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Suicidality among children and adolescents

By Laurie Meyers August 25, 2021

This past spring, Children’s Hospital Colorado declared a “state of emergency” in youth mental health. Over the course of the COVID-19 pandemic, the hospital system’s pediatric emergency rooms and inpatient units had become increasingly overrun with children and adolescents with serious mental illness, many of whom were actively suicidal.

“It has been devastating to see suicide become the leading cause of death for Colorado’s children,” the hospital’s CEO, Jena Hausmann, told journalists and reporters at a pediatric mental health media roundtable on May 25.

This mental health crisis is not confined to Colorado, however. Pediatric medical systems across the nation have reported a significant and sustained rise in mental health-related visits for children and adolescents that began in spring 2020. According to the June 18, 2021, issue of the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report, mental health-related emergency room visits among adolescents ages 12-17 increased 31% compared with the rate in 2019. In addition, the report found that in this age group, the mean weekly number of emergency room visits for suspected suicide attempts was 22.3% higher during summer 2020 and 39.1% higher during winter 2021 than during the corresponding periods in 2019. This increase was more pronounced in girls; during winter 2021, suspected suicide attempt visits to the emergency room were 50.6% higher among girls ages 12-17 than during the same period in 2019.

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A confluence of factors

Research indicates that mental health concerns and suicidality have been increasing in children and adolescents for years. The current crisis cannot be linked to any singular cause, but it is evident that the isolation and anxiety of the pandemic added an accelerant to an already burning flame.

Renee Turner, a licensed professional counselor (LPC) in San Antonio, points to several factors she believes have been detrimental to child and adolescent mental health. Although she declares she is not by any means anti-technology, Turner admits she is concerned about the influence of social media, which not only continues to feed cyberbullying — which, unlike “old-school” offline bullying, is inescapable and omnipresent — but also encourages children and adolescents to view the world through an artificial lens, she says. “Children don’t have the ability to sort out what is real, what’s true,” and many parents are not teaching them how to consume online content in context, explains Turner, a registered play therapist supervisor. Technology is all-consuming, and many parents do not monitor or restrict their children’s screen time.

For that matter, Turner notes, many adults struggle with their own screen addictions. She believes this contributes to another modern problem: attachment issues. The rise of dual-income families, in which parents work demanding hours or multiple jobs for financial reasons or because of career demands, makes it more difficult to find time for bonding, she asserts. 

Turner also considers the pressure of living in such an achievement-oriented society another potential factor in the increase of suicidality among this population. “I see kids who are chronically overscheduled,” she notes. These young people are involved in myriad activities in consistently competitive environments in which achievement is conflated with self-worth, Turner points out. “It’s all [based on] their output, instead of them being valuable for just being them,” she says.

Turner, the director of Expressive Therapies Institute PLLC, has counseled middle school-age children who are already anxious about how they’re going to get into college. The demands on their time are such that they are staying up late into the night to get everything done, she says. What really stands out for Turner is that some of her clients who are in middle school and younger are self-harming and suicidal because they see no end to the treadmill they find themselves on. The COVID-19 pandemic further complicated the situation, she says, because children and adolescents struggled with online schooling even as parents tried to juggle working from home, taking care of the kids and helping with schoolwork. 

Turner stresses that children and adolescents need to have areas of their lives that exist simply for enjoyment — not performance. “If everything is evaluated, everything becomes work,” she observes.

Sarah Zalewski, an LPC who specializes in child and adolescent counseling, was working as a school counselor in a Connecticut middle school at the beginning of the pandemic. She noticed that the coronavirus restrictions had a profound effect on her clients and on students. “The kids who were in virtual schooling and separated from their peers struggled way more than those in school,” she says. “That routine and the connection with their peers is almost like a distraction from the stuff that is going on in their heads.” Things that had been on a “low boil” suddenly flared up, she says. 

Children and adolescents also seemed to struggle with the loss of familiar routines, Zalewski adds. Interestingly, she noticed that students who had been perennially overscheduled before the pandemic had a particularly hard time coping.

Catherine Tucker, a licensed mental health counselor in North Carolina and Indiana who specializes in trauma therapy for children, adolescents and adults, notes that early adolescence (approximately 11 to 14 years) is a particularly vulnerable time. “One of the normal developmental pieces [during early adolescence] is that every generation thinks they’ve invented all the normal problems, such as peer pressure, sex, bullying, dating. They feel like nobody older than them can possibly understand what is happening to them,” she says. As a result, adolescents often feel seen and understood by their peers but not by adults, especially their parents, notes Tucker, an American Counseling Association member and a licensed school counselor at the middle school level. This is a vital source of emotional validation that adolescents have been missing while separated from their peers, she points out.

Tucker also thinks that we’re underestimating the value of physical contact. “Just basic touch; it doesn’t have to be intimate. Just being near other people. The more we find out about neurobiology, the more we learn that things like eye contact, physical gestures and cues can help regulate the nervous system,” she says.

Marginalized populations are at an even greater risk for mental health issues and suicide, and the disproportionate toll of COVID-19 on Black, Indigenous and people of color communities has been an exacerbating factor. Brenda Cato, a professional school counselor who has experience with elementary, middle and high school students, says many of the students at her predominantly Black high school in Augusta, Georgia, saw school not as a social event but as an escape. Most of her clients come from impoverished homes where parents are working multiple jobs and utilities are skyrocketing. At school, these students get two meals a day. Cato believes not being able to get these meals during the pandemic played a significant role in students’ general inability to cope. 

Working with parents

The counselors interviewed for this article contend that educating parents is a vital part of addressing the suicide crisis among children and adolescents. Learning the warning signs of suicide and knowing what to do if a child becomes suicidal is crucial for parents, but it all begins with establishing communication and a sense of trust and safety. “The most important thing is to be able to establish a safe … [environment] where your kid can come and talk to you,” Zalewski says. 

She advises parents to schedule regular one-on-one time with their children. That might involve going out to eat ice cream together or playing games and talking, for example, but she emphasizes that the time should be spent without the parent being on their phone. It is important for children and adolescents to know that they have their parent’s full attention, she says. Zalewski also recommends having regular conversations in which the parent communicates that anything their child tells them in that time or space has no consequences.  

Turner’s clients include overscheduled and single parents who often struggle with the idea that to truly be there for their children, they need more time — time that they don’t have. So, Turner emphasizes quality time to these parents. “It’s essentially meeting the child where they are,” she says. “Taking an interest in what the child is interested in and asking them about that, engaging in their world.” Turner suggests parents have “date nights” with their kids and schedule times when everyone shuts off their phones and puts them in a basket to create a distraction-free zone. 

It can also be helpful to teach parents to establish “bursts” of listening time, Turner says. For example, when a parent is in the middle of something and a child is saying, “Mom, Mom, Mom,” the parent can reply, “OK, I have five minutes right now, so tell me what you need to tell me.” 

Of course, parents may struggle with how to respond appropriately when they find out that their child is experiencing a mental health crisis, especially if the child says, “I don’t want to live anymore.” Zalewski reminds parents that it is important to first take a moment to listen to their child. She then advises parents to say something that lets their child know they are there for them. For example, “Thank you for telling me. That was a brave thing to tell me. Do you want to tell me more about that?”

Zalewski then helps her clients plan for the next steps. “It doesn’t need to be a heavy-handed thing,” she says. Parents can use language such as “We are going to collaboratively figure out what our next steps are. I don’t want you to feel that way, and I want to keep you safe.” The child and parents can then discuss options. 

She adds that parents should ask one crucial question: “Are you able to keep yourself safe?” If the child isn’t sure, she advises parents to say, “I think maybe we need to go to the hospital and see if the counselor there can give us some ideas.” In many states, clients can call 211 to reach appropriate health agencies and even request that a mobile crisis unit come to the home to help establish a crisis plan, she adds.  

But even children and adolescents who have trusting and open relationships with their parents don’t always speak up when they’re experiencing suicidal thoughts. So, counselors need to ensure that parents recognize the warning signs, which are similar to those in adults. “What’s scary is that adolescents can be so much more impulsive than adults, especially … kids who have poor impulse control generally,” Tucker acknowledges. “There are fewer warning signs and fewer opportunities for intervention.”

Tucker emphasizes the importance of educating parents about reducing children’s access to means of suicide, such as having unlocked firearms and medications in the home. 

“The warning signs that I look for are not necessarily different than [those for] adults but are often written off as ‘teenage behavior,’” Zalewski says. For example, withdrawing may be either a warning sign or simply a wish to be alone. Parents should look for major changes in their child’s behavior in areas such as eating, sleeping and socializing, she says. Giving away prized possession is also a major red flag, she adds. 

Zalewski stresses that parents should not dismiss a child’s statement of wanting to hurt or kill themselves. “So many parents have said, ‘I thought this was just them expressing themselves for attention.’ If this is your kid’s way of getting attention, you need to pay attention and find out why they are using those words,” she says. 

Zalewski also urges parents to honor their intuition: “If you think there is a problem,” she says, “there probably is.”

Teachable moments

Cato faced a different kind of challenge when educating parents of students who had been identified as suicidal. “I was working in a predominantly Black elementary school, and a teacher sent a child to me who had been making suicidal comments,” she recalls. After assessing the student, Cato called the grandmother, who was the child’s guardian. The woman was irate and asked how many students in the school had been tested for suicide. Cato reassured the grandmother that the school didn’t test — it assessed. This taught Cato the importance of educating parents on suicide rates and the percentage of children who attempt or die by suicide.  

Cato didn’t approach the situation with the student’s grandmother from the attitude of “your kid is suicidal, and you will get help.” As a parent herself, she knew that if she didn’t understand what was happening with her own child, she would want someone to walk her through it. So, Cato sat down with the grandmother and explained that her granddaughter wouldn’t necessarily be put on medication or need ongoing therapy. However, Cato recommended that the child be seen by an expert. She told the grandmother that the school just wanted to make sure the child was OK and that she wouldn’t harm herself. Cato also reassured her that her granddaughter would not be stigmatized or labeled as a “problem” student, nor would a note be put in her permanent record. “I think everything is about how you communicate with people,” Cato says. Besides, the grandmother’s concerns were understandable, she adds. Black students are commonly — and disproportionately — diagnosed with serious mental health issues, Cato says, adding that she has seen students of color sent to special education classes based solely on disciplinary issues.

After the student was medically cleared, Cato worked with the student to create a reentry plan that included regular check-ins. These were sometimes as simple as walking casually with the child and asking her to rate her day on a scale from 1 to 10.

Cato tries to turn all her interactions with students and parents into teachable moments. She provides them with pamphlets, resources and crisis hotline numbers, and every time she visits a classroom, she reminds students that the counselors and teachers are there for them. She says she tries to “help them to understand it is not abnormal to feel this way.” She purposely uses “we” when she speaks to students: “We’ve all gone through rough times; we all need help sometimes.” 

Zalewski believes it is essential to also point out and honor the resilience strategies that children are already using. If listening to music helps a child or makes them feel better, then it is a good coping skill, she says. Discovering coping strategies helps build children’s confidence, she notes, and she informs parents of their children’s coping strategies too.

For that matter, Zalewski has found that her young clients often love to teach the strategies they have learned in session to their parents. In fact, to encourage clients to practice a skill outside of session, she recommends that they teach their parents how to correctly take a deep breath and explain what deep breathing does to the brain to calm the body. “Because then we’re helping parents regulate, [and] then we are co-regulating,” Zalewski says. “It can also really give a child a sense of self-efficacy that a lot of kids are lacking because kids are inherently powerless.”

She also works with clients on mindfulness, guided imagery, progressive relaxation, and identifying what physical activities they enjoy and why. For example, a child might like to play basketball in the driveway, but in Connecticut, snow often gets in the way. So, Zalewski helps them figure out the source of their enjoyment: Is it the physical energy they’re expending? Is it the repetition? They then come up with alternatives such as using weights in the basement. Zalewski is a firm proponent of anything that can get clients moving and (when possible) outside. “Nature is reparative for most humans,” she notes.

Tucker says that before the pandemic, children and adolescents were already experiencing stress related to a lack of connection, which she thinks could be associated with too much screen time. As children and adolescents begin to return to in-person activities, it is crucial to make sure they strike a healthy balance between screen time and social activities such as playing sports, working on art projects or simply hanging out together, she stresses. She also believes that the currently common practice of banishing recess in favor of test preparation or other extra classroom work has contributed to children’s anxiety levels. She argues that kids need a lot more time dedicated to free play and imagination.

Helping the helpers

Julia Whisenhunt, an LPC and certified professional counseling supervisor, specializes in studying and training others in suicide prevention. She always frames her workshops around suicide data to “help people understand that [suicide] isn’t uncommon.” Her goal isn’t to normalize the idea of suicide but rather to let people know that it happens and there is help. 

“I know there’s an assumption that talking about suicide makes people suicidal, but the research doesn’t bear that out,” notes Whisenhunt, an ACA member who is an associate professor in the counseling department at the University of West Georgia (UWG). “I think it’s the opposite. I’m confident that trainings have saved lives and helped individuals. I know that. I’ve lived it. The suicidality is there — people are just struggling in silence.”

It is important when training people who are not mental health professionals to emphasize that their role is not to “save” an individual who is suicidal but rather to get them help, Whisenhunt adds. 

Although Whisenhunt’s workshops are geared toward college staff (and students in positions of authority, such as resident associates), she is trained in Applied Suicide Intervention Skills Training (ASIST), which can be used to train staff in public school districts. ASIST is a 14-hour training created by the company LivingWorks that is grounded in research, Whisenhunt says. UWG’s counseling department does ASIST training with practicum students, and Whisenhunt says they report feeling much more confident once they have taken the course, even though they have already learned a good deal about suicide in their program.

One of the main components of ASIST is the “pathway for assisting life,” Whisenhunt explains. “They have a model for how to have a conversation about suicide with someone.” She tells practicum students that this is a model that summarizes everything they already know, but it presents the information in a format that is easy to keep at hand in a crisis. 

The first part of the model is about connecting with suicide, she says. It has two main tasks: exploring indications of suicide risk and then spotting warning signs and naming them. Once warning signs are identified, trainees learn to act directly without beating around the bush, Whisenhunt says.

Whisenhunt and her follow trainers also instruct workshop participants on how to talk about suicide and what to do if someone is expressing suicidal thoughts. She warns participants not to ask, “Are you thinking of hurting yourself?” because that could mean many different things to the person. Instead, she encourages training participants to be direct and not be afraid to use the word “suicide.” For example, they could ask, “Are you thinking of killing yourself? Are you thinking of suicide?”

She also advises them not to ask leading questions. “If you ask, ‘You’re not thinking about suicide, are you?’ the person knows the answer you want them to give,” Whisenhunt explains. “If the person seems hesitant, trust your gut, talk a bit more, make them feel more comfortable, and circle back around.”

She also tells people to keep asking about suicide. Don’t just ask once and feel “relieved that you got that out of the way,” she insists. “If you felt like you needed to ask and the answer doesn’t feel right, ask again,” she says. “A lot of people don’t want to die — they just want the pain to end. Help them know there’s another way out.”

Counselors also need to be prepared to provide resources, Whisenhunt adds. She advises her trainees to keep hotline numbers in their phones and to carry suicide prevention cards in their wallets. 

“When talking with an individual and hearing about their despair, chances are you are going to hear something that means that they don’t want to die. It’s often something like, ‘I don’t want to leave my dog,’” Whisenhunt says. “If you hear that little thing that says they don’t want to die, you don’t [want to] be manipulative, [but] you say, ‘I know that you’re in a lot of a pain, but it seems to me like you’re still thinking about living because you want to be there to take care of your dog.’ That’s the turning point — where they start to turn away from suicide and toward life.”

Counselors can then ask clients if they want to develop a plan to keep them safe for now, Whisenhunt continues. The use of the phrase “for now” is important, she stresses, because when people are in a suicidal crisis, talking about living for years and years is overwhelming to them. The safety plan should be for a matter of hours or days — just until the person can be connected with help, she explains. 

The ASIST safety plan includes “safety guards” and “safety aids.” Whisenhunt says safety guards include protecting clients from risk factors such as a plan to die by suicide, problematic alcohol or drug use, prior suicidal behavior, or mental health concerns that might exacerbate risk. Counselors can help clients consider ways to mitigate these risks such as by reducing or eliminating drug use. 

Guarding also involves being mindful and looking at previous suicide attempts for clues to keep the client safe, Whisenhunt adds. For example, the client might be impulsive, so part of keeping them safe involves having someone stay with them for a few days. 

Safety aids are elements that help improve a person’s chances of staying safe, Whisenhunt explains. Counselors can help clients consider the strengths they already possess and the supports they need to build. “It’s strengths-based,” she says. “We try to help individuals see their strengths and resilience and see options to help them feel better.”

Being prepared 

Counselors may be trained in suicide assessment and prevention, but putting that knowledge to use can still be a scary prospect, Zalewski acknowledges. For that reason, she stresses the importance of specialized training. If possible, she recommends that counselors find a local training opportunity with someone who can continue to serve as a resource for them afterward. She chose to work with a mobile crisis unit to learn more about helping those in suicidal crisis.

“There are a lot of modalities out there for suicide assessment,” Zalewski notes. “I would recommend not just picking one modality to learn. To be competent, you have to have a good understanding of what’s out there. Whatever you choose to work with has to mesh with you as a human. Explore what’s out there [and] learn several. … It’s well worth it, so when you are faced with some child who has decided they don’t really feel like living anymore, you’re not looking in your file cabinet or texting saying, ‘OMG.’”

Supervision is also essential, Zalewski stresses. “As counselors,” she says, “it’s easy to get to the point where you think, ‘I’ve been doing this for years, and I don’t need supervision.’” But that’s not the case. Sometimes, Zalewski says, she’s certain that she knows something, but supervision helps her realize that somewhere along the way, what she thought she knew got twisted. 

Counselors also need to have their own sources of support when doing this difficult work. “If you’re working with children and adolescents who are suicidal, it is a heavy weight,” Zalewski acknowledges. “It is so easy to question yourself.” And if the all too imaginable happens and a client completes suicide, the counselor is going to need backup, she adds. 

“Everyone in the end makes their own decisions,” she says. All that counselors can ultimately control is the level to which they provide clients with the best preventive tools, and “a good supervisor will help you assimilate that.”

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Laurie Meyers is senior writer at Counseling Today. Contact her at LMeyers@counseling.org

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

Feeling the strain: The effects of COVID-19 on children and adolescents

By Laurie Meyers April 23, 2021

One of the most contentious — indeed, at times, vitriolic — public health debates of the COVID-19 era has revolved around the safety of opening schools for in-person classes. For some politicians, the push to open seemed to be influenced by optics — a signal that states were “open for business.” At the same time, parents have struggled to help children and adolescents with their schoolwork and other aspects of distance learning and have longed for a safe way to get back to a less chaotic educational experience. Some parents were forced to leave their jobs to take care of children and still cannot return to work. Teachers and other school staff have expressed concern for their own safety and the safety of their families and students. 

Everyone agrees that online learning is not ideal for most students — and can be virtually inaccessible for marginalized populations — but in many areas, it seemed like the safest option. However, mental health professionals, educators, parents and community activists remain apprehensive about the negative effect that the lack of in-person instruction and interaction with peers is having on the mental, emotional, social, developmental and academic well-being of children and adolescents.

There has been much confusion about how often children and adolescents get COVID-19 and how likely they are to spread the coronavirus. Recent guidance from the Centers for Disease Control and Prevention (CDC) stated that while fewer children than adults have had COVID-19 in the United States, the number of cases among school-age children was rising. Not only can children and adolescents be infected and get sick, but they can also spread the virus to others. At the same time, the CDC revised its guidance for physical distancing in schools in March, saying that 3 feet of distance (as opposed to 6 feet) is sufficient in elementary, middle and high schools where masks are worn and where community transmission is low.

In many states, teachers and other educational system personnel have received vaccinations. School districts are implementing physical distancing protocols, and the American Rescue Plan Act of 2021 passed by Congress in mid-March includes money to improve building ventilation. With these developments, many schools that weren’t already open were planning a return to in-person education, either full time or on a hybrid basis. 

Amid all the debating and planning, one group has been noticeably silent: the students themselves. Many children and adolescents are struggling with a feeling of powerlessness, says Adam W. Carter, a former school counselor who is currently the coordinator of the trauma-informed counseling graduate certificate at Northern Illinois University’s Department of Counseling and Higher Education. “We’re not asking children if they want to go back to school, if they feel safe,” he says. “We’re making decisions as adults with [the needs of] children almost as an afterthought.”

The lack of agency in decisions regarding in-person schooling is not the only area in which many children and adolescents feel voiceless, say the sources Counseling Today spoke to for this article. Like adults, children and adolescents miss their friends; are frustrated by the inability to get together with others without fear of infection; mourn the loss of celebrations and the marking of milestones; are afraid that they, or a loved one, will get sick; and are tired of spending so much time in front of a computer screen. 

In other words, they have all of the stress but not as much control as adults do, notes Carter, an American Counseling Association member. Children and adolescents often don’t know how to talk about — or, for that matter, recognize — how the pandemic is affecting them. 

For example, “Children may not know how to talk about how they miss getting together at school or with friends,” says ACA member Barbara Mahaffey, a licensed professional clinical counselor and executive director of the Scioto Paint Valley Mental Health Center in Ohio. They might ask often about visiting others but not recognize that they’re having stomachaches and other psychosomatic effects because they’re lonely, she adds. “Children may not ask for help, and parents may not recognize a child’s distress,” Mahaffey says. 

Many parents are experiencing significant worry and stress about their finances or how they can keep their family safe from COVID-19. They may also be grieving the loss of friends or family members who have died from the coronavirus. Parents often believe that it’s best to shield their children from these concerns, but the reality is that kids pick up on the underlying fear without understanding its source, say Mahaffey and Carter. 

The strain on children and adolescents is showing. According to the Nov. 13, 2020, issue of the CDC’s Morbidity and Mortality Weekly Report, child and adolescent emergency room visits related to mental health began increasing in April 2020 and remained elevated through October 2020 (the latest date for which statistics were available). Compared with the same period in 2019, emergency room visits related to mental health rose 24% for children ages 5-11 and 31% for those ages 12-17. 

Missed connections

Children and adolescents want to be with each other, Carter says. Absent in-person classes and social activities, it is difficult for them to figure out how to interact. This generation is used to socializing through social media platforms and chat apps, but after spending six to seven hours online each day for school, interest in electronic gatherings has diminished throughout the pandemic, he says. Being in the company of others all day virtually but rarely if ever getting the opportunity to interact in person has produced a particular kind of loneliness for children and adolescents.

Counselors are also finding it difficult to connect with these clients online. Once the pandemic began and counseling shifted online, Sarah Zalewski, a licensed professional counselor (LPC) who specializes in child and adolescent counseling, knew she needed a new way to engage her clients. At the time, in addition to her private practice, Zalewski was working as a school counselor in a Connecticut middle school. 

“When they come into my office, I always have toys,” she says. “They love to play, [and] I do too.”

The toys functioned as an icebreaker, with students and young clients finding it easier to open up while their hands were busy, explains Zalewski, an ACA member. But with that icebreaker gone thanks to the abrupt end of in-person sessions, she had to start thinking of alternative ways to connect. “I didn’t want to do the traditional grown-up thing, like, ‘How was your day? What was school like?’” Zalewski says.

Zalewski thought about what she had been doing herself to cope with the stresses of the pandemic. One of her favorite coping mechanisms: playing video games. Given the popularity and ubiquity of video games, she decided they might offer a great way to bridge the gap with young clients.

In the beginning, Zalewski mainly discussed the games with her clients, asking them what games they liked and why. Whenever role-playing games entered the discussion, she explored what characters her clients typically chose to inhabit. Did they pick a warrior or a priest? How was the character similar to them? How was it different? In what ways did the character reflect who the client wanted to be in real life? “Why do you want to be a druid?” Zalewski might ask. “What is it about druidism that is really cool?” 

Zalewski emphasizes that counselors who try this approach need to know or learn the language of the games. “Gaming is a culture,” she says. “Use cultural humility. If you don’t know, for example, what a druid is — [because] it’s different in different games — ask. They love to talk about it.”

Eventually, Zalewski began playing the games with her clients. They start in Google Meet, where they do all of their communicating. They then use an online link or gaming platform. Zalewski has multiple screens, and clients often use tablets. 

Sometimes the games are relatively simple. For example, Zalewski recently began playing Connect Four with a young client as an exercise in frustration tolerance (because the client doesn’t always win). When a client expresses frustration during the course of a game, Zalewski probes for the source. Is it truly about the outcome of the game itself or is it frustration at a person in the client’s life that is coming out during the gaming session? Sometimes the frustration is really about the situation that children and adolescents find themselves in with the pandemic, including feeling like they no longer have the ability to do the things they once enjoyed.

Game-based problem-solving helps clients build coping skills as they are playing, Zalewski points out. In addition, she often directs young clients to use relaxation techniques that she has taught them, such as square breathing (breathing in for four counts, holding for four counts and then breathing out for four counts).

Zalewski also likes to use Roblox, an online platform that features various games and also gives users the ability to create their own games (a function that she likens to sandbox therapy). By creating games or even leading Zalewski through a virtual obstacle course, young clients can develop a sense of leadership, she says. 

Children and adolescents are struggling with the lack of social contact during the pandemic, Zalewski says, and this is often manifesting in anxiety, depression, anger and withdrawal. The isolation is particularly difficult on clients who have depression and attention-deficit/hyperactivity disorder, she adds. 

Because physical activity helps with mood levels and basic functioning, Zalewski tries to get her young clients moving through games such as Just Dance, Ring Fit Adventure (a fantasy adventure world that uses physical exercise to navigate in-game movement), and other virtual reality games.  

To keep clients moving, Zalewski will often give clients “homework” (with parents’ permission), asking them to play a game a certain number of times between sessions. Zalewski also encourages clients to engage in social interaction. Just like any other skill, social skills will atrophy if you don’t use them, she says. 

Many role-playing games enable users to communicate with each other in chat boxes. Zalewski says there are also “clans” and “guilds” that gamers can join. Another resource she likes is Discord, a platform that allows users to discuss games and other interests on secure topic-based text channels. 

Zalewski says her clients laugh at her for her enduring love of Pokemon Go. Still, she feels it is an encouraging way for children and adolescents to get outside with parents and interact with others in a safe, physically distanced way as they collect Pokemon.  

School daze

Although some children and adolescents are doing well with virtual learning, in general, it’s not developmentally aligned to child and adolescent needs, says ACA member Jennifer Betters-Bubon, an LPC and former school counselor. “We know young kids need to move,” she says. “They thrive on environments that provide sensory stimulation and movement. Even in traditional high school, kids get to get up and move through hallways and can interact with friends.”

“We have kids who are on Zoom for hours and not necessarily getting up,” continues Betters-Bubon, an assistant professor of counseling at the University of Wisconsin-Whitewater. “It’s fatiguing for their brains and bodies, [and] it doesn’t lend itself to building relationships.”

When adults feel the fatigue of too much screen time, they can usually disconnect, at least for a little while. “When children get tired, adults are still in charge,” Carter points out. And if a child asks to take a break, parents or caregivers may think that the lack of structure will cause them to fall behind. “They may not understand that children have the same need to disconnect,” Carter says.

Betters-Bubon is noticing a lack of motivation in the children and adolescents she sees in her practice. She believes that’s in part because schoolwork isn’t as engaging without the connection to other people and the school itself. “It can feel like ‘What is the point of doing this work?’” she says. Betters-Bubon points out that on top of COVID-19, students are dealing with the impact of racial trauma and other significant stressors, all of which influence their view of whether their current math assignment is really relevant right now.

Betters-Bubon says some of her younger clients are so disengaged that she has shifted the focus of her work to their parents. She has sought to keep middle and high school students engaged by asking them to create things between sessions such as a vision board of how they’re coping with their anxiety and then sharing their creation with her.

Now that many schools are opening up, at least on a hybrid basis, Betters-Bubon and other counselors say they are witnessing excitement among students about reuniting with friends, mixed with a lot of trepidation. Many of Betters-Bubon’s clients are experiencing anxiety — about the possibility of getting COVID-19, about catching up academically or, in some cases, about starting at a new school without the normal transition. Betters-Bubon has been doing a significant amount of exposure therapy work with child and adolescent clients. This involves having them imagine a list of scary things that they might encounter and working up to doing each one in ascending order. In some cases, she has been able to reach out to school officials to ask them to allow her clients to at least see the inside of their new environment before classes start. 

Betters-Bubon acknowledges that it’s a strange new world for students returning to school. Even the nature of recess has changed. Because of the need to maintain physical distance, her son’s elementary school no longer allows balls on the playground. Students just kind of stand around and concentrate on keeping themselves separated, Betters-Bubon says. As a result, they’re not engaging those gross motor movements essential to healthy growth that they used to engage when they could run around, climb on equipment and toss balls. Betters-Bubon wonders what the implications might be if this scenario becomes normalized. 

Some schools have implemented sensory paths in hallways with different obstacles to run and jump over, Betters-Bubon says. She’d like to see more of those, particularly outdoors. Noncontact games that involve actions such as students moving to different parts of a circle can also be an excellent way to keep children moving while still remaining physically distant, she says.

LPC Melissa Brown works with an Atlanta-area community behavioral health center as a mental health counselor in a local school district with a majority Black student body, most of whom live in poverty. The community has been hit hard, both by COVID-19 itself and by the economic devastation of the pandemic-induced recession. 

The school district has been on a hybrid schedule since January. Brown has tried to give students a sense of normalcy by providing that one thing that will be consistent. “When we meet, this is going to be your safe place,” she tells students. “We can talk about anything and do anything you want.”

Many of the children still worry that they or their loved ones will get sick, so Brown holds family sessions to help students and their families develop a plan to stay safe. The children are used to having a plan for what happens if there is a fire in the school, so the idea of coming up with something similar for home seems natural to them, she says.

In sessions, they talk about teaching kids how to wash their hands, come up with examples to demonstrate what 6 feet of physical distance looks like, and discuss why they can’t see their grandmother, uncle or friends today. They also look at alternatives, such as driving by a friend’s or loved one’s house or mailing them a picture.

Brown also tells parents that they have to be honest with their children. They can’t hide information that they think might be harmful because their children are likely to be exposed to it anyway through social media, the news or friends. Instead, parents can be their children’s first source of information, Brown says.

Grief and trauma

Brown has encountered a substantial amount of grief connected to the pandemic, particularly in elementary school settings. After attending a funeral every Friday for a month, one little girl asked Brown if it was wrong that she didn’t cry anymore. 

Brown frequently uses play therapy and art therapy to help younger children explore their feelings. Eventually, the little girl was able to process her feelings and contextualize them, such as, “This person who died was a friend of my mother’s, and I didn’t really know her” and “This was my grandfather, but he was sick with cancer, and I know he’s in a good place now.”

Zalewski has helped young clients process the loss of grandparents and pets. She notes that furry family members have become even more vital companions during the pandemic. 

One child particularly liked the idea of creating a memorial for a beloved dog. So, with Zalewski’s help, the client created a space on his island in Animal Crossing, a social simulation game that gives players the ability to build and create things. Zalewski and the child found a virtual dog and gave him a red bowl to drink from. The child’s real-life dog had enjoyed being outside and sniffing flowers, so they also created a fenced-in area with flowers, the drinking bowl, a sofa (in case the dog wanted to curl up) and a radio for the dog to listen to. Players in Animal Crossing can pick the radio’s music, so the child chose happy songs because they wanted the dog to be happy.

“Creating it was very powerful, and then [the child was] able to visit [the memorial],” Zalewski said. She suggested that the child share the memorial with their mom and dad, which ended up being an emotionally significant experience. They discussed how losing the dog felt to each of them and were able to mourn together, Zalewski says. She believes the process helped to normalize grief for the child. Mom and Dad were sad too, but they were getting through it, and the client could as well. 

“Now Mom and Dad and the kid can talk more comfortably about the dog,” Zalewski says. “It’s OK to be sad. Sadness won’t break you. It’s OK to share the happy stuff too.” 

Zalewski has also helped child and adolescent clients navigate the loss of loved ones such as grandparents. Many kids are hesitant to share some of their feelings about loss because they are afraid it might be painful for the people around them, Zalewski says. She helps young clients express their grief by inviting them to have a conversation with her about the things they remember about their grandparents or other loved ones who have died. “Everyone has loss,” she says. “I help them access the good memories.” 

These memories are often funny, such as how the grandparent always made the client a cup of coffee or tea, and the client always drank it, even though they thought it tasted terrible. Or they might remember a unique sweater that their grandmother made for them. 

“Many times, kids haven’t grieved before, and they don’t know how to do it,” Zalewski says. She provides a safe place to explore the feelings of being really sad and missing a loved one.  

Moving forward

“We are not holding space for children to be scared to return to in-person learning, especially with the increased safety protocols in place,” Carter says. “Masks, no touching, no singing, playground shut down — all of these things can be scary, yet we expect children to be able to turn that off and learn as usual.”

As schools continue to open, Betters-Bubon believes that a trauma-informed approach with a schoolwide focus on relationships is essential. “Integrated within a trauma-informed approach is social-emotional learning, embedding sensory strategies into the classroom and allowing for voice and choice,” she says. “It also would include a focus on staff wellness. School counselors would focus on teaching and assisting all staff in understanding the impact of trauma on the brain and on student learning, including helping schools carve out specific ways to build relationships.”

Betters-Bubon would also like to see more collaboration between schools and outside mental health counselors to focus on building resiliency in children and adolescents. This may involve taking a wider systemic view and working with the critical adults in students’ lives, she says. “I could see an increased need for family counseling in an effort to create systemic change within families that ultimately helps children and adolescents.”

 

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

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

Working our way through a pandemic

By Laurie Meyers February 25, 2021

To appropriate a turn of phrase from Queen Elizabeth II, 2020 was our collective annus horribilis (horrible year). The queen was referring to 1992, a year that featured the implosion of three royal marriages, a devastatingly destructive fire at Windsor Castle, and unfortunate headlines involving Sarah Ferguson’s new beau and his, ahem, admiration of the Duchess of York’s feet.

But as the meme goes, 2020 said to 1992, “Hold my beer.”

The year that the queen “shall not look back upon with undiluted pleasure” included family losses, property destruction and embarrassing press. Stressful, to be sure, but ultimately personal and mundane (although, granted, most of us don’t have to face the paparazzi). But 2020 pelted us with events of a virtually seismic nature that have in one way or another affected billions of lives worldwide. The emergence of the novel coronavirus was not the only stressor or calamity the year visited upon us, but it remains arguably the most disruptive. And perhaps nowhere is that more apparent than in people’s work lives.

When the great shutdown began in the U.S. in March 2020, most of us thought we’d be confined to the house and working virtually for only a few months. But approximately one year later, and with more than 450,000 American deaths attributed to COVID-19 through the first week of February, many people are still hunched over their makeshift office equipment.

In the beginning, some of the work-from-home snafus were funny. Newscasters broadcasting with jackets — but no pants (which seems to be the preferred work-from-home style for a surprising number of people). The boss who accidentally turned herself into a potato on Microsoft Teams and didn’t know how to change back. Amusing, embarrassing and sometimes horrifying comments and conversations caught by accidentally unmuted microphones in video conferences. Other disruptions, such as cats on the keyboard and dogs chiming in during meetings, were a bit chaotic but too cute — at least at first — for their human companions to truly complain about. But other people struggled to carve out a workspace and found themselves joining meetings from underneath the stairs or barricaded behind the bathroom door because it was the only private space in a house full of busy (and noisy) family members. Even people who frequently telecommuted pre-pandemic often found adapting to an all-virtual workplace a challenge.

Balancing work, school and child care

One of the most significant challenges to working — whether virtually or on-site — during the COVID-19 era has been the lack of child care options and the need to assist children with their virtual schooling.

“Coaching folks on how to handle their work life without child care is a big focus of my practice these days,” says Katie Playfair, a licensed professional counselor (LPC) and management consultant located in Portland, Oregon.

“I tell clients to be as flexible and creative as they can in figuring out how to get their job done despite these obligations and to consider, when possible, cutting back hours to something more manageable,” she says. “As the mother of children who are 8, 6 and 2 years old, I home-school them during the day and then work from 5 p.m.-10 p.m. every evening after my spouse gets home. It’s a rough schedule.”

Playfair says many parents are having to take breaks to help with schoolwork during the day and then catching up on work themselves at night. Even children who are old enough not to need constant supervision often interrupt the workday to request a snack, to seek permission to take a break or to ask a quick homework question. As a result, parents are continually task-switching, unable to block out time for uninterrupted work, Playfair explains.

“Developing a system to communicate with older kids about when parents are interruptible and when they aren’t is vital,” she stresses. The use of physical or virtual calendars, door signs or predetermined “office hours” when they will be available to their children can help parents protect meeting times and allow for concentrated work during the day, she says.

“Providing kids with a way to table their questions until appropriate times is the other side of this equation,” Playfair continues. “They may need a whiteboard on parents’ doors or some other ways of tracking things so they don’t forget about them and get frustrated. Older kids can also be taught to email or text parents. Nonetheless, parents may still find themselves having to work nights or weekends to make up for the work that isn’t getting done during the school day.”

Even with families in which one spouse was already a stay-at-home parent before the pandemic, the virtual work and school mix can throw a wrench into the routine, says Keri Riggs, a Texas-based LPC whose specialties include relationship stressors, stress management and work-related issues. In one couple with whom Riggs worked, the mother was accustomed to structuring her day around the schedule of their middle school-age children. The family had managed to incorporate virtual school into their routine when, suddenly, the father began working remotely.

The only available workspace was the kitchen table, and the husband frequently needed everyone else to clear out of the room so he could participate in meetings. But he also recognized the need to give his wife a break — and the need to get away from the table himself — so they scheduled in lunches and other times when they would trade responsibility for the children. Because his meeting schedule varied, the couple sat down every night and plotted out the next day’s schedule, blocking off times when the kitchen needed to be in “do not disturb” mode and carving out time for breaks, says Riggs, a member of the American Counseling Association.

Fitting in the demands of work and school is even more difficult for single parents because, absent an available and willing relative or neighbor, there is no one to help shoulder their burden. Uninterrupted blocks of time may be available only when the children are asleep. However, some work-related tasks, such as meetings and phone calls, generally have to take place during the day. To help minimize disruptions, Jessi Eden Brown, an LPC whose specialties include trauma and workplace bullying, suggests parents buy or create “some kind of super-involved art project that they [children] only get to work on during meetings, so it’s kind of like a treat.”

“I don’t love this,” she continues, “but some clients have [also] had success with a television show or movie that can be started or stopped.” Brown, an ACA member, recognizes that isn’t an ideal solution, but it may be the only way that some clients can prevent interruptions in meetings. As she tells parents, with all the stressors they’re coping with, an extra hour or two of television here and there for their children is not the end of the world.

Of course, as Sharon Givens, an LPC who specializes in career development and mental health, points out, “Not everyone was able to just pick up a laptop and go home. If you’re a housekeeper, you can’t work from home.”

This is particularly problematic for single parents, she says. Some of her clients have family members who can assist with child care during the day, but others have had to relinquish their jobs. They are experiencing devastating financial difficulties that were exacerbated by the end of federally supplemented unemployment benefits.

“And, so, we’re working together to create some strategies to pay the rent,” says Givens, president-elect of the National Career Development Association, a division of ACA. Some clients have pulled money from their retirement accounts or tapped family members for financial assistance. Givens has also helped clients find local assistance programs and search for jobs that they can do from home.

The pandemic and resulting recession have demanded that counselors put on their “practical strategy hat” to help clients, Givens says. She has advised clients to speak with their mortgage company or landlord and their utility companies to see what type of deferment or other relief they can offer.

Setting boundaries and navigating distractions

The virtual office poses other challenges, such as the blurring of boundaries between work and home. By getting rid of the daily commute, office workers have gained extra time, but it has also deprived them of a natural boundary that signaled the beginning and end of the workday, Riggs says. The computer is always right there — a siren beckoning workers to check their email one last time or to do just a little more work. Suddenly, it’s midnight, and they’ve spent all day at the computer.

Riggs works with clients to replace the commute with other routines, asking what symbolizes starting and ending the workday for them. Is it taking a shower or changing out of their work clothes at the end of the day? She also suggests engaging in rituals such as hanging a “closed” sign on the computer or home office door or voicing a mantra such as “I did my best today.”

Sometimes, however, it isn’t employees who have trouble setting boundaries. American work culture is often brutal and not supportive of health and well-being, Playfair asserts.

“Unless an organization has set out to really change themselves into a more compassionate and empathetic place to work, they’re going to expect lots of hours, productivity and performance from everyone nearly all the time,” she says. “But even within this culture, there are opportunities for boundaries. First, I encourage people to ask their bosses, ‘Do you want the truth or what I think you want to hear?’ when an employee feels pressured past what they can take. Most people will choose the truth, and that will give the opportunity for healthy disclosure. I also like the phrase, ‘I wish I could do that for you, but I can’t because …’ to introduce a boundary.

“Finally, I think it’s helpful for employees to empathize with their bosses while still demanding support themselves. For example: ‘I understand that you’re short-staffed for this shift and that headquarters is expecting you to figure it out. That’s unfair. If our company would budget and plan sufficiently for contingency staffing, this wouldn’t be a problem for you or me, would it? I know they expect you to be fully staffed today, but they haven’t given you the resources to be successful with that, and I can’t personally make up for their poor planning.”

Brown encourages her clients to look for fellow employees who seem to be able to set boundaries. “Like ‘Bob’ — he always seems to sign off at 5. How does he do it?” she asks.

In other cases, Brown and the client may review their job description or the company’s policies and procedures manual to see if expectations for work hours have been set out.

Home itself can often be a distraction, Riggs notes. It can be difficult for people to focus exclusively on the work they are paid to do when they are surrounded by ever-present reminders of household tasks that also need to be completed, such as doing the laundry or loading the dishwasher. Cell phone pings announcing texts and social media notifications also beckon.

Riggs and her clients try out different solutions to find what works. This might involve setting a timer to complete 30-minute blocks of focused work, giving themselves a healthy reward for completing work, or setting up accountability partners. Riggs also suggests that, if possible, clients leave their cell phones in another room. If that isn’t feasible, she encourages clients to disable their notifications. She also counsels clients to prepare for the unexpected by allowing some margin for “white space” — a block of free, unscheduled time — during the day to attend to urgent requests or time-sensitive tasks.

The mental toll

Working under less than optimal conditions — or not working at all — has created significant challenges among a population that is already struggling with grief, Givens says. “All of us, if we’re being honest, are feeling a sense of loss: loss of activities, loss of career opportunities, loss of income.”

The uncertainty ushered in by the pandemic has challenged many clients’ coping skills, Givens says. She uses a variety of methods to help, including exploring what methods have supported clients’ ability to cope in the past. For some people, that involves more physical activity, whereas for others, it’s about increased (virtual) connection.

Givens also uses cognitive behavior therapy interventions such as having clients keep a thought record. They then look at this together and evaluate what is and what isn’t under the client’s control. “Many of them see the visual: ‘I spent four hours per day worrying about something that I couldn’t control,” she says.

Many of her clients are also engaging in frequent catastrophizing, obsessing about what will happen and whether they’re going to die in the pandemic. These concerns are natural, but some clients are mentally building worst-case scenarios, Givens notes. For these clients, she uses a different kind of thought record known as an evidence record. The concept is the same — clients write down their thoughts and then go over them with Givens — but what they’re looking for is any evidence to support the likelihood of their worst-case scenarios becoming reality.

All of the practitioners Counseling Today spoke to for this article urge clients to be patient with themselves as they navigate the myriad challenges of working during the COVID-19 era. Riggs recommends Kristin Neff’s five-minute self-compassion break (a guided version is available at self-compassion.org/guided-self-compassion-meditations-mp3-2/).

The practice begins by, as Neff puts it, “calling up a little suffering,” or reflecting on something that is currently causing stress or worry. Neff then provides a series of phrases “designed to help us remember the three components of self-compassion when we need it most.”

The first phrase is “This is a moment of suffering.” Or, as Riggs tells her clients, “I’m having a hard time today. I’m struggling.”

The second phrase is “Suffering is a part of life.” Riggs describes this as recognizing one’s connection to all of humanity: Not only am I struggling, other people struggle too. I am not alone.

The third phrase is “May I be kind to myself in this moment.” To support being kind to oneself, Neff suggests that listeners place their hand over their heart or another place on their body that feels soothing, then focus on the warmth of their hand and let that sensation stream through their fingers. She then recommends that listeners direct kind and supportive language toward themselves, such as words they might use with a friend going through a similar situation — e.g., “I’m here for you. It’s going to be OK.”

At the end of the practice or “break,” Neff asks listeners to notice how their bodies feel and to allow themselves to just “be” in the moment with those sensations.      

Riggs also suggests clients ask themselves what would make them feel better at that moment. “That’s really the hardest piece if you don’t know what you need,” she says. “Do I need to move my body? Do I need to journal? Call my best friend? Put on music? Give myself a hug?”

Finally, Riggs tells clients to remind themselves that the stress or anxiety they are currently experiencing will not last forever — that they won’t feel like this forever. Eventually, it will change.

Amid the suffering caused by the pandemic, Brown sees opportunities for personal growth. “Never before have we had … [such a] profound opportunity to slow down and focus on life’s priorities with such intention,” she says. “COVID-19 has affected nearly every person on the planet. Countless people live in fear, and many have lost family, friends, livelihoods and so much more.

“The tragedy is undeniable. That said, I have always believed that low moments like these potentially set the stage for meaningful change as we reflect on what is important and how our decisions either support or impede our progress.”

 

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The pandemic and a frayed political climate have also been at the center of various instances of workplace bullying. Read more in our online exclusive article, “No rest for the bullied.”

 

 

 

 

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

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

Delivering difficult news: From adults to future adults

By Kelsey Mora February 10, 2021

As a dual certified child life specialist and licensed professional counselor, the questions I most often get from parents and caregivers are “What will I tell the children?” and “How will I tell the children?” These questions come up when facing a new diagnosis, a loss of a pregnancy or loved one, a traumatic injury, or a suicide attempt.

Although I work in a setting and with a population where I am prepared to assist families and parents through such life-altering events, many clinicians are not. To support other providers when faced with similar questions from their clients, I have developed three key tips for delivering difficult news to young children. These tips can be applied not only to medical events and loss, but also to divorce, an upcoming move, a local tragedy, and other life-altering events.

1) Honesty really is the best policy.

Being honest with children builds and maintains their trust. By not telling children about an event, we risk the likelihood of them hearing false information from someone else or finding out about it in an uncontrolled way. This may involve an overheard phone call, a read text message or an encounter with a neighbor, friend or relative. As counselors, we can empower our clients by explaining to them that they, as trusted adults, have the ability to control the delivery of this information to their children and create an environment where it is OK for them to talk about the event.

When children are forced to come to their own conclusions about what is happening, their imaginations may create something far worse than the reality. The caregiver should follow the child’s lead by assessing what they already know before providing or correcting the information. It is important for parents/caregivers to use simple, clear and honest language with their children and to understand that this may need to be repeated over and over again.

Avoid euphemisms. Even though terms such as “cancer,” “dying” and “divorce” may seem harsh or scary for children, these terms are less likely to lead to misconceptions later. Adults can always clarify terms along the way, but starting with the real words is recommended. For example: “Dying means he will not come home; his body no longer works” and “Divorce means we couldn’t get along anymore. We have decided to live in different houses, but we both love you very much.”

Find an appropriate setting. Encourage the adult to identify a private, quiet and comfortable setting, preferably outside of the child’s safest place (which, for most children, is their bedroom). Consider the living room or dining table. Practice starting by giving a warning shot. For example: “I have something sad or difficult to tell you.” Help parents/caregivers to think about the best timing of the conversation. Who should be there?

Finally, it’s OK for adults not to know what to say or how to answer their child’s questions. They can say, “I don’t have all of the answers, but as soon as I do, I will tell you.” This builds trust and is still honest. Help the child to at least know what will happen next and what they can expect. Once the discussion has taken place, give the child or adolescent time to adjust. Rehearse by acknowledging, “I know this was not what you expected to hear,” and practice providing empathy and reassurance that they (the adult) will be there if the child or adolescent has more questions, concerns or feelings. Young children may need time to play, whereas older children may prefer being with their peers. Both responses are developmentally appropriate.

 

2) When in doubt, keep things normal.

Children benefit from structure and clear expectations. However, it can be very hard to maintain routine for children when disruption is taking place. When this is the case, encourage your adults clients to prepare their children for anticipated changes. For example, if the children are able to attend their extracurricular activities or playdates but will be picked up by a friend or relative instead of their parent, make sure this is communicated to them. Similarly, if the bedtime routine or school drop-off will look different, parents/caregivers should ensure their children know who and what to expect. Children are resilient, but they do best when prepared for change.

Help your adult clients consider ways to include the child. Children may benefit from having a role or purpose. For example, they could be responsible for packing a bag or making a card. When possible, parents/caregivers should identify choices to offer to give children a sense of control and mastery during a time that feels out of their control. The child should not be forced to do something such as say goodbye to their loved one, but they should be given the option and presented with different ways to do so.

Caregivers may think they know what is best for their child and then be surprised by the child’s decision. I have worked with children who have persistent regret over not participating in their parent’s funeral but were denied the opportunity because the surviving parent was trying to protect their child. Often, parents will ask, “What if they [the child] regret their decision?” I reassure parents that they can remind their child that they were given a choice and that they made the choice that was best for them in that moment.

 

3) Expressing feelings is healthy.

When your adult client says, “I have to be strong for them [the children]” or “I can’t let them see me cry,” ask the parent/caregiver: “What does being strong really mean?”

Children who grow up in a home where they are shielded from feelings may inadvertently learn to internalize their feelings. Parents, caregivers and other adults possess the potential to teach children about the healthy expression of all emotions — the good, the bad and the ugly. It is inevitable that children will experience heartbreak, disappointment and upset throughout their life trajectory. When they are faced with these circumstances, it is imperative that they have learned how to identify their feelings and express them safely and effectively. Being strong can mean demonstrating appropriate reactions to situations.

Help your adult clients name their own feelings. Have them practice “I feel” statements such as “I feel sad because your grandpa is in the hospital” or “I feel worried about everyone’s safety.” Then, encourage them to follow these statements with plans that can be shared with their children, such as “But I am going to do everything I can to help you feel safe and cared for during this difficult time.” This encourages children to express their own feelings safely and effectively and to feel comfortable asking questions when they have them because they know it is OK to talk about the situation. Furthermore, practicing this gives the adult client an opportunity to process their own thoughts and feelings about the event before being in front of their child.

 

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These three tips can be applied to and modified for children of any age facing nearly any difficult event. I have used these principles to provide guidance for parents and caregivers on explaining recent events, including the pandemic and social unrest, to their children.

Developmental reactions to difficult circumstances will vary by age. Infants may demonstrate increased crying, clinginess or fussiness. Toddlers and preschoolers may regress or display a fear of separation. School-age children may exhibit irritability, confusion and distractibility. Adolescents may display anger, take on new roles and express criticism. But when parents and caregivers provide honest information, present clear expectations and encourage healthy discussions, children and adolescents are more likely to experience a positive adjustment both during and beyond the situation.

 

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Kelsey Mora is a dual certified child life specialist and licensed professional counselor who works both in a hospital setting and for a private practice in the Chicagoland area. She specializes in helping children and adolescents cope with illness- and grief-related challenges and is specifically trained to coach caregivers on language and techniques to use when parenting their child through medical conditions, family life transitions and traumatic loss. Contact her at kmora@illnessnavigation.com or through her website at illnessnavigation.com.

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

Far away, so close: Negotiating relationships during COVID-19

By Laurie Meyers January 26, 2021

COVID-19 has taken away many of our in-person interactions. Office chitchat by the coffee maker. Happy hour with friends. Holiday celebrations. Friends, co-workers, extended family — since the pandemic began, many of us have seen them only virtually. In many ways, it’s like we’re all stuck on our own desert island — closed off from the outside world yet sometimes desperately wishing to vote our “fellow inhabitants” off.

The people we live with. We love them. We’ve treasured the extra time with them. But sometimes we just want them all to go away.

The never-ending togetherness; the uneven distribution of household responsibilities; the challenges of balancing work, child care and virtual schooling; and the career sacrifices that many people (women primarily) have had to make are all creating new stress and tension, while also exacerbating pre-existing conflicts in couples and families. In other words, couples and family counselors are very much in demand.

Seeking moments of solitude and respite

“Time and space are just different this year,” says licensed professional counselor (LPC) Christina Thaier. “We no longer divide our roles and tasks into different spaces, and that means all of who we are has to exist within less space. This is tough for kids and adults alike.”

Work, school, family, intimacy, socializing and relaxing are all wedged into the home.

Esther Benoit, an LPC with a private practice in Newport News, Virginia, points out that many parents are really struggling with roles they never expected to play — such as teacher and tutor when their children encounter difficulties with virtual schooling — while still trying to work from home. Other clients are working outside the home but spending substantial time on the phone providing “tech support” to their adolescent children who are at home alone, Benoit says.

Thaier notes that clients are floundering to find a way to balance everything in the absence of real-life connection to their communities and support networks. “It’s limiting. We miss a lot, and if we live with others, we are taking this on without any real break from our family or roommates,” says Thaier, a couples counselor who is the founder and director of Terrace House, a group practice located in St. Louis. “It’s a strange feeling to feel lonely and cut off from our usual life and, at the same time, never feel we get a break from others.”

“We [also] miss the versions of ourselves that exist in our usual spaces — our co-worker self, our happy-hour self, the version of us that shows up at the gym or the part of us that sings in the car after dropping the kids off at school — and the natural breaks and alone time that were previously built into our day,” she continues.

Thaier, an American Counseling Association member, helps clients envision alternative ways to be their different selves. “Maybe I can access the part of me that comes alive during time with friends by moving our time together to the park with masks,” she suggests. “Or I can plan a 10-minute Zoom call with my favorite co-worker at a time we would usually stop by one another’s desks.”

Thaier and her clients also seek simple ways to re-create those moments of solitude with activities such as taking a walk in the middle of the day, running errands, completing a solitary trip to the store to pick up groceries, or taking a bath or shower. “We’ve also talked about meditation apps and making the most of the early morning or late evening time when most of the house is sleeping,” she says.

Megan Dooley Hussman, a provisional licensed professional counselor and clinical supervisor at Terrace House, says many clients have found not just alone time but also a way to stay centered by engaging in daily rituals such as meditating, walking or even making and drinking tea mindfully.

Some clients also seek quasi-solitude by establishing family reading or movie-watching times, Thaier notes, adding that “quiet is almost alone.”

But with the multiple roles that parents are playing, stolen moments of solitude often aren’t enough, Thaier asserts. She helps parents map out the logistics of making sure that each partner gets their own break at some point during the week. That often involves one parent — or a family member within the household bubble — “hanging” with the kids while the other parent gets some time to themselves, she says. Thaier describes it as a “big win” for parents when everyone else leaves the house — even if only for an hour.

Sharing the struggle

The pandemic has been overwhelming for everyone — in unique but also universal (or at least common) ways. For parents and couples, the biggest contributor to distress and conflict is often unequal distribution of the “mental load,” says LPC June Williams, whose specialties include couples counseling. The mental load, she explains, is everything that needs to be done to keep the household moving. And much of it seems never-ending.

As Williams, a private practitioner in Cedar Park, Texas, points out, everyone is eating all the time when the kids are at home due to virtual schooling. Meals need to be planned and scheduled because family members aren’t necessarily eating at the same time. The dishes seem to self-replicate, requiring multiple dishwasher runs per day. It isn’t uncommon for one parent to manage this process — in addition to keeping the children engaged in online schooling and attempting to perform their “regular” job duties from home. In such cases, the parent spends the day constantly switching focus from their work laptop to their children’s screens. One of Williams’ clients is working and managing the family’s three children while their partner is in another room with the door shut.

When the distribution of household responsibility is not equal, it is often because much of the mental load is invisible, Williams says. She helps make it visible to her couples clients.

Williams will sit with the couple and task the partner carrying the uneven load to walk her through their day. Williams asks the other partner to listen without interrupting. Often, the partner who has been contributing less is shocked to learn the full mental load that their loved one has been carrying, Williams says.

It isn’t always possible to achieve a 50-50 split, Williams says, but she helps couples distribute the load more equitably. They discuss all of the tasks that make up the mental load and talk about how to handle them as a team. Williams asks the partner with the lesser load to think about what areas they would be willing to take over. She then asks the other partner to decide where they are willing to relinquish control. “What’s something you are willing to give away, knowing that it’s not going to be done your way?” she asks. If the partner offloads dish duty, they have to accept that the dishwasher may not be loaded “correctly,” Williams counsels.

Williams also has couples take responsibility for different areas of the house. Once that’s done, each partner’s domain is sacrosanct. “No micromanaging,” she says. “If the trash is your partner’s deal, you don’t say anything — it’s in their lap.”

ACA member Paul Peluso agrees that cooperation and flexibility are essential for navigating home life during the pandemic. He recommends that couples come up with a practical, workable schedule that allows each partner some time off. Unlike Williams, he recommends that couples switch off tasks such as bathing the children, taking out the trash and cooking. This cooperative effort creates a sense of fairness that allows a partner who has had a particularly bad or busy day to ask the other partner to take over a task that the tired partner feels too tapped out to do. The understanding is that the same grace will be extended to the other partner when needed, says Peluso, a professor of counselor education at Florida Atlantic University and a former president of the International Association of Marriage and Family Counselors, a division of ACA.

Peluso also recommends that couples cut themselves and each other some slack, especially during the pandemic. For instance, perhaps the routine has been to fold and put away clothes immediately after they come out of the dryer. “Give yourself a break and let it be in the basket for a few days, and use that time to watch a show together or to talk,” Peluso urges.

Sometimes, an unevenly distributed responsibility cannot be transferred from one partner to another, Williams says. The couple with one partner working and managing school for three kids is doing it out of necessity because the partner with the closed door is constantly in meetings.

In cases such as these, Williams typically encourages couples to explore possible outside resources that can be brought in: “Can we talk to family [about providing help]? Do we have a COVID-safe nanny? A COVID pod so that two days a week the kids are going to another parent’s house?”

Sharing the load becomes more difficult when one partner is working outside the home and the other works virtually or has put their career on hold. This scenario can easily lead to resentment, Benoit says. To the partner who stays home, it can seem as though the partner who works externally has experienced a return to business as (almost) normal, she explains. Meanwhile, the “inside” partner feels like their life has been completely upended because they are either trying to work from home while also providing child care or may even have felt it necessary to leave their job, Benoit says. Resentment builds because the partner at home feels trapped.

Benoit finds it helpful to externalize these conflicts for couples, emphasizing that it is the situation that is the problem, not the person who is working outside the home. Adopting this perspective, it becomes something that the couple can address as a team. The goal is to avoid recrimination and accusations, Benoit says, and to ask instead, “How do we get through this together?”

Although the essential circumstance cannot be changed, the level of resentment can be lowered dramatically, Benoit says, by something as simple as the partner working outside the home acknowledging that the other partner has the tougher end of the deal and asking, “What can I do to help?”

Benoit also emphasizes self-compassion. “I tell a lot of clients that what we’re aiming to do is get through,” she says. “We’re not aiming to thrive, but to survive.”

Couples also must learn that they are not responsible for each other’s moods, Williams says. A felt need to “fix” everything is often present in the partner who feels “overloaded,” she says.

“I work with that person who is trying to fix and [I] help them get more comfortable with everyone’s discomfort,” Williams says. This is doubly beneficial because the person who is underfunctioning may be hanging back as a result of receiving the message from their partner (directly or indirectly) that they never do anything right. Williams wants to help the partner carrying the lighter load to take on more of the burden not because they are being nagged but because it is important to the family.

Williams also asks the “overburdened” spouse about the feelings they are living with. Do they feel the need to fix, rescue, save and control? Do they feel anxious and resentful? If the client acknowledges these patterns, Williams asks whether they like feeling that way.

The usual response? “No, I am mad all the time and tired.”

Possessing a sense of responsibility does not mean that the client is responsible for everyone in the world, Williams counsels.

She gives clients a scenario: Your husband comes in and is in a terrible mood. He sighs heavily and drops his bag. As his wife with an overdeveloped sense of responsibility, you may flutter about and try to step in and take over. The end result? You haven’t fixed anything. He’s still irritated, and now you are too, Williams says.

She tells clients that they can still be compassionate, check in with their partner and ask how their day was. But if the partner responds that their day was terrible, clients need to ask themselves whether they have the emotional energy to carry that burden with their partner, Williams advises. If not, “It’s OK to say, ‘Here’s a soda water,’ give them a hug and move on,” she says.

When clients feel that tension in the pit of their stomach that is pushing them to step in, Williams urges them to do something calming in another room, such as belly breathing, stretching or taking a quick shower. These strategies also have the advantage of physically separating the person from the partner and their bad mood.

“Offer them compassion and allow yourself to remain separate,” Williams advises.

The price women pay

Williams doesn’t generally like to make assessments along gender lines, but she says the consequences of the pandemic are clearly delineated. Women are typically the ones expected to put their careers on pause — to be the caregivers and nurturers, to be more in tune with the children and to meet the family’s needs — even if they are the family’s highest wage earner, Williams asserts. She references a pithy and pitch-perfect quote from sociologist Jessica Calarco: “Other countries have safety nets. America has women.”

Thaier agrees. “Women already tend to take on more of the emotional, social and household roles, and that has not changed despite those tasks further multiplying,” she says. “In my practice, we talk a lot about our humanness, and that no one human can do all the things. We work on asking for help, prioritizing and eliminating what we can, establishing boundaries, and making time for ourselves.”

Women have absorbed a tremendous number of losses but haven’t had time to properly acknowledge those losses, Thaier says. “It’s hard to grieve within the experience of trauma,” she continues. “If we use the definition of trauma as too much, too fast, all of 2020 has been that. The quick reorganization of our lives has required [clients] — especially women — to move into crisis management mode. In crisis management, we do, we don’t get to be. In that way, therapy itself invites a chance for being, even if, after the hour, we revert back to survival mode a good portion of the time. We begin to carve out moments, which build on each other, for something different.”

“In some ways, because everything is different, there are opportunities for everything to be different, and that means families can brainstorm and strategize together on how to take care of the home and one another,” Thaier says. “It’s not easy, and there are lots of challenges. But I see a lot of great conversations happening, and with that, a lot of change too.”

In therapy, clients get to recenter themselves and their experiences, Thaier says. “They can voice resentments, frustrations, fears and anxieties, and their fear that feeling this way makes them a bad mother, partner, employee or friend.”

Thaier encourages clients to question these assumptions and where they came from, and then begin to redefine what is important to them about the roles they play. “For example, if we are redefining being ‘good’ at a relationship from an old definition of trying to not let anyone down to a new definition of being present and authentic with the people we love, we can begin to think about what this might look like,” she explains. “We can notice when the old definition is guiding our behavior and patterns, and we can start to practice new ways of relating.”

Reimagining clients’ relationships and roles often involves rejecting parts of the past by breaking patterns driven by cultural assumptions. But the past can also inform the future. Thaier uses narrative therapy to help clients grieve their losses and find ways to preserve elements of what was lost. “I think a lot about telling the stories of the people and experiences we have loved and that have significantly influenced our lives,” she says. “For a woman who has made the sacrifice of a current work role that is a significant part of her identity, we explore that.

“How did the job bring you alive? What did it make possible? What were the best parts of your day? Where did you imagine this would take you next? How did this role fit into an imagined and cherished future?”

“We can actually strengthen that story even as we grieve the space it has left in the present,” Thaier says. “And we can begin to narrate how the client can access her relationship to her work — or [what] she found possible there — and bring that into the present. In other words, the people and experiences we love become a part of us, and we can continue to take them with us into our futures. Our relationship with them gets to continue, if we want it to.”

An existential pause

The pandemic-induced global slowdown has provided people an opportunity (even if unrequested) to examine their lives and reevaluate their priorities, Peluso says. A number of people are asking themselves if they want to get back on the treadmill of constant activity and productivity, “or do I want to start thinking about what I was saving for someday and do it now?” he says.

Regardless of whether they choose to return to the treadmill, stepping off of it even temporarily has granted many people clarity about their relationships, Peluso observes. Some have grown closer to their partners during the pandemic, whereas other couples who were gritting their teeth and staying together for the sake of the children beforehand are asking themselves whether it’s worth the price they are paying.

Some couples are reassessing how they were choosing to spend their time prepandemic, he says. “I think especially early in the pandemic, when there was a hard stop to a lot of activity, it created a window of opportunity to just build some new rituals for connection,” Peluso says. “Couples were able to do things together — tasks, projects around the house.”

This ability to slow down — rather than charge through a list of chores — allowed some couples to rediscover pieces of each other that may have been subsumed in the daily grind, Peluso says. “For a lot of them, it forced them to look at some places where they had been neglecting relationships,” he adds.

“While this year has been incredibly challenging, it has also been an invitation,” Thaier says. “An invitation to slow down, to be together more, to take stock of what we’re doing and how we spend our time. To be at home more. To rest. To see our limitless creativity and resilience and strength. To acknowledge that our lives really could look different at a moment’s notice. To learn to be together in new ways. To be outside more. To take less for granted.”

“I wouldn’t say it’s been ‘worth it,’” she continues. “That would disrespect all of the loss and tragedy and, frankly, just wouldn’t be true. But there’s good here too. And there’s invitation in every holding pattern to see something that is waiting to be acknowledged. There’s a mirror here, if we’re willing to look into it.    

“I’m thankful for the invitation, and I’m hopeful about what’s next.”

 

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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.

Counseling Today (ct.counseling.org)

Books & DVDs (imis.counseling.org/store)

  • Theory and Practice of Couples and Family Counseling, third edition, by James Robert Bitter
  • Mediating Conflict in Intimate Relationships (DVD) presented by Gerald Monk and John Winslade

Continuing Professional Development (https://imis.counseling.org/store/catalog.aspx#)

  • “Creative Counseling for Couples: Using the Integrative Model” (webinar) with Mark Young
  • “Imago Relationship Therapy” (podcast) with Susan Hammonds-White

International Association of Marriage and Family Counselors (iamfconline.org)

IAMFC is a division of the American Counseling Association that embraces a multicultural approach in support of the worth, dignity, potential and uniqueness
of families.

 

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

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