use these techniques outside of class time. Examples reflected by students using the stress breath technique include:

  • “I used it before seeing my client”
  • “I use it all the time now”
  • “I never knew I didn’t know how to breathe!”
  • “I catch myself using it before tests or presentations.”

Many students acknowledged that the “stress breath” was one of the most useful interventions they learned in class.

Although the majority of student reflections have been positive, some students struggle with the concept of mindfulness:

  • “I don’t know how to clear my mind.”
  • “How do I stop thinking?”
  • “I can’t think about nothing.”

Comments such as these need to be explored, and extended discussions on barriers to mindfulness can offer clarification. Before every practice, I give students the option to “pass or play,” meaning they can choose whether to participate in the mindfulness activity. If they chose not to participate, they are asked to sit and engage in a quiet activity.

 

Integrating mindfulness training

One of the biggest challenges I face in implementing mindfulness training is believing in myself as an experienced practitioner and qualified teacher. Although I have practiced mindful meditation for almost a decade, I am not certificated in yoga or meditation. For all intents and purposes, I am an ordinary professor with a personal practice.

The majority of researchers and practitioners agree that teaching mindfulness requires a dedicated personal practice. In fact, Jon Kabat-Zinn advised, “Don’t turn mindfulness into a commodity.” He believes that mindfulness needs to become a way of life, not just a skill, an intervention or an outlook.

In a 2012 article (“Teaching mindfulness to create effective counselors”) for the Journal of Mental Health Counseling, Jennifer Campbell and John Christopher described it as the sort of teaching that cannot be done from a manual. Instructors must be able to dive deep and connect with themselves through a kind of altered state. The authors recommended that those who do not yet have years of personal experience co-teach with experienced meditation teachers.

Another challenge is finding time during class or in the curriculum for mindfulness training. Time constraints and the pressure to cover course material is an ongoing concern in higher education. At times, implementing mindfulness practice can feel like an indulgence or an overwhelming addition rather than a useful tool. Taking time to implement mindfulness requires discipline and planning. I chose specific times throughout the semester to implement mindfulness training (i.e., before role-play activities, midsemester wellness day, finals week). Every course is different, and the needs of the students vary. Choose what works best for you.

The greatest challenge and best motivator for implementing mindfulness is helping students understand how mindfulness can be used to manage emotional reactivity. Incorporating research literature to support mindfulness as a tool for emotional and mental health is necessary to gain students’ trust. Mainstream information about mindfulness can be overwhelming and confusing. My job as a professor is to clarify the facts and demonstrate the tools.

 

Take-home lessons

I choose to incorporate mindfulness practice in my courses based on positive outcomes relevant in the literature. Many of the students in my counseling courses have never practiced mindfulness or had any training on how to breathe. I find it both humbling and exciting to introduce this practice to students. I am humbled to share the art of meditation and excited to introduce mindfulness to students for the first time. The insights and changes that come with studying and practicing mindfulness carry over into life and work.

My self-efficacy as a mindfulness educator stunted my motivation and confidence to do this kind of work. I erroneously believed that I lacked the qualifications and information required to help others learn to meditate. In essence, I was standing in my own way. Therefore, I conclude this article by appealing to the reader for brazen courage. If implementing mindfulness practice is your intended goal, commit to your own practice, align with like-minded and experienced faculty, and get out of your own way.

 

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Allison Buller is a licensed professional counselor and an assistant professor of counseling and psychology in the Department of Arts and Sciences at the University of Bridgeport. She is also a staff counselor for the university’s counseling center. Contact her at abuller@bridgeport.edu.

 

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