Tag Archives: parenting

When yelling doesn’t work

By Lindsey Phillips April 29, 2019

Stop! Stop throwing that toy! Put it down. Put it down now! Don’t make me say it again. If you don’t stop that right now …” We all know how this story ends — with a frustrated parent and an upset child. But the story doesn’t have to end this way.

In Play Therapy: The Art of the Relationship, Garry Landreth asserts that to improve future adult populations, counselors must equip parents with counseling skills and help them become therapeutic agents in their children’s lives. This plan sounds simple, but how do counselors broach the topic of child discipline, especially when working with clients from cultural backgrounds that differ from their own?

Christa Phipps, a therapist and clinical supervisor at Hickory Grove Counseling Center in North Carolina, notes that parenting and discipline can be touchy subjects, and counselors often fear mentioning it. In fact, she says, the counselors she supervises are terrified to talk with parents about anything that may rupture the therapeutic relationship, so they often skirt around the issue of child discipline. Phipps has also noticed that the one African American counselor she supervises is apprehensive about discussing discipline with clients from other cultures, while her white supervisees are timid about approaching the issue with parents of all cultural groups, including their own.

Phyllis Post, a professor of counseling and director of the Multicultural Play Therapy Center at the University of North Carolina at Charlotte (UNCC), advises counselors to address cultural differences outright rather than pretending that they don’t exist. Post, as an older white woman, acknowledges the cultural differences between her and her clients and asks clients directly how they feel about having her discuss child discipline and parenting with them.

Peggy Ceballos, an associate professor of counseling at the University of North Texas, says that parenting style and child discipline are both closely linked to one’s cultural background. “The main mistake I see is people avoiding those [cultural] conversations” in counseling, she says.

Carla Adkison-Johnson, a professor in the Department of Counselor Education and Counseling Psychology at Western Michigan University, agrees that counselors often avoid the topic of discipline because that is where the cultural aspects of raising a child come into play. Rather than neglecting the topic or making assumptions, counselors should ask clients about their child-rearing values and traditions, she advises. They can do this by asking questions about their parenting: What types of disciplinary methods are you using to prepare your child for adulthood? What behaviors warrant discipline? What are you struggling with right now? Do you feel comfortable with the boundaries between you and your child?

Adkison-Johnson, a licensed professional counselor (LPC) and a member of the American Counseling Association, also points out that how people were disciplined themselves often plays a role in how they parent their own children. Thus, she says, counselors might ask clients how they were disciplined when they were children, whether they are using any of these methods with their own children, and what disciplinary methods their parents used that the clients found ineffective.

In the 2015 article “Child Discipline and African American Parents With Adolescent Children: A Psychoeducational Approach to Clinical Mental Health Counseling,” Adkison-Johnson described an activity that helps identify how parents define discipline and what child behaviors they consider problematic. In the activity, a counselor shows parents a video clip or a written example of a child displaying inappropriate behavior. The counselor then asks the parents what an appropriate behavior would be and how they would handle the problem.

Ceballos advises counselors to introduce the topic of child discipline in ways that are nonjudgmental and accepting. Parents are typically more receptive to learning new skills — including skills related to appropriate discipline methods — when counselors establish a relationship in which clients feel accepted.

Post, an LPC supervisor and registered play therapist, agrees. “I never tell a parent that what they are doing is wrong,” she says. Instead, she introduces alternative parenting techniques.

Counselors should assure clients that their role isn’t to tell parents what to do, Ceballos says. Instead, they are there to offer additional parenting skills, to process those skills with clients, and to see whether clients might want to try the skills because they think that the techniques might work for their families.

When clients feel there is a parenting skill that they can’t incorporate, Ceballos, an ACA member, talks about it with them. She says she wants clients to feel safe and comfortable having these difficult conversations with her rather than telling her that they will try a new skill and then not following through.

Putting discipline in (cultural) context

Ceballos and Adkison-Johnson agree that before discussing child discipline with clients, counselors need to be aware of their own biases and beliefs around parenting. For example, how does a counselor define “good” parenting? How does the counselor’s cultural background influence this definition?

Adkison-Johnson, who co-edited Counseling African American Families in ACA’s Family Psychology and Counseling Series, argues that counselors also need to understand the current and historical context when broaching the topic of child discipline. For example, African American parents are often viewed in society in a pejorative way, as incompetent parents, she says. Thus, counselors must be intentional about dismissing this false perception and reminding themselves that African American clients are competent parents who have goals, ideals and values for their children. Discussing child discipline also means addressing assumptions, she says, including the fact that most counselors may still determine what is in a family’s best interest on the basis of a widely white, middle-class, mainstream perspective.

Rather than waiting for clients to bring up these cultural contexts, counselors should take on the responsibility of learning more about what their clients experience, Adkison-Johnson stresses. For example, counselors should know that African American parents often engage in racial socialization practices as a part of their parenting activities, she says. This involves communicating messages and behaviors to children to bolster their sense of identity, especially given that their life experiences may include racially hostile encounters.

Parents who are undocumented immigrants may instruct their children to behave well at school because they fear being called in for a meeting or having someone look into their family if their child misbehaves, Ceballos adds. For these families, establishing trust in the counseling relationship is crucial because it may be difficult for them to openly discuss how their undocumented status affects their parenting, she explains.

Ceballos advises counselors to use cultural humility when learning about clients’ belief systems regarding parenting and what parenting means within their cultural context. She also recommends that counselors get involved in the community to build trust with parents. For instance, she finds that partnering with schools helps make Latinx parents more comfortable with getting counseling services because it allows counselors to meet these parents in a place that is familiar to them and where they may have already established a level of trust. In addition, schools often have people who know clients’ cultural backgrounds and speak their native languages, she adds.

Yung-Wei Dennis Lin, an assistant professor in the Counselor Education Department at New Jersey City University, points out that some cultures may not be familiar with the counseling profession. A Taiwanese family who immigrates to the United States may not be aware of the role that school counselors play, for example. So, he explains, if a school counselor suddenly contacts the parents in reference to their children, the parents may wonder who this person is and what the person’s role is with their children.

Adkison-Johnson and Lin, an ACA member who specializes in play therapy and filial therapy, say that counselors — including those who have been out in the field for a while — would benefit from interacting with different cultural groups under supervision.

Multicultural development is a lifetime commitment, not just one workshop, class or book, Ceballos adds. She challenges counselors to continue working on recognizing and addressing their unconscious biases. “We learn best through experiences, so … expose [yourself] to different cultural groups, to different cultural experiences … within the community,” she says.

Spanking and the discipline continuum

“When we think of child discipline, we only think of spanking, and I think that’s where we’ve missed the mark,” Adkison-Johnson says. “In general, across all racial groups, child discipline is a broad program of parenting. … It’s [parents] teaching children basically how they want their children to be, how they want to socialize their children within their family structure.”

Spanking generates a lot of heated opinions and often overshadows other aspects of child discipline. Counselors can be prone to taking a position on spanking and focusing exclusively on that aspect of discipline while ignoring all the other parenting tools that people may use along with spanking, Adkison-Johnson says. However, research indicates that “children are more impacted by the whole program of discipline than just the isolation of spanking in and of itself,” she argues.

Spanking also evokes stereotypes of minority cultures relying heavily on physical discipline. In fact, Ceballos did focus interviews with Latinx mothers and found they were cognizant of a pervading stereotype of Latinx parents spanking and abusing their children. The mothers discussed the distress this stereotype causes them and how it made them feel unsafe to discuss child discipline openly with just anyone.

Similarly, Adkison-Johnson acknowledges the stereotype of African American parents primarily using physical discipline to address inappropriate child behavior.

However, Post says, research indicates that parents in all cultural groups spank. “It is not just that some cultural groups spank more,” she adds. In fact, as recently as 2013, two-thirds of parents in a Harris Poll reported that they had spanked their children.

When parents ask Phipps her thoughts on spanking, she tells them that what she thinks is not important and turns the conversation back to what is working for them. “Usually they say that spanking is not working for them. They feel bad about it, but they don’t know what else to do,” she says. “They feel powerless.”

Lin, the recipient of an ACA Best Practices Research Award in 2016 for his work on child play therapy, says that spanking often hurts parents emotionally. Plus, parents often realize that spanking requires double the work. He explains that parents spank to stop the behavior, but then they must wait until the child calms down from crying — as a result of the spanking — to communicate why they spanked them.

Adkison-Johnson finds that physical discipline is often used as a last resort with children. People opposed to spanking typically equate it with violence, she says, and because they consider it a violent act, they feel it is inappropriate. “A blanket injunction with spanking when we have not provided empirical research to support that blanket injunction is problematic because that’s more of an opinion,” she argues.

She notes that parental use of physical discipline is a topic of much debate in the social science and legal literature. Several studies, including a meta-analysis by researchers Elizabeth Gershoff and Andrew Grogan-Kaylor (2016), associate physical punishment with negative childhood outcomes, which supports the premise that physical discipline is equated with violence. However, the most commonly cited studies on the consequences of spanking are correlational and do not show a direct causal link between physical punishment and long-term negative effects on children (see, for example, Robert Larzelere, Ronald Cox and Gail Smith, 2010).

“And from a culturally competent perspective, we’re actually still pushing our own [counseling or psychology profession] agenda because this is the way we want society to be regardless of whether it adequately addresses the child-rearing goals of parents,” she adds.

For this reason, Adkison-Johnson thinks that spanking, which is only one aspect of child discipline, has received too much attention. In fact, from her research with African American parents, she has found that child discipline happens on a continuum — one that is context and age specific. “That means … what the child does warrants the type of discipline that they will receive,” she says. “There’s no spanking randomly. There’s no discussion randomly. There’s no withdrawal of privilege [randomly]. Child discipline in African American homes is comprehensive and strategic and is dictated by the context [of the disciplinary situation] and age of the child.”

With the first behavioral offense, parents may explain what was wrong and tell the child not to do it again, she says. However, if the child has to be told repeatedly not to do something, then the parents may use a more severe form of discipline. As children age — roughly 6 to 11 years old — the discipline may become more restrictive (with physical discipline as a last resort) because the parents realize their children are interacting with the world, peers and the school system, and they want their children to behave a certain way regardless of what others do or say, Adkison-Johnson continues. When children become adolescents, parents typically use less physical discipline and more withdrawal of privilege unless the child commits a serious offense such as disrespecting the parent, she adds.

Several studies (such as one published in 2012 by Jennifer Lansford, Laura Wager, John Bates, Kenneth Dodge and Gregory Pettit) reveal that the negative effects of spanking often seen with white American children aren’t mirrored with African American children, probably because of how and when spanking is used, Adkison-Johnson says.

ACT, don’t react 

Post, Lin, Phipps and Ceballos all use child–parent relationship therapy (CPRT), a play-based treatment for children with behavioral, emotional, social or attachment disorders. The aim of CPRT is to teach parents how to use play therapeutically to strengthen the child–parent relationship and to reduce child behavioral problems and parent stress. CPRT skills include responsive listening, reflecting feelings and limit setting.

One CPRT rule of thumb is for adults to act as thermostats, not thermometers. This saying reminds adults that they control the situation (i.e., the “temperature” in the room) even when a child engages in negative behavior. If the adult is not in charge or not in control of his or her own emotions, then things can turn into a power struggle between the adult and child, further escalating the situation, Ceballos explains.

Because CPRT’s aim is to build a stronger relationship with one’s child, the approach is culturally congruent with Latinx culture and familismo (a Latinx cultural value of dedication, commitment and loyalty to the family), Ceballos says. Thus, when Latinx parents are exposed to CPRT, they are often receptive to learning the associated skills, she adds.

Once when Post was teaching child-centered play therapy skills, an African American student told her that he didn’t see how the child-centered approach would work for his culture, which preferred a more authoritarian or directive parenting style. By the end of the class, however, the student had a new appreciation for the approach. Because African American children grow up in environments that can be racially hostile to them, African American parents often see a need to engage in racial socialization practices — for example, teaching their children to be compliant for their own safety. However, the student eventually recognized the value of also providing these children with a safe space in the playroom where they could freely communicate who they were and what they were feeling. He reasoned that this would help them to grow more confident and competent.

Phipps, an LPC supervisor and a registered play therapist supervisor, recommends an IDEAL response for discipline — one that is:

  • Immediate (within three seconds)
  • Direct (be within 3 feet and make eye contact with the child)
  • Efficient (be measured and use the least amount of firmness possible)
  • Action-based (have the child model appropriate behavior to create motor memory for making future choices)
  • Leveled (aim the response at the behavior, not the child)

Phipps, a member of ACA, also teaches parents how to listen, acknowledge and accept children’s feelings even if they don’t agree with those feelings. For instance, she will often hear a child say, “I feel anxious,” and the parent’s response is, “There is nothing for you to feel anxious about.” That statement is not helpful, Phipps says.

Parents often need help discerning the difference between children’s behaviors and their feelings, she continues. She explains the distinction with the following example. It is OK for a child to feel angry at his or her parents, but it is not OK for the child to hit the parents. Many parents do not recognize the difference between the two, and they discipline the child if he or she gets angry, Phipps says.

Fussing at children because they are not behaving at home or school will not make them feel safe or secure, notes Post, a member of ACA. She advises adults to use the 30-second burst-of-attention technique. For example, when a parent is on the phone and a child is tugging on his or her shirt, the parent should stop for 30 seconds and attend to the child. After the parent gets on the child’s level and listens, then the parent can say, “I’m going back to my phone call now.”

Post, who currently trains teachers to use these skills, recently witnessed the power of listening to children rather than simply reacting to bad behavior. A young boy was being disruptive — throwing things and yelling — in a classroom. Instead of yelling for him to stop or threatening to call his parents, the teacher used CPRT skills. She got down on his level and in a calm voice said, “You feel sad.” The boy was silent for a time, and then he told her that the night before, someone had broken into his home while he was sleeping, and it was chaotic. After the teacher listened to his story, the boy calmed down and returned to the classroom.

Acknowledging feelings is the first step of the ACT model of limit setting. The subsequent steps are communicating the limit and targeting an alternative. Post and Phipps presented on this topic at the ACA 2018 Conference in Atlanta.

Post provides an example of using ACT to correct a child’s behavior. If a child is walking around when the family is eating dinner, the parent would say, “I know you want to get up from the table while we are having dinner, but now is the time to stay at the table and eat with the family. But you can walk around after dinner is over.” In this instance, the parent is providing the child with a way to meet his or her need at another time, Post explains.

Phipps, an adjunct professor at UNCC, practices the skills of the ACT model of limit setting with her counseling students, her counseling supervisees and her clients. With parents, she provides a scenario of a child misbehaving (e.g., throwing a toy), and then they discuss how to respond to the child using ACT. Sometimes, parents even write down the wording to practice later. Next, Phipps brings parents into the playroom so they can watch her execute these skills or even do them along with her. This helps parents feel more comfortable using the skills on their own later.

Although limit setting can be a difficult skill to learn, it is one of the most powerful tools that counselors have, according to Phipps, whose dissertation revealed its effectiveness. She worked with a child who was displaying aggressive behavior at preschool. After two sessions that involved limit setting, the child’s behavior improved at school. Phipps’ study also showed that as the child’s behaviors improved, so did the behaviors of his classmates.

Letting children take control

What happens when setting limits isn’t enough and the child continues to misbehave? Counselors and caregivers can turn toward choice giving. Landreth explains the skill of choice giving in his Choices, Cookies & Kids DVD, which Post says is a great resource for parents because it is humorous and contains relevant examples. When Post was in private practice, she would let parents watch the video while she worked with their child.

Phipps knows from personal experience that setting limits may not always be enough, and she says that choice giving is an easy skill for parents to use. She once had a young client who decided to throw sand in her office rather than play with it. First, Phipps tried setting limits: “I know you want to throw the sand, but the sand is not for … ” The boy threw sand in her face before she could finish her sentence. So, Phipps tried again, getting out the entire sentence this time before he threw sand in her hair. The third time that he picked the sand up, she set the limit again, and he decided to drop it. But when he picked the sand up for the fourth time, Phipps had had enough. She decided to use choice giving: “If you choose to throw the sand again, you are choosing to lose the sand.” The boy decided not to throw the sand.

“When you get to choice giving,” Post says, “do it once and be sure that you can follow through on your choices. [Also] be absolutely sure that you’re ready for this.”

Post advises using the word choose or choosing four times and leading with the positive choice first. She provides the following example: A child is walking around the classroom and won’t sit in a seat. First, the teacher sets a limit: “I know you want to walk around, but now is the time to sit in your seat. You can walk around at recess.” If that doesn’t work, the teacher gives the child a choice: “If you choose to sit in your seat right now, you are choosing to use the iPad for five minutes this afternoon. If you choose not to sit down in your seat, you are choosing not to have your iPad this afternoon.”

“Then that’s it,” Post says. “Then that child has to decide.” If the child is still walking around, the teacher says, “Oh, I see you’ve chosen not to have your iPad this afternoon.” The language should always emphasize that the child, not the adult, is the one choosing, Post explains. If the child gets upset, the teacher can say, “Oh, I am sorry you chose not to have your iPad. I would have chosen for you to have your iPad.”

The decisions the child is allowed to have control over will differ based on the developmental age of the child, Post continues. For example, a 3-year-old shouldn’t be allowed to decide if riding a bike alone around the block is a good idea, but the parents could let the child pick out his or her clothes for preschool.

With both limit setting and choice giving, children learn to control their behavior, begin to think of themselves as choice makers, and assume responsibility for their decisions, Post explains.

Phipps agrees. In her example of the boy throwing sand, the aim was not just to get him to stop throwing it and making a mess. It was for him to learn how to make decisions that would work for him in the real world.

Similarly, counselors can help parents view discipline from a completely different perspective — as a means to help children learn how to make decisions for themselves and control their own behavior, Post says. “It’s not to stop a child from doing something in the grocery store right this minute,” she explains. “It is to help a child learn that they make decisions for themselves and that their decisions count.”

Dealing with resistance

Parents who have been court ordered to attend counseling or whose children have been removed from the home because of the parents’ discipline practices are likely to be resistant to therapy, Adkison-Johnson notes. In such situations, counselors first need to confirm that the parents have a right to be angry, she advises. Counselors must also remember that their duty is to the client (the parent or parents), not the agency that made the referral, she says. (See sidebar, below, on the counselor’s role as a witness in court on physical discipline.)

When working with issues related to child discipline in such cases, counselors should prepare themselves to experience the full brunt of clients’ emotions, Adkison-Johnson says. Sometimes, white counselors feel uneasy with African Americans’ emotions, especially when those emotions involve anger, she adds.

“Be comfortable with the resistance. Be comfortable with the anger. Be comfortable with the fact that the client may not want to talk to you,” Adkison-Johnson advises. “They may have short responses at first. Sometimes they may not want to come back [to] the next session, but [they] come back anyway because they have to.”

Adkison-Johnson stresses the importance of counselors addressing these clients formally (unless they indicate otherwise), shaking the parents’ hands, and using their child’s name. These simple actions show respect for the family dynamic of authority, she explains.

The mental health field has a checkered past when it comes to its treatment of racial minorities, so African American families may also have a healthy paranoia that the clinician isn’t really operating in their favor. As a result, counselors must take baby steps to establish trust, Adkison-Johnson says. She advises doing this by acknowledging the parents’ fears and anger and by showing that the counselor is knowledgeable on the topic and understands the depths of the situation. Another important step toward establishing trust, she adds, is clearly explaining informed consent, limits to confidentiality, and clients’ right to remain silent.

Lin’s counseling students conduct free parenting training, and they post flyers to find parents who are interested. Although the parents are participating voluntarily, the training is sometimes recommended to them by their children’s teachers, and this can cause parents to have a bad attitude initially. Sometimes, parents also complain that they are too busy and don’t have time to complete the homework assignments, such as having uninterrupted playtime with their children for 30 minutes once per week. When parents come in with a negative attitude, Lin reminds his students that they must listen and avoid blaming the parents. One of the first skills counselors teach to parents is how to reflect children’s feelings, so counselors must model this behavior themselves, he stresses.

Sometimes, parents’ resistance to counseling stems from personal or cultural differences. When working with immigrant Taiwanese parents who identified as Christian, Lin’s counseling students voiced frustration that the parents were arguing with them about spanking, including quoting Bible verses on why it was appropriate to discipline their children this way. Lin’s advice in such situations is simple: “Never argue with parents. They have their own value system. They have their own beliefs.”

Instead, he advises counselors to focus on providing parents with additional parenting skills such as limit setting. “The more skills [parents] have, the better,” he says. “They don’t want to hold that stick in their hands all the time.”

Raising an adult 

While reading Michelle Obama’s book Becoming, Post found herself nodding in agreement with the parenting philosophy of the former first lady’s mother, who said she was raising adults, not children. According to the former first lady, “Every move she made, I realize now, was buttressed by the quiet confidence that she’d raised us to be adults. Our decisions were on us. It was our life, not hers, and always would be.”

Today, however, parents often assume their children’s responsibilities rather than viewing their role to be raising future adults. This is a tendency that crosses cultures. Lin recounts a saying in Taiwan: “If I give birth to a child and I don’t teach, then it’s my fault as a father.” This saying relies on the inaccurate belief that parents are responsible for their kids’ behavior, he says.

“When [parents] are so out of control in their own emotions when their kids are throwing a fit, usually it’s because they don’t have a clear boundary between themselves and their kids,” Lin says. With CPRT and filial therapy techniques, counselors can teach parents that children need to learn to be responsible for their own actions. This perspective will help parents remain calm and not become so upset if they misbehave, he adds.

Phipps’ belief is that parents are doing the best they can — whether she agrees with all of their parenting decisions or not. “We need to have a humbler approach to parents. … I have to walk humbly with a parent because I’m not walking in their shoes. I don’t experience that [child’s] behavior every single day,” she says. “I am the expert in the skills, but parents are the experts on their children.”

 

****

 

Being a witness in court on physical discipline

According to a 2013 Harris Poll, nearly 8 in 10 Americans believe that spanking children is sometimes appropriate. The question is when does corporal punishment become abuse?

That answer is complicated because it varies by state. The most common approach, used in more than half of states, says that parents may use reasonable force if necessary to maintain discipline.

Counselors may be asked to inform the courts on this distinction. Being an expert witness on child discipline is a pressing issue right now, notes Carla Adkison-Johnson, a licensed professional counselor and a professor in the Department of Counselor Education and Counseling Psychology at Western Michigan University. In fact, much of her work has moved into expert testimony, which involves discussing her research to inform the court whether a parent should be brought up on criminal charges just for spanking their child. She works to inform court judges on how to distinguish between child discipline and child abuse when dealing with families.

As anti-spanking groups gain more political clout, they put pressure on child protective services to carry out their perspective, and this puts families of color at risk, Adkison-Johnson contends. She says that because of racial bias in our society, African American parents are disproportionately brought up on charges of physical abuse related to the child discipline practices they follow. The large majority of her cases as an expert witness have involved African American parents who have had their children removed from the home and who face potential jail time or a felony because they spanked their child.

Adkison-Johnson says that clinicians might also be called to serve in court as “witnesses of fact” (which differs from the role of an expert witness), particularly if they are working with families that have been mandated to attend counseling. In this role, counselors are working directly with the parents to help them but are also being asked to inform the court about the facts of the case. Thus, the questions that counselors ask these parents and the approach they take in counseling the parents are crucial, she stresses. Counselors must find out what parents have done, and they should ask specific questions about the goals and aspirations parents have for their children. This information will help address the “why” and “how” questions when evaluating parents’ disciplinary approach, she explains.

Adkison-Johnson points out that today’s parents often wrestle with establishing healthy boundaries and may have become more lenient in terms of discipline. The current parenting generation has been told not to spank or to use strict discipline with children and has been directed to instead negotiate with children on what the rules will be, she adds.

Counselors may also be asked to write letters on the progress they are making with clients. Adkison-Johnson advises counselors to let clients read these letters before sending them to the outside agency. “See if the client feels comfortable [that it is] an accurate portrayal of how they parent and what they believe took place in the counseling session, and be open to that discussion,” she says. She finds that clients will sometimes remember a detail that the counselor forgot or overlooked.

“Also, let them know that you are their counselor and not an agent for the court or child protective services and that you are committed to them and the success of their family,” she adds.

— Lindsey Phillips

 

****

 

Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

****

 

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.

New maternal mental health certification available to counselors

By Bethany Bray April 25, 2019

It’s estimated that 1 in 9 American mothers experience peripartum depression.

Because maternal mental health issues are so prevalent, many counselors’ caseloads include clients who are struggling during the first weeks and months of motherhood. However, few practitioners are well-trained enough to fully understand the unique needs and risks this population presents, says Birdie Meyer, the director of certification for Postpartum Support International (PSI), a Portland, Oregon-based nonprofit established to raise awareness of and connect people to resources for maternal mental health issues.

“There are a lot of nuances to this stage of life,” says Meyer, a registered nurse with a master’s degree in counseling. “You can really do damage if you send someone to a therapist who doesn’t know perinatal mental health … [And] There aren’t enough providers out there.”

Worse yet, a practitioner who treats perinatal clients but hasn’t completed comprehensive coursework or trainings in this area can risk doing harm to mothers at a vulnerable time of life. In her decades working in perinatal mental health, Meyer says she’s witnessed horror stories of women being reported to their local department of social services by a practitioner who mis-read the symptoms of peripartum distress – which can include feeling ambivalent toward a new baby or, in severe cases, thoughts of harming the baby or themselves.

“The despair that comes with [peripartum depression] feels like life will never be better, never be the same again. Many times, women seek help but don’t get someone [a practitioner] who understood, or the woman didn’t know where to turn,” says Meyer, who recently retired as coordinator of the perinatal mood disorders program at Indiana University Health, a large hospital system based in Indianapolis.

For this very reason, PSI has begun to offer a certification for helping professionals in perinatal mental health. It’s a project that has been three years in coming, and Meyer was closely involved in the certification’s development and launch.

PSI’s new Certification in Perinatal Mental Health became available in August to counselors, social workers and other mental health practitioners, as well as prescribers (medical doctors, psychiatrists), doulas, midwifes, lactation consultants and other affiliated professions. So far, 130 practitioners have become certified but hundreds more have begun collecting the hours of coursework required to qualify to take the certification exam, Meyer says.

Before a practitioner can list PMH-C after their name, they must pass a rigorous exam and have at least two years of experience in their field. They must also show proof of completion for 14 hours of continuing education in a subject related to maternal mental health. Finally, applicants must participate in an intensive, six-hour training that PSI offers in locations across the U.S., or a pre-approved course equivalent.

PSI has partnered with Pearson VUE, a company with testing centers across the U.S., to proctor the certification exam. The cost to sit for the exam, a test of 125 multiple choice questions, is $500.

PSI developed and refined the certification exam with several teams of subject-matter experts, including professional counselors, Meyer says.

“The test is rigorous,” says Meyer, “but if you’ve had the training that is required you should be able to pass.”

In order to keep up the PMH-C certification, a practitioner will have to complete at least six hours of continuing education each year, she adds.

Meyer believes that the PMH certification will ensure that more and more practitioners are qualified and available to give parents get the help they need in a most critical and vulnerable time of life.

The certification came to fruition after the family of Robyn Cohen, a woman who passed away as a result of a maternal mental health issues, donated to PSI to fund the project in her memory.

 

****

 

Find out more about PSI and the Certification in Perinatal Mental Health at postpartum.net

 

Email questions about the PMH-C to certification@postpartum.net

 

Listen to an extended interview with Birdie Meyer on the Mom & Mind podcast (episode 104): drkaeni.com/podcast/

 

 

 

Related reading: For more on the unique mental health needs of peripartum clients, see the feature article “Bundle of joy?” in the April issue of Counseling Today.

 

****

 

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

 

 

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

 

 

****

 

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.

 

 

Bundle of joy?

By Bethany Bray March 28, 2019

What day of the week is it?” “Why can’t I get my baby to stop crying?” “Did I take a shower this morning, or was that yesterday … or the day before?” These are the types of questions that parents — and especially mothers — often find themselves asking in the foggy, exhausting and often-overwhelming months that follow the birth of a new baby.

“The first three months [of motherhood] are a twilight zone,” says Susannah Baldwin, a licensed professional counselor (LPC) who is the founder and director of a Greenville, South Carolina, counseling practice that specializes in maternal mental health. “Some people call it the fourth trimester, but I call it the twilight zone phase. … They go from working to, boom, they have a baby and don’t leave the house for two weeks.”

Regardless of whether the child is the woman’s first or fifth, the postpartum period can be characterized by the presence of unique mental health needs and challenges. In addition to learning (or reacclimating to) the ropes of parenting and bonding with a new baby, mothers must adjust to changes in their identity and to different pressures on their relationship with a partner and the family system as a whole. Navigating this major life change is made more difficult by sleep deprivation and by bodies that are undergoing the biological and hormonal shifts associated with not being pregnant anymore.

Counselors can play a vital role in preparing clients for this “twilight zone” and normalizing the often anxiety-provoking challenges that accompany the postpartum period. One of the most important things counselors can do for postpartum clients, Baldwin says, is to create a welcoming space and foster a therapeutic bond so that these mothers are comfortable talking through the good, the bad and the ugly of their experience. This includes bringing to light the irrational, fearful and sometimes shame-inducing thoughts that can be part of new motherhood.

These challenges are amplified for mothers who have a pre-existing mental illness, who don’t have a stable partner or strong family supports, or who are part of various at-risk populations, including those living in poverty. Clients who already struggle with self-doubt, negative thought patterns, unprocessed trauma or other issues related to mental illness may find it overwhelming to assume the role of caregiver for themselves and for an infant, says Baldwin, whose practice serves clients going through issues related to infertility, pregnancy, traumatic childbirth or postpartum distress.

Postpartum “is such a critical time,” says Baldwin, a practitioner certified in perinatal mental health. “If existing issues are left untreated, it will affect their attachment and entire [parenting] experience. Do not underestimate that this is a time of gravity in a new parent’s life. Really attend to that and keep it in mind.”

Baby blues

It is normal for new mothers to experience periods of worry or sadness in the days and weeks following the birth of a baby. If these feelings intensify or last longer than a few weeks, however, it may be a sign of postpartum depression.

The Centers for Disease Control and Prevention reports that 1 in 9 mothers nationwide experience depression either in postpartum or peripartum, which includes the period of pregnancy through and after the birth of a baby. Peripartum depression is the more accurate term to use because symptoms can begin during pregnancy itself, not just after the birth, notes Isabel A. Thompson, a licensed mental health counselor in Florida who is writing a book for mental health practitioners on strength-based approaches for working with clients with peripartum depression.

Counselors working with clients who are pregnant or are new mothers should listen carefully for potential indicators of peripartum depression. According to the organization Postpartum Support International, these red flags can include:

  • Crying and having persistent feelings of sadness
  • Feeling ambivalent toward the baby
  • Feeling numb, angry, irritable, guilty, restless or hopeless
  • Worrying about or having thoughts of harming the baby or oneself

Thompson, a member of the American Counseling Association, recommends that counselors conduct periodic wellness check-ins with all peripartum clients. This action helps screen for peripartum depression and mood disorders but can also identify other areas in which these clients are struggling. Check-in questions can include:

  • How is the client feeling in her relationship with a partner (if applicable)?
  • How much is the client socializing?
  • How is the client’s physical health? Is she eating regularly and sleeping when she is able?
  • Is the client feeling connected to her religion or spirituality (if applicable)?

“Also ask about her sense of meaning and purpose,” suggests Thompson, an assistant professor in the counseling department at Nova Southeastern University. “Sometimes in the day-to-day slog of caring for an infant, it’s easy to lose your sense of meaning. Bring her back to why she wanted to be a parent in the first place.”

Isolation can also come into play for new mothers. “Before,” Thompson says, “they were working and having social contact, and now they’re home alone. Help her find ways she can reintegrate with previous friendships and find support with other parents.”

Tools for the journey

The estimated prevalence of peripartum depression in the United States ranges from 8.9 percent of women during pregnancy to as much as 37 percent of mothers during the first year after birth of a baby. These statistics were included in a February 2019 JAMA article that recommended counseling — specifically cognitive behavior therapy (CBT) and interpersonal therapy — as an effective means of preventing perinatal depression.

The journal study, conducted by a government task force, compared the effectiveness of CBT and interpersonal therapy versus the effectiveness of physical activity, the use of antidepressants, omega-3 fatty acids, and other supportive and behavioral interventions such as infant sleep training and expressive writing. Researchers found the two therapy methods to be most effective in preventing perinatal depression, especially for mothers with a history of depression or “certain socioeconomic risk factors” such as poverty or single parenthood. Women who received either CBT or interpersonal therapy during the study were 39 percent less likely to develop perinatal depression than those who did not receive counseling.

The anxious and fearful thoughts that often come in pregnancy and postpartum can generate a barrage of new cognitive distortions, says Quinn K. Smelser, an ACA member and LPC in Washington, D.C., who is working on a doctoral dissertation about parent-child attachment and the Marschak Interaction Method. Teaching clients to challenge these distortions — such as through the help of CBT — can greatly enhance their ability to cope and persevere through the challenges of peripartum.

Smelser, who presented a session on attachment and maternal mental illness at the ACA 2018 Conference & Expo in Atlanta, says that person-centered approaches, mind-body interventions, breathing techniques and mindfulness can also be helpful with this population. Likewise, grounding techniques can be beneficial, but Smelser cautions counselors to remember that a woman’s body will process sensations differently as she progresses through pregnancy and postpartum. For example, Smelser had a client who found that pressing her feet into her shoes helped her to center herself — until she was about six months pregnant and the exercise just became painful.

Thompson notes that narrative therapy can also be helpful for new mothers. Each woman’s experience of conception, pregnancy, birth and postpartum will be different — and can range from easy to miserable. Having the client tell her story, whether it involved an unplanned cesarean section or was a long-awaited miracle after struggling with infertility, can help her process the experience, Thompson says.

Remember also that the childbirth experience itself can be traumatic and might require processing with a counselor. Thompson suggests having clients talk through or write (if they prefer) how the entire pregnancy, birth and postpartum period went for them and what they wished had been different.

A population at risk

When it comes to clients who are pregnant or new mothers, counselors’ first instinct may be to screen for signs of peripartum depression. That’s wise, given how common it is. But this population is also at risk for a number of other issues, from social isolation and burnout connected to exhaustion, to guilt and other emotions related to wanting — or not wanting — to return to work after maternity leave.

Baldwin, a co-author of the ACA Practice Brief on peripartum and postpartum anxiety, separates the issues that these clients are at risk for into three categories: perinatal distress, interpersonal distress and relationship distress.

Perinatal distress includes the classic symptoms associated with peripartum depression or anxiety, such as crying and sadness, but it extends to anything that is interfering with aspects of everyday life such as eating, sleeping, relationships or home life, Baldwin explains. For example, a mother with perinatal distress may be so worried that her baby is going to stop breathing that she stays up all night watching the child sleep. Or she stops checking the mail because there is a steep hill leading to her mailbox, and she’s afraid the baby might somehow fall out of the stroller.

Risk of isolation also falls under this category. An example is a mother who fears taking her baby out in public because it’s flu season, Baldwin says. “In American culture, we are driven to be independent and individualistic, and that drives parents to feel like they have to do everything alone. If they ask for help, it’s seen as a shortcoming,” Baldwin says. “The biggest threat [that can lead to isolation] is the cultural belief that you’re supposed to do this without anyone’s help.”

Interpersonal distress involves issues related to a woman’s changing identity and her transition to motherhood. Similar to what people experience during a midlife crisis, new mothers may feel generally unsettled in life. They may wrestle with difficult thoughts such as “I love my kid, but I don’t love this role” or “This isn’t what I thought it would be,” Baldwin says. This sense of unease can arrive with a first baby or a later birth.

“These crises come from subconscious places. [Mothers] don’t realize why they’re upset or unsettled,” Baldwin says. “They may find themselves making rash decisions. All the sudden, they have an awareness of a gap or hole that must be filled, and they don’t know what to do but try and fill it in.”

Relationship distress involves the new pressures that come when baby makes three (or four or five). Couples often assume that having a baby will make them stronger and create the family that they always wanted, Baldwin says. “But it can be the opposite if we’re not attentive to it. It’s so often underestimated, the huge impact that adding a child or dependent to a family will have,” she says.

Babies often provide lots of joy, but the simple reality is that they also exert a substantial drain on a couple’s finances, time and personal energy — all of which can affect the relationship dynamic. Clients may report feeling distant from their partner or struggling with a lack of intimacy after having a baby, Baldwin says. She adds that those struggles don’t revolve just around sex but also around finding time alone or experiencing a loving connection.

“Couples often put themselves on the back burner” when a new baby arrives, Baldwin says. “They haven’t been on a date in six months. Or perhaps they’re not fighting but only talk about bottles and play dates and not about other things. … Resentment and bickering over tasks — that’s what often brings people to therapy.”

Smelser, a trauma and play therapist at the Gil Institute for Trauma Recovery and Education in Fairfax, Virginia, notes that peripartum clients and their partners are at risk for developing unhealthy patterns in their relationships. Examples include not making time for each other, having vastly different parenting styles, not dividing up responsibilities in an equitable manner, and getting so ingrained in certain roles and patterns that all flexibility is lost. If not addressed, these issues can create tension and grow into larger problems later in the relationship, Smelser says.

Counselors can broach the subject by asking questions about a client’s dynamic with her partner, Smelser says. Prior to having a baby, the client may never have seen her partner with a child or in a caregiving role. How she perceives her partner now may need some therapeutic attention, Smelser says. In cases of a pre-existing mental illness, counselors should stress the importance of these clients getting the support they need so that they can focus on themselves and engage in self-care.

“There’s so much opportunity to psychoeducate a pregnant client or new mom,” Smelser says. “They just need help adjusting. Really deep dive into that rather than glossing over how stressful new motherhood is. Don’t dismiss it [as a clinician]. Really talk about it and validate those feelings.”

How counselors can help

Do you know the difference between a doula and a midwife? How about what organizations offer postpartum support groups in your community? Are you comfortable conferring with a client’s OB-GYN if she has questions about taking antidepressants while breastfeeding?

Counselors don’t have to be parents themselves to offer empathy and a listening ear to peripartum clients. Becoming familiar with and sensitive to the unique needs of this population can make a major difference to mothers who are struggling.

> Make a plan: During pregnancy, help these clients create a safety plan to ensure that both they and their babies get the support they need in the months ahead. This is important for any mother, but it is vital for those with pre-existing mental illnesses, Smelser says. Counselors should discuss what steps the client would take to keep herself and her child safe were she to find herself in crisis and unable to manage. Identify the supports that she can rely on ahead of time. Also talk through what her therapy plan will look like with an infant at home. What might her needs be, and what should she focus on in counseling?

“Stopping therapy for a few months because of the demands of motherhood is the absolute last thing we want to happen,” Smelser says. “Plan on how and when she will give herself breathers. Will it be a neighbor taking the baby for 30 minutes while she goes for a walk? What does she do now to regulate [her mental health], and how can we ensure that it still happens? Make sure the mother has lots of support so she can take a break if she needs to, to help her better regulate to return to caring for the child. Even an hour a day for self-care, that can be vitally important.”

> Identify supports: Counselors should familiarize themselves with the parenting and maternal support groups — especially those geared for participants with a particular mental health diagnosis such as depression — in their local areas. If one doesn’t exist, Smelser suggests counselors consider starting a group themselves.

Thompson advises counselors to also be aware of lactation consultants, breastfeeding support groups, and pelvic floor and other women’s/maternal health specialists in their communities. In addition to birth doulas, there are also postpartum doulas who can support mothers in the weeks after a birth, she notes. Also, counselors can help connect clients who are struggling financially with programs that provide food and other assistance to new mothers, including the federal Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

Some mothers may not feel comfortable sharing their struggles in a support group format, Baldwin notes. She suggests that play groups and other child-focused activities can offer an alternative that helps these mothers find social support and meet parents who are facing similar stressors. Counselors should also be aware of parenting classes, moms groups and exercise classes for mothers at local houses of worship, community centers or medical centers.

Baldwin also encourages counselors to become familiar with Postpartum Support International (postpartum.net), an organization that provides various resources and maintains local networks across the country.

> Focus on strengths: A new mother may experience feelings of inadequacy when a new baby arrives and she struggles with seemingly simple tasks such as figuring out her baby’s sleep schedule. First-time mothers especially may have thoughts such as “Why can’t I do this?” or “I have a Ph.D., but I don’t know how to help my baby stop crying,” Thompson says. These assumed inadequacies can spur feelings of guilt, shame or anxiety.

Counselors can help by normalizing clients’ experiences, Thompson says. Explain that it’s routine to struggle, and there are nuances to learning a baby’s needs and preferences. In addition, counselors can highlight clients’ strengths and focus on what they are doing well, she says.

“Help her identify her strengths, even if she’s not feeling them currently. How did she feel strong before she had the baby? How can she reconnect with that?” Thompson says. “Ask questions in a way that can help [her] identify the differences between caring for an infant and succeeding at work. Explain that it’s a totally new role, and validate that it will be hard: ‘You are used to being able to accomplish things easily, but now even taking a shower requires you to wait for your husband to get home from work.’ Normalize those challenges.”

Smelser tells clients that it’s normal for all parents — including those without pre-existing mental health issues — to feel like they’ve reached their wits’ end at times. “Recognize those moments as just thoughts. It’s just a moment and will pass,” Smelser says. “There are so many shoulds, such as ‘I should be able to handle this.’ Identify that as a cognitive distortion and equip the client with tools to handle it.”

> Ask the right questions: Baldwin suggests that counselors start by asking peripartum clients general, broad questions and then “follow the trail” to identify areas where they are struggling and need more therapeutic work or support outside of counseling. Have them discuss life “before” and “after” the baby: How are they sleeping? How often do they get time to themselves? How is their relationship with their partner?

“Depending on how open they are,” Baldwin says, “ask more specific questions, such as ‘When was the last time you talked [with your partner] about something other than the baby, chores or errands? Do you have a ritual in place for spending time together and connecting?’ Depending on their answer, go down the trail and ask more: ‘How often do you bicker? How often do you feel you’re parenting solo?’ One of the biggest challenges is that prioritization. The baby and the bills and the stuff gets prioritized.”

Follow up with more leading questions, Baldwin suggests, such as “Tell me how much of your energy goes into worry. Who in your life helps you out emotionally, practically and socially? Do you have people who can help you in all three areas?”

One of the most important questions counselors can ask, Baldwin adds, is whether a client has a family history of postpartum depression.

> Explore expectations versus reality: Exploratory questions can also help clients work through expectations they might be harboring (either consciously or unconsciously) about parenthood, Baldwin says. She suggests asking, “Where did you imagine you’d be at this point, and how does it compare to where you are?”

“Perhaps they always imagined loving staying home [with a baby], and it turns out they hate it. … Expectations can get people in trouble,” Baldwin says.

Control issues can stem from creating an expectation — such as planning to breastfeed or have a natural birth — that goes unmet due to factors outside of a client’s control, Baldwin says. Clients who have perfectionist or Type A tendencies may struggle in this area. Counselors may need to help these clients understand that having a baby is simply not a controllable experience, she says. It’s not as simple as making a plan and sticking to it.

> Discuss returning to work: Counselors can play a key supportive role as clients navigate emotions surrounding the decision of whether to return to work. Remind clients that there is no right or wrong decision and that nothing is permanent: If they return to work and find themselves overwhelmed, they have the power to make changes, Baldwin says.

“The whole point of questions on this subject is to empower them to realize that they choose their job, their lifestyle,” Baldwin says. “Ask them, ‘What are your plans for returning to a job?’ I don’t even say your job. If they express hesitation or distress, then I’ll focus on it and ask more questions: ‘How did you imagine it would be? How did you imagine it would feel to drop your child off at day care?’”

Counselors can help clients who have made the decision to return to work prepare both mentally and practically. Baldwin suggests that clients do a “dry run” long before their first day back. This includes waking up early and getting themselves and their child ready as if they needed to leave by a certain time to make the drop-off at child care. “Going back to work doesn’t have to be this big ominous day,” Baldwin notes.

> Work on your vocabulary: Do you know what a nipple shield is? When was the last time you walked down the baby aisle at Target? Unless a counselor is familiar with a new mother’s world, that mother isn’t going to feel comfortable disclosing feelings that are intense, personal and sometimes scary in therapy sessions, Baldwin says. Counselors who don’t specialize in maternal mental health should bring themselves up to speed on current birth and parenting practices to connect with peripartum clients. Postpartum Support International has a page of resources for practitioners on its website and offers a certification in perinatal mental health.

Counselors should also be aware of the different options for childbirth, adds Thompson, who presented a session on breastfeeding and peripartum depression at the ACA 2017 Conference in San Francisco. Babies are born today in hospitals, at home or at birth centers with a range of support professionals, from midwives to nurses, all of which have different philosophies.

> Focus on attachment: Counselors who are working with postpartum clients should be mindful of the importance of the mother-infant bond and provide support for mothers who are struggling in this area. Research suggests that the bond formed through breastfeeding can be protective for mothers and reduce symptoms of peripartum depression, Thompson notes. However, many mothers are unable to breastfeed for various reasons, so counselors should frame questions on this topic carefully to avoid inducing guilty feelings. In addition to breastfeeding, mothers and infants can bond through skin-to-skin contact, by making eye contact while bottle feeding and in other ways, Thompson says.

Maternal mental illness — and untreated mental illness in particular — has the potential to affect the attachment bond, which can have negative implications for a child’s cognitive development and relationship patterns later in life, Smelser says. Counselors can ask questions to get indications of how well mothers are connecting with their babies. “How does she react when her child cries? Are there moments in the day when it’s harder?” Smelser says. “If she has a baby with colic, she may need a space where she can simply be honest and say, ‘It’s awful.’ Can she soothe her baby? What’s working and not working? Is she figuring [her child] out?”

Counselors can also normalize these struggles and stress to these clients that it is OK to ask for help whenever they need it, Smelser adds.

> Talk about medication: Many psychiatric medications have different risks and side effects when taken during pregnancy, breastfeeding and postpartum. Counselors must make sure that their clients are communicating with their prescribers, Smelser emphasizes. Counselors should also check in regularly during counseling sessions about clients’ medication management and how medications are affecting their mood. If granted permission by the client, counselors can also check in with the client’s OB-GYN and other medical professionals.

“Make sure everyone is talking to one another and that the mother is getting all the information she needs from her prescriber. Help and empower her to advocate and ask questions,” Smelser says. “Connections between practitioners — a client’s OB-GYN, prescriber and counselor — are not always that great. Medical professionals don’t always ask [patients] about mood or mental wellness. In an ideal world, all these people would be housed in the same space, but we are not there.”

Thompson also stresses the need for regular check-ins with clients about medication usage. Clients should discuss any changes in dosage with their prescribers, weighing the possible risks of taking the medication during pregnancy or breastfeeding against the risks to their own wellness if medication is reduced or not taken, she adds.

> Be baby friendly: Allowing and even inviting mothers to bring their newborns into counseling sessions can go a long way toward helping them feel supported and understood, Thompson notes. Finding child care can often be a barrier to treatment. When it comes to referrals, counselors should look for inpatient programs that allow new mothers to attend with their child, she adds.

> View mother and baby as one unit: In the United States, medical professionals often place greater focus on an infant’s health in the first few months of life. In reality, Thompson asserts, the mother’s and baby’s health are intertwined, and counselors should keep this in mind.

“During pregnancy, they were literally one unit, and only recently have become two. Emotionally, they’re still so bonded. That connection needs to be honored,” she says. “Addressing any mental health needs the mother has will automatically help her connect with her baby. If she is struggling with mental health, she will be less responsive to her baby’s facial cues and expressions. Healthier moms mean healthier babies.”

****

 

Contact the counselors interviewed in this article:

 

****

 

Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

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

Use your ACA member login to access practice briefs on postpartum posttraumatic stress disorder, peripartum and postpartum anxiety, and peripartum and postpartum depression.

Counseling Today (ct.counseling.org)

ACA Interest Networks (counseling.org/aca-community/aca-groups/interest-networks)

  • Women’s Interest Network

 

****

 

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

Letters to the editor: ct@counseling.org

 

****

 

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

Parent-child interaction therapy for ADHD and anxiety disorders

By Donna Mac March 6, 2019

When one hears the term “parent-child interaction therapy” (PCIT), it might be assumed the therapy’s purpose is solely for that specific use — i.e., for parents to use with their children. However, this couldn’t be further from the truth. In fact, PCIT can be used in therapy sessions, then the therapist can teach the child’s teacher how to use PCIT in the school environment and, of course, the therapist can teach parents how to use these skills at home and in community settings, all in an effort to coordinate and synchronize treatment across settings.

Sheila M. Eyberg developed PCIT in the 1970s out of the University of Florida. It was built from multiple theories of child development, including attachment, parenting styles and social learning. In the past, PCIT was intended mostly for children 2 to 7 years old with disruptive emotional disorders and behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder. The purpose of PCIT was to work on rapport building and to enhance the relationship between the child and parent, for the child to develop more intrinsic motivation to comply and for the parent to develop more positive feelings toward the child — a cycle that can then be positively repetitive.

In addition to disruptive disorders, PCIT also seems to help children with anxiety disorders. In particular, there is research demonstrating its efficacy with the anxiety disorder of selective mutism. Therefore, clinicians have also begun using it for social anxiety disorder, social phobia, school phobia and agoraphobia. In school and community settings, PCIT is used as an antecedent intervention that helps shape the environment to create an emotionally safe space for these types of anxiety disorders to be more effectively managed. (It should also be noted that PCIT can be used to treat ADHD and anxiety beyond age 7 with simple modifications.)

The goal of this therapy is to produce more prosocial behaviors, regardless of the diagnosis. For example, with anxiety disorders that specifically manifest as a fear of being around people or communicating with others, the goal is for the child to be less inhibited and avoidant. The child’s symptoms might include struggling to leave the home, averting eye contact, displaying a shrinking body posture and having frozen reactions, both in terms of a lack of verbal response and a lack of body movement (think of a “deer in the headlights” appearance). The goal in such cases is to help these children manage their symptoms so they can present in a socially expected manner.

On the other hand, children with ADHD can present as too disinhibited, demonstrating hyperactive, impulsive, incessant and intrusive behaviors, so the goal is to adjust those behaviors to be more inhibited.

Subsequently, the PCIT goal for both of these populations is to produce more desired social behaviors, which will lead to better social outcomes, thus perpetuating the cycle in a positive manner. When children receive positive social feedback, they are likely to keep using these skills in an effort to continue engaging in positive interactions.

Addressing self-esteem

PCIT is a relationship-enhancing therapeutic technique. The concepts from this therapy that I use with children who have either ADHD or avoidant anxiety disorders revolve around Eyberg’s child-directed interaction (CDI) and PRIDE skills. CDI and PRIDE go hand in hand and, when combined, have been shown to build rapport with the other person and build confidence and self-esteem within the child (in an effort to manage both disruptive and anxious-avoidant behaviors). If a child feels comfortable with a certain relationship, that child may feel more valued, worthy and confident and have stronger self-esteem. As a result, the child will be less anxious, better able to manage disruptive impulses and more likely to use expected social skills.

Children with ADHD often struggle with their self-esteem because of the amount of negative feedback they tend to receive on a daily (or more frequent) basis: “Don’t touch everything in this store.” “Stop asking me if we can go to the pool.” “Leave your sister alone.” “Why can’t you just behave?” Yet if a child receives positive feedback versus corrective feedback in an approximate ratio of 4-to-1, the child will be more likely to comply with the directive to “stop asking that question,” to “leave your sister alone,” etc.

Children with the avoidant types of anxiety disorders also struggle with self-esteem because of the negative judgments they assume and perceive that others are making about them. When these children receive praise, it helps them feel less anxious. In turn, when their brains are stabilized, they are more able to use their actual abstract counseling strategies (such as cognitive behavior therapy, or CBT) on themselves to manage their anxiety and actually “leave the house,” “maintain eye contact,” “use complete sentences” (rather than one-word answers), etc.

In therapy, PCIT can be used as a stand-alone treatment, but I recommend combining it with other therapeutic treatments such as operant conditioning, exposure therapy and CBT. Of course, the use of CBT will depend on the age of the child and whether his or her brain is developed enough to process abstract counseling strategies. Children don’t usually possess this ability until age 7 or 8. It should be noted that use of these treatment techniques (alone or in combination) does not guarantee success or an absence of symptoms.

Implementing PCIT with CDI and PRIDE

Some professionals refer to CDI as “child chooses.” Regardless of the terminology, during this portion of PCIT, no directives are to be given to the child and no questions are to be asked until CDI has been used for at least three minutes. This allows the child to feel positive about himself or herself because nobody is giving directions to correct something that the child was “doing wrong” upon entering a room or during a new transition.

When children feel positively about themselves, they are more likely to comply later down the line. Therefore, it should be noted that CDI is not a time to criticize. CDI means that the child will choose something to do without any adult direction. The adult (whether that is the counselor, the parent or the teacher) is to observe what the child does and give the child physical space if the adult’s presence seems to agitate or increase anxiety in the child. After at least three minutes of CDI, the adult uses PRIDE skills (verbal interaction from the adult) when the child seems more emotionally regulated. PRIDE is an acronym that directs the adult to offer the child labeled praise, reflection, imitation, description and excitement/enjoyment (in the adult’s voice).

As a real-life example, let’s say that “Alison” is in homeroom at school first thing in the morning. At the therapeutic school in which I work, this is where the students meet in the mornings to get any homework lists, eat healthy food, use coping skills, check in with their teachers and therapists, and practice socializing with peers appropriately. CDI is used immediately upon students’ arrival.

In this case, Alison puts her backpack on the floor upon entering the room, then goes to sit at her desk (her backpack is not where it is supposed to be, plus it is open, with its contents falling out). When Alison enters the classroom for the first time, it is time for CDI, so the teacher is not to direct her to move the backpack, at least for a few more minutes. (If your first interaction involved someone telling you to correct something, think about how you would feel.)

At her desk, Alison eats an apple, and then a peer asks Alison for a piece of paper. Alison silently gives her peer the paper, without offering any eye contact, and then gets up to throw away the apple she just finished eating. She then remembers to get her assignment notebook out of her desk. Even though Alison’s backpack is open on the floor with papers, food and more disorganized contents spilling out, the teacher doesn’t direct her to do anything until after offering Alison the full array of PRIDE skills:

  • Praise: Praise appropriate behavior. This should be specific labeled praise about what is positive. In this case, it could be any number of things: “Alison, thanks for sharing your paper with Sarah. You are so helpful” or “Thanks for throwing away that apple in the garbage. You are very responsible” or “You remembered to get out your assignment notebook. You have a great memory!” This labeled praise includes helpers to build confidence in Alison related to both her IQ and her EQ (emotional intelligence), therefore lessening her anxiety and helping her manage her impulsivity.
  • Reflect: Reflect appropriate talk. This means the adult reflects back what the child says to them. For example, when Alison is done with her assignment notebook, she asks the teacher, “When is the fire drill?” The teacher is to reflect the main concept of the question. In this case, the teacher might say, “I am glad you want to know when the fire drill is so you can be prepared. That is very responsible of you. It is at 9.” Reflection is key to letting children know you are really listening to them. And if someone is listening to them, then they feel valued, understood, worthy and accepted, lessening their anxiety and raising their self-esteem. In this case, the teacher also offered more labeled praise about Alison being prepared and responsible.
  • Imitate: Imitate appropriate social behaviors. If Alison takes out paper and colored pencils to draw as a “quiet coping” skill during the appropriate time, the teacher takes note of how to imitate this same concept down the line. “Your drawing just reminded me of something, Alison. When all of the homeroom students have arrived, we can all play that drawing game we played a few weeks ago. Would you be willing to lead the game since you really understood it last time and are such a talented artist?” This lets Alison perceive that she is worthy because she was doing something that the teacher also wants to do (artwork). This serves to lessen Alison’s anxiety. It also helps her realize that she can in fact be a leader herself, increasing her self-confidence.
  • Describe: This is the time to give behavioral descriptions. Simply describe what the child is doing, which shows the child that someone is both attending to them and giving approval of their actions. This serves to increase the child’s confidence and decrease anxiety. For example, the teacher might tell Alison, “You’re drawing a sports car with a mountain in the distance. That looks fast and powerful yet peaceful at the same time. That’s pretty impressive and creative that you’re able to capture all of that in one picture.” This description also includes more labeled praise pointing out that Alison is creative.
  • Excitement/enjoyment: Demonstrate excitement in your voice, which is key to attending skills. This strengthens the relationship with the child and allows the child to experience many positive feelings. This also increases the chances the child will comply when you give a corrective direction.

It should be noted that some people with anxiety fear receiving positive praise in front of other people. If this is the case, adjustments can be made to the treatment technique.

In Alison’s case, all of the PRIDE letters were used, and she received even more than the allotted three minutes of CDI time. Alison’s CDI time included getting to choose to eat her apple, asking her fire drill question and taking out paper to draw a picture. Once CDI and PRIDE have been used, the teacher can move to adult-directed interaction, in which the teacher can finally:

  • Ask questions: “Alison, do you have your math assignment from last night?”
  • Direct some peer interaction (such as getting the students together for the drawing game referenced earlier).
  • Give instructions (such as addressing that backpack issue): “Alison, it would help us out if you could close your backpack and put it in your locker. I would hate for anything of yours to get lost or for someone to get hurt tripping on it.” When Alison complies with that direction, the teacher can follow up with more labeled praise: “Thanks for following directions.” One caveat: Never say, “Thanks for listening.” There is a big difference between someone “listening” and someone “following directions.”

Other considerations

The CDI/PRIDE skills/adult-directed interaction combination should be used in the child’s home continuously, at play dates in others’ homes, at school and community activities and, of course, in the therapy office. PRIDE continues to be a way of communication, so it doesn’t stop when the conversation gets going.

In the therapy office, once emotional regulation has been established with the combination of CDI/PRIDE/adult-directed interaction, the counselor can move to reminding the child of the operant conditioning plan, then work on CBT skills or exposure skills to continue building strategies to manage impulsivity or anxiety.

If children’s ADHD symptoms are impairing their social and educational functioning with significant intensity, frequency and chronicity, it is also likely that a psychiatrist will prescribe a stimulant medication. ADHD is a genetically based, neurobiological disorder that affects many parts of the brain. Medication can touch parts of this, especially when it comes to dopamine and norepinephrine disruptions, but it can’t adjust everything. Even for the parts of the brain that can be medicated, medication doesn’t guarantee an absence of symptoms. That is why it is crucial to continue using therapeutic techniques as antecedent management and counseling strategies to help children function in their different environments.

In terms of anxiety, for those suffering impairment in their social and educational settings on an intense, frequent and chronic level, the first line of medication will likely be a selective serotonin reuptake inhibitor (SSRI). This is because the main area of the brain affected is serotonin (in addition to anxiety affecting norepinephrine, glutamate and the limbic system structures of the hippocampus, hypothalamus and amygdala). Again, however, an SSRI will not guarantee an absence of symptoms, which is why therapeutic techniques, exposures and counseling strategies remain key.

 

****

 

For more examples of how the attending skills of CDI, PRIDE and others related to PCIT can be used in school settings, home situations and community/recreation settings, please reference my two books: Toddlers & ADHD and Suffering in Silence: Breaking Through Selective Mutism.

 

****

 

Donna Mac is a licensed clinical professional counselor in her 12th year working for AMITA Health in one of its therapeutic day school locations. Previously, she was a teacher in both regular and special education settings. She has three daughters, including identical 9-year-old twins diagnosed with ADHD hyperactive/impulsive presentation and selective mutism anxiety. Contact her at donnamac0211@gmail.com or through her websites: toddlersandadhd.com and breakingthroughselectivemutism.com.

 

Letters to the editor: ct@counseling.org

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

 

****

 

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 messy reality of perfectionism

By Lindsey Phillips February 26, 2019

Philip Gnilka, an associate professor of counseling and the coordinator of the counselor education doctoral program at Virginia Commonwealth University (VCU), has heard of severe cases of perfectionism at college counseling centers in which a student refuses to submit any work out of fear of being evaluated. As long as the student does not turn in work, his or her sense of self remains intact, he explains.

This raises a question: Is perfectionism a bad thing? Within the mental health professions, healthy debate is taking place on this very topic. Some therapists view all forms of perfectionism — whether self-oriented, others-oriented or socially prescribed — as negative, whereas others believe there is an adaptive component to perfectionism.

Gnilka, a licensed professional counselor (LPC) and the director of the Personality, Stress and Coping Lab at VCU, is in the latter camp. He notes that, historically, perfectionism has been considered a negative quality, so the goal was to reduce clients’ perfectionistic tendencies to make them “better.” However, he says, this black-and-white thinking — a quality of perfectionism itself — does not fully capture perfectionism.

Instead, Gnilka, a member of the American Counseling Association, argues that perfectionism is a multidimensional construct that consists of perfectionistic strivings (i.e., Do you hold high personal expectations for yourself and others?) and perfectionistic concerns, or one’s internal critic, (i.e., If you don’t meet these standards, how self-critical are you?). He says these two dimensions can help counselors determine who they are working with: an individual with adaptive, or healthy, perfectionism (someone with high standards but low self-criticism) or an individual with maladaptive, or unhealthy, perfectionism (someone with high standards and high self-criticism).

In his research, Gnilka has found that one’s perfectionistic concerns, not one’s strivings, are what correlate with negative mental health aspects. “What’s really correlating with depression, stress and negative life satisfaction is this self-critical perfectionism dimension. It’s not holding high standards itself per se,” he explains.

In fact, Gnilka argues that lowering clients’ perfectionist standards or instructing them to do things less perfectly is the wrong approach. Anecdotally, he’s found suggesting that clients lower their standards is a nonstarter and often doesn’t work. Instead, Gnilka advises counselors to focus their interventions on the self-critical voice. “Focusing on that internal critic … is where you’re going to get your most malleability because that’s the one [dimension] that’s connected with all the [negative aspects of mental health],” he says.

Healthy striving

Beth Fier, the clinical director of SEED Services: Partners for Counseling and Wellness in New Jersey, finds perfectionism to be problematic. “It’s rigid and it’s interfering in some way, and it’s pretty unforgiving in terms of its high standards so that it actually is creating difficulty either for [people] and their experience of themselves or maybe in their relationship to others or how they’re interacting in the world.” However, she also acknowledges that many people want to be high achieving.

Because perfectionism can be limiting with its focus on being “perfect,” Fier, an LPC and an ACA member, likes the concept of excellentism. As an excellentist, people still want to do their best, but the term allows them to think more flexibly about how to do that, she explains. The focus is more on the process, which allows people to appreciate and enjoy the effort, the learning curve and their growth along the way. Perfectionism becomes problematic when people focus solely on the outcomes — on if they meet a certain goal, Fier adds.

Emily Kircher-Morris, the clinical director and counselor at Unlimited Potential Counseling and Education Center in Missouri, offers a similar perspective. Rather than using the term adaptive perfectionism, she prefers the phrase striving for excellence. Perfectionism, she explains, often implies there is no room for error, which becomes self-defeating. “All of these [perfectionistic] characteristics can be strengths,” she notes. “It’s when they go too far that they start causing disruptions to our lives.”

Despite their differences in terminology or mindset about perfectionism, Gnilka, Fier and Kircher-Morris all agree on the importance of healthy strivings and the need to intervene on the critical voice.

Kircher-Morris does this in part by having clients create realistic reframes, which is a way of changing a negative thought into something more optimistic. Counselors can draw thought bubbles and ask clients to fill in one of the bubbles with the negative thought and the other bubble with a realistic reframe. For example, the negative thought “I got an answer wrong when the teacher called on me. Now everyone thinks I’m dumb” could be rewritten as “I am allowed to make mistakes just like everyone else.” This exercise helps clients figure out a way forward without ignoring the uncomfortable emotions, Kircher-Morris adds.

However, too much reframing may cause clients to feel like counselors are imposing a “right” way to think about the situation, says Kircher-Morris, an LPC and a member of ACA. She finds that using dialectical thinking to look at and validate both sides is empowering for clients. For example, one technique she finds helpful is moving clients from either/or statements to both/and statements such as “I’m doing the best I can and I know I can also do better” and “This is going to be really hard and I know I can get through this situation.” By shifting their thinking, clients realize that two opposite statements can both be true; they are not necessarily exclusive to each other, she explains.

Much of Fier’s work involves softening the critical voice. She often poses the following scenario to her clients to illustrate the potential danger of this voice: “Imagine you are put in charge of selecting a child’s kindergarten teacher. Would you want a teacher who is strict and will tell the children they are horrible as a means of motivating them to learn and grow? Would you want a teacher who lets children do whatever they want and not worry about the quality of their work? Or would you want a teacher who has high expectations but works with and supports children to help them figure out opportunities for growth and learning?”

Although the answer seems obvious in that context, it is often difficult for people to apply that same balance of high expectations and support to themselves, Fier says.

Valuing progress, not outcomes

It is common for people who possess perfectionistic tendencies to assume they can achieve something quickly and easily, Fier points out. That’s why breaking down activities into smaller step-by-step pieces that clients can build on is important, she says. This process provides opportunities for positive reinforcement; allows clients flexibility in achieving their overarching aim; and allows clients to focus on what they have accomplished rather than on the ultimate outcome, she explains. 

Fier, the past president of the New Jersey Association for Multicultural Counseling, redirects clients from working toward goals to working toward values and aims, which allows them greater flexibility in how they address the situation. This includes asking clients the reasons they set a particular goal and why that goal matters. Shifting the focus to values and aims helps clients feel good about what they accomplish rather than beating themselves up for what they fall short of achieving, she adds.

Fier recently worked with a client who had a goal of balancing care for her mental and physical self. The client focused on outcome-based goals of diet, exercise and weight loss. By focusing on the outcome, she would berate herself whenever she didn’t make it to the gym. Fier helped the client broaden her perspective on how to achieve her aim or value of having a healthy lifestyle, which can include exercising, eating well, getting adequate sleep and pursuing good mental health.

“Some days that might be going to the gym. Some days that might be taking a quick walk outside because [she has] all of these other competing priorities,” Fier says. “It’s that intention and motivation that keeps [the client] focused on the care piece as opposed to the ‘I didn’t make it’ piece — ‘I screwed up and did it again.’”

Kircher-Morris also warns counselors to watch out for “goal vaulting.” This is when people set a goal and, as they close in on reaching that goal, they instead raise the bar. In the process, she explains, they forget about all the steps they completed to get to that point, which makes them feel like they aren’t making progress or haven’t accomplished anything.

One technique Kircher-Morris uses to address this counterproductive thinking is to have clients write down the steps they have accomplished to reach a certain goal on a graphic organizer, such as a visual symbol of stairsteps or a ladder reaching an end goal.

Kircher-Morris worked with a gymnast who was frustrated because she couldn’t seem to master a back handspring. Kircher-Morris helped the client break down all the skills she had accomplished in pursuit of that goal, such as learning how to do a cartwheel and roundoff. “You have to recognize those successes along the way because, otherwise, you’ll always feel like you’re falling short,” Kircher-Morris says. “A lot of times it’s easier to work backward — starting with the end goal but then thinking back to what were all of the things you had to do to get to that point. That, sometimes, is a little bit easier to conceptualize.”

Understriving

Most people equate perfectionism with overstriving and overachieving. But this isn’t always the case. Perfectionism manifests in different ways, Kircher-Morris points out.

“When clients come in … I hear anxiety, I hear stress [and] I hear being overwhelmed,” she says. “When we get into what is causing that level of distress, I find that it’s often coming from a place of perfectionism, whether that’s manifesting as procrastination or risk avoidance or just really trying to control situations.”

Avoidance, Gnilka says, “seems to be a big coping difference between adaptive perfectionists and maladaptive perfectionists. They use the same amount of task-based coping and emotion-based coping, but the avoidance-based coping seems to be very, very high for maladaptive perfectionists compared to an adaptive one.” Thus, counselors might ask clients why they are avoiding certain things and what they are afraid of, he says.

Kircher-Morris agrees that counselors should help clients understand what they are avoiding. People often assume that avoidance is based on a fear of failure, but what they don’t realize is that avoidance can also result from a fear of success, she argues. For example, imagine a student who avoids going to medical school based on a fear of doing well at school only to discover that he or she hates being a doctor and is unhappy.

“They fear the success that then might lead to something negative in the future,” Kircher-Morris explains. “It’s not something you would typically think of when you’re thinking of perfectionism, but it can have a negative outcome in the future and lead to procrastination or avoidance of decision-making.”

The challenges children and parents face

Socially prescribed perfectionism extends beyond the microcosm of the nuclear family, Kircher-Morris says. Thanks in part to the influence of social media, children and parents alike often start to think that others have a “perfect” life and then feel the pressure to measure up to that impossible standard.

Kircher-Morris recalls a client who chose a college degree program based on the respect he thought it would garner from others rather than based on his own interests. The client had struggled in high school, so he wanted to prove to others that he was capable.

To offset these societal pressures, counselors can help clients become aware of their own personal goals and ways to measure success for themselves, Kircher-Morris suggests. This might include guiding clients to figure out what is at the root of their motivation to get into a particular school or to achieve a certain ACT score, she says.

Kircher-Morris has also noticed a connection between perfectionism and people who are gifted or of high ability. “Part of the reason why you see [perfectionism] so commonly with people who are gifted and … with talented athletes is because things come so naturally to them, so then they don’t know how to handle it when something is difficult,” she says. People who are gifted are often told that they are smart, so they internalize this quality as a part of their identity, she continues. Then, when they face something difficult or challenging, they don’t know how to handle it because it doesn’t fit with who they think they are.

Kircher-Morris builds on these clients’ strengths by using analogies about times in the past when they got through something difficult or handled a situation differently. Then she points out how they could apply those same skills to their current situation. Counselors might also encourage clients to find their own comparisons, which facilitates independence, she adds.

Many parents also feel the pressure to be perfect. Seeing other people’s children getting accepted to elite schools or competitive athletic teams (things that often get trumpeted on social media posts) can cause parents to worry about not being good enough, Kircher-Morris points out. “When they see their child fail, it feels like a reflection on them,” she says. Or there’s the “fear that if [they] don’t handle this correctly, it’s going to change the trajectory of [their] child’s life.”

Counselors can help parents reframe this negative line of thinking. One method is to have them consider how allowing children to make mistakes is actually a sign of good parenting because it helps children learn, grow and become independent, Kircher-Morris says. “You don’t have to be the parent who always has all of the answers and who always manages your emotions,” she reminds parents. “It’s OK to show that vulnerability and process through that.” In fact, she often advises parents to be vulnerable within the parent-child relationship. Rather than hide their vulnerability, parents can talk through their feelings and model how to handle the stress.

For example, if a parent is anxious about a phone call or a meeting, the parent can share that feeling with the child and show the child how he or she would handle the situation. “You’re teaching the kids that it’s OK not to be perfect,” Kircher-Morris says. “It’s OK to have worries and stresses, but also you can still work through them.”

Kircher-Morris also finds that parents sometimes unintentionally facilitate perfectionism in their children. For instance, when a child brings home a school assignment, parents might focus on the errors and have the child correct them. Parents might also offer praise whenever the child scores 100 percent but question the child otherwise (e.g., “What happened? Why wasn’t this a better grade?”).

Another common example is when a parent unloads the dishwasher after the child loads it because it was not done to the parent’s standards, Kircher-Morris says. This behavior undermines the child’s level of independence and feeling of self-efficacy, she explains. In constantly critiquing and correcting their children in such ways, parents are teaching them that there is no room for error and that they aren’t “good enough” unless perfection is attained, she says.

Instead, counselors can help parents learn to focus on the process, not the outcome, Kircher-Morris advises. For instance, rather than fixating on individual test grades, parents can ask, “What did you learn on this paper? What did you get out of the assignment? What was the area of struggle?”

In an episode last year on Kircher-Morris’ Mind Matters podcast (mindmatterspodcast.com), Lisa Van Gemert, an expert on perfectionism and gifted individuals, discussed how teachers and schools also inadvertently engage in behaviors that increase perfectionism in students. She cited two examples of ways the educational system isn’t set up to recognize effort, persistence and diligence. First, teachers often give out stickers to reward “perfect” work. Second, having a perfect attendance award causes some children to come to school even when they are sick just to get the award. These types of rewards set up an unreasonable standard, Gemert said

“When we focus on the outcomes — the grades — then that’s going to lead to that perfectionism,” Kircher-Morris says. “When we focus on the process and the learning, then we’re going to move away from that and really focus on that striving for excellence.”

Imperfect experiments

To ease clients’ expectations of doing things perfectly, Fier often uses the word experiment: “We’re going to experiment this week with trying this [practice] and see how it goes. … This is simply a process that we’re going to test out and troubleshoot and come back to.”

The emphasis on experimenting is also a way of modeling flexibility, Fier stresses. “It doesn’t have to be all or nothing, I succeeded or I failed,” she says. “You’ve succeeded in the process of attempting.”

Rather than asking clients who expect to do mindfulness or meditation practices “perfectly” to engage in that practice every day, Fier may ask them to experiment with practicing their soothing rhythm breathing (slowing the exhale and inhale down to a rhythmical rate) twice during the week for 30 seconds. Then, the next week she may ask them to engage in this practice for five minutes every day or every other day. Again, counselors should emphasize that they are experimenting and exploring what works for the client, she says.

Kircher-Morris also finds it helpful to frame counseling activities as experiments. She often instructs her younger clients to be “scientists” with her. She tells them that together, they will come up with a hypothesis and test it out.

She has a middle school client who was deliberately not submitting work unless it was “perfect” (i.e., a completed assignment that lived up to her standards). In this situation, Kircher-Morris and the client crafted the following hypothesis: “If I turn in a math assignment and I have missed two problems, nothing will happen.” To test this hypothesis, the client intentionally missed two problems on an assignment that wasn’t worth a lot of points. In doing this, the client realized that the world didn’t fall apart when she got an 80 (instead of a 100) on this one assignment because it didn’t affect her overall A in the class. Kircher-Morris adds that this technique is similar to prescribing the symptom or systematic desensitization (a method that gradually exposes a person to an anxiety-producing stimulus and substitutes a relaxation response for the anxious one).

As scientists, clients also collect data. Kircher-Morris asks clients to document every time that they procrastinate on an assignment, think they are going to mess up or believe they have to do something perfectly. They can track these data with a phone app, in a notebook they carry with them or on an index card placed on the corner of their desk, she says.

Counselors should avoid framing this activity so that it unintentionally becomes a reward system for clients — an assignment they can “win” or “lose,” she warns. Instead, the point of the experiment is to have clients gain awareness, establish a baseline and test whether their beliefs associated with perfectionism are based on emotions or facts, she explains.

The shame of ‘falling short’

Fier doesn’t think she has ever worked with a client with perfectionistic tendencies who wasn’t also experiencing a sense of shame. She finds that perfectionism, depression and anxiety often cluster together, and the underlying thread is “this proneness toward self-conscious emotions, particularly shame, and that tendency to then get caught in a feedback loop in the brain that leads us down this road of self-criticism.”

Because clients who have perfectionistic tendencies often mask their struggles, building rapport and a trusting and open relationship with them as counselors is crucial, Kircher-Morris emphasizes. “They know that they’re in distress. They know that they’re struggling, but they don’t want it to be perceived that they can’t handle it on their own,” she says.

Perfectionism reinforces the idea that we are not enough to reach the standards we set for ourselves — the ones that are unrelenting and too high to be achieved, Fier says. “We start to have this sense of self that is based on this global sense of failure,” she explains. “It’s not that my behavior failed or that one part of me hasn’t been able to accomplish something. It’s that I’m the failure.”

In addition, shame makes people feel like they don’t belong, so they want to hide or disappear, Fier adds. In fact, some clients experience such a sense of unworthiness — to the point of self-loathing — that they often don’t feel they deserve compassion, she says. Thus, she finds compassion-focused therapy beneficial. Some compassion-focused techniques that help to regulate the body include soothing rhythm breathing, body posture changes (e.g., making the back and shoulders upright and solid and raising one’s chin to help the body feel confident) and soothing touch (e.g., placing hands on one’s heart).

Fier will also have clients imagine a compassionate image such as a color that has a quality of warmth and caring. She has clients explore their various emotional selves, such as their anxious self or their angry self, and think about how these emotions feel and sound when they speak to the client and to each other (e.g., “What does the angry self say to the anxious self?”).

Fier acknowledges that these practices and techniques do not get rid of the self-critical thoughts or difficult emotions entirely. However, over time, clients learn to pull up a compassionate self to sit alongside the difficulty, she says. “The compassionate self is the hub of the wheel that holds all these other parts of [the individual together],” she adds.

Kircher-Morris also identifies another point of emphasis. “One of the main components of perfectionism is a discomfort with vulnerability,” she says. “So, when [counselors] can facilitate that and give permission for that vulnerability, that’s where the change happens.” She recommends that counselors look for opportunities to use appropriate self-disclosures with these clients. She believes this gives clients permission to be vulnerable and reduces the power differential between client and counselor.

Being vulnerable and compassionate takes strength, Fier points out. She helps clients redefine strength — which in the United States is often viewed in terms of competition and domination — to realize that it is about being open to care and vulnerability.

Fier has also learned an important lesson: When working with clients, she doesn’t begin discussing compassion as something warm and caring. When counselors begin a session discussing compassion as a caring aspect, some clients think this emotion is too scary or difficult for them to relate to, she explains.

Instead, Fier begins by talking about accessing courage and eventually transitions into the courage it takes to be open, vulnerable and compassionate. She finds that some clients have experiences of feeling courageous or strong, but they have a difficult time connecting to experiences in which they have offered themselves any sort of care or comfort. “So, if [counselors] can start with where the client is and build up that courage, [they] can use that to help access the vulnerability and begin to redefine the strength aspects of being vulnerable,” she says.

Living with imperfection

For some counselors, perfectionism hits close to home. Counseling is a profession in which people often feel like they need to get it “perfect,” Fier says.

Kircher-Morris suggests that counselors follow the advice they often give to clients: Make the best decision based on the information you have at the time. “Our clients give us what they can, and it’s our job to connect with them and facilitate that and help them put those pieces together,” she says. “But we’re also working with what we have at the time, whether that’s our training and our professional development … [or the client] relationship and what we know about that particular client.”

Kircher-Morris says she often looks back at herself from five years ago and sees a counselor who thought she had everything figured out and knew what she was doing. Now, she says, she
realizes she was just doing what was best in the moment.

Counselors have to remember that they will not always get it “right,” and they have to learn to tolerate imperfection, Fier says. Every morning, Fier glances at the misaligned shower shelf in her bathroom, which serves as a gentle reminder that it’s OK to live with imperfection. Counselors can guide clients to find similar reminders to help them feel less threatened by imperfection, she suggests.

Perfectionism always goes back to one central issue — the self-critical voice, Gnilka asserts. “The idea that human beings are going to be able to walk around in life and not have any self-critical talk is just not possible. It’s not that healthy perfectionists are just walking around with no self-critical piece to them. It’s just that they’re walking around with no more, or maybe slightly less, than the average person of the population,” he says. “What [counselors] are trying to do is alleviate [the critical voice] so it’s not so critically depressing and keeping people from enjoying life.”

At the end of the podcast episode on perfectionism, Kircher-Morris acknowledges that if we don’t allow ourselves to admit we have flaws, then we are setting ourselves up for disappointment. “Perfectionism is the refusal to show any vulnerability,” she says. “It’s vulnerability that allows us to be authentic, who we really are, and establish those strong relationships with those around us. Giving ourselves permission to make mistakes allows us to be perfectly imperfect.”

 

****

 

Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

 

Letters to the editor: ct@counseling.org

 

 

****

 

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.