Tag Archives: parenting

Bundle of joy?

By Bethany Bray March 28, 2019

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

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

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

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

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

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

Baby blues

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

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

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

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

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

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

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

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

Tools for the journey

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

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

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

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

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

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

A population at risk

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

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

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

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

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

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

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

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

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

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

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

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

How counselors can help

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Contact the counselors interviewed in this article:

 

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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:

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

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

Counseling Today (ct.counseling.org)

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

  • Women’s Interest Network

 

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

Letters to the editor: ct@counseling.org

 

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

Parent-child interaction therapy for ADHD and anxiety disorders

By Donna Mac March 6, 2019

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

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

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

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

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

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

Addressing self-esteem

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

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

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

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

Implementing PCIT with CDI and PRIDE

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

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

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

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

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

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

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

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

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

Other considerations

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

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

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

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

 

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

 

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

 

Letters to the editor: ct@counseling.org

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

 

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

The messy reality of perfectionism

By Lindsey Phillips February 26, 2019

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

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

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

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

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

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

Healthy striving

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

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

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

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

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

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

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

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

Valuing progress, not outcomes

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

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

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

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

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

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

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

Understriving

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

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

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

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

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

The challenges children and parents face

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

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

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

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

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

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

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

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

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

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

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

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

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

Imperfect experiments

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

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

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

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

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

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

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

The shame of ‘falling short’

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

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

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

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

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

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

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

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

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

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

Living with imperfection

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

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

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

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

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

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

 

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

 

Letters to the editor: ct@counseling.org

 

 

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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.

Volcanic adolescence

By Chris Warren-Dickins January 14, 2019

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

Supporting clients through the anxiety and exhaustion of food allergies

By Bethany Bray November 27, 2018

The diagnosis of a food allergy is life-changing, not just for the individual but for those who love and live with that person. In addition to avoiding exposure to certain foods, the condition requires that these families and individuals explain, over and over again, the seriousness of the allergy at schools, restaurants, social gatherings, workplaces, daycare facilities and countless other places.

It can all be exhausting, says Tamara Hubbard, a licensed clinical professional counselor whose son was diagnosed with a peanut allergy six years ago. Families receiving a new allergy diagnosis face steep learning curves that can cause them to worry and to overthink every detail of what their child or other loved one eats or might be exposed to.

“It’s almost like Russian roulette. You don’t know when an [allergic] reaction will happen, even when you take precautions,” Hubbard explains. “There’s a constant level of fear and anxiety at all times in the background that parents and caregivers need help managing.”

Food allergies affect an estimated 4 to 6 percent of children in the United States, according to the U.S. Centers for Disease Control and Prevention. Between 1997 and 2007, food allergies increased 18 percent among American children and adolescents younger than 18.

A food allergy reaction sends someone in the United States to the emergency room every three minutes, reports the nonprofit organization Food Allergy Research & Education (FARE).

Counselors can help clients work through the anxiety and other mental health issues that food allergies sometimes exacerbate, but they can also be a source of support simply by serving as a listening ear. Clients may come to a counselor’s office worn out from the self-advocacy and constant vigilance that a food allergy requires, explains Hubbard, who has a private practice in the suburbs of Chicago that specializes in supporting clients (and their families) with food allergies.

With food allergies, there is sometimes “a constant feeling of having to fight in every conversation to get your point across,” she says. “Just being an empathic, listening ear [as a counselor] and wanting to learn, that makes a huge difference in their anxiety level and ability to release tension.”

At the same time, counselors should research and learn about food allergies to become a competent support to clients, Hubbard emphasizes. For example, they should know that an intolerance or sensitivity to a food is very different from a diagnosed allergy.

With a food allergy, the immune system views the allergen — for example, wheat, shellfish or peanuts — as an invader and overreacts whenever it enters the body. Someone who ingests a food that he or she has an intolerance or sensitivity to will experience discomfort but not the potentially life-threatening reaction that comes with an allergy, Hubbard explains.

Counselors who understand the biological and mental health implications of food allergies can help these clients to live fuller lives, Hubbard says. Although the most important thing counselors can do is learn about and understand food allergies, exercising compassion is also essential, she says.

“Sometimes, even medical professionals aren’t good at that part. They send [people] off with an EpiPen and say, ‘Come back in six months.’ In a perfect world, they would send them off with a list of resources for mental health and wellness,” says Hubbard, an American Counseling Association member. “Counselors can play a very important part to fill in that gap, even if it’s just an empathic ear. That is incredibly therapeutic in itself.”

 

Tempering the uncertainty

The anxiety that families and individuals with food allergies often experience is more complex than simply worrying about possible exposure to an allergen, Hubbard says. Anxiety can spike over everything from sending a child to school and worrying that the staff won’t follow allergy-safe protocols to second-guessing whether a food product might contain nuts, even when the label says it doesn’t.

In the United States, companies are required to note on food labeling whether a product contains one or more of the eight most common allergens. These potential allergens are:

  • Milk/dairy
  • Eggs
  • Fin fish (e.g., salmon, flounder, cod)
  • Shellfish (e.g., crab, lobster, shrimp)
  • Tree nuts (e.g., almonds, walnuts, pecans)
  • Peanuts
  • Wheat
  • Soybeans

However, U.S. companies are not required to disclose whether a product is made in a facility or on equipment that is or was exposed to those eight allergens, Hubbard notes.

With that in mind, navigating grocery stores, restaurants and social gatherings involving food can be anxiety-provoking for those with food allergies — and especially for newly diagnosed families, Hubbard says. Some parents react by restricting their child’s activity to reduce the risk of exposure.

Allergy diagnoses are sometimes given after a person has experienced one initial anaphylactic reaction. This can create uncertainty concerning how much of the allergen is too much. For example, is it OK to be near someone else who is eating the food to which the person is allergic?

“There is fear of the unknown: ‘How much of the allergen will it take for my child to react?’ There are different layers to the anxiety, and it’s important [for counselors] to understand each layer,” Hubbard says. “Also, the anxiety affects each member of the family; they will all feel it. There’s a lot to unpack when you are assessing a client who is dealing with food allergies.”

Counselors who understand the complexity of the issue can help clients find balance and equip them with tools to manage the anxiety, Hubbard notes.

“Ultimately, the goal is to help the client — whether it’s the allergic person themselves or a caregiver — assess the risk for every situation they’re going to be in. Is their anxiety based on fact or emotion? We can tell ourselves that everything is unsafe, or we can navigate [the risk] and take precautions,” she says.

 

Finding balance

There is a balance between living in fear and frustration because of food allergies and still enjoying a good quality of life, Hubbard stresses. “Understand that in many cases, when someone is newly diagnosed, especially if it’s a young child, the person or family may be very overwhelmed initially,” she says, “as there can be a steep learning curve when your lifestyle needs to suddenly change due to a food allergy diagnosis. Some people navigate this well, while others need support and guidance. I typically encourage people to remember that it will take time to get used to the diagnosis and gain all of the necessary knowledge to live a well-balanced life between food allergy fears and empowerment. I also encourage those who are newly diagnosed to learn the basics at first and, over time, as they feel ready, branch out to other related food allergy topics, such as potential treatments, research and advocacy.”

Here are some tips for counselors to keep in mind related to food allergies:

> Prepare for an emotional roller-coaster: Food allergies can be life-threatening, so it’s understandable when individuals (or their families) experience strong emotions such as fear, sadness, anger or guilt connected to the diagnosis. Of course, these emotions can eventually lead to becoming overwhelmed or burning out, Hubbard says.

“If a child has a [allergic] reaction, the parents can feel strong emotions of ‘what did I do wrong?’ At the same time, they could have done everything 100 percent right,” Hubbard says. “The reality is that it’s a big deal, but that doesn’t mean it has to be a … crisis every day.”

Equipping clients with coping mechanisms will not only help them manage their own anxiety and strong emotions but will also keep them from transferring those feelings to the child or family member with the allergy, Hubbard says.

Counselors can also help clients work through their feelings of loss concerning what their life (or their child’s life) might have been like without the limitations of a food allergy. For example, they may yearn to eat at a restaurant without having to ask about the establishment’s allergy protocols or to eat lunch with friends in the school cafeteria instead of sitting at a separate table or worrying about what foods they could be exposed to.

“These children [with food allergies] have to grow up a little quicker in some respects. They have to learn to speak up for themselves and make decisions,” Hubbard says. “It’s about managing the feelings and finding ways to help them empower themselves and advocate to come through with some balance.”

> Move toward acceptance: One of the most important things counselors can do is help clients reach acceptance of the food allergy diagnosis, Hubbard says. This can have similarities to grief work, including helping clients come to terms with the fact that they can’t change the situation, she explains. Narrative therapy can assist clients in reframing their feelings and taking control of their story.

Role-play can be beneficial for clients of all ages because it helps them learn to navigate their feelings and the language they will need to use to advocate for themselves. (For example, how will they explain that they can’t eat the cake at an upcoming birthday party?) Hubbard says she also finds play therapy, mindfulness and cognitive behavior therapy helpful for clients with food allergies.

Above all, she says, counselors should make sure their approaches are tailored to and appropriate for the individual client. “For kids, it’s not appropriate to talk about the risk of death [involved with food allergies], but coping with their feelings and worry is appropriate,” she notes.

Counselors can also model acceptance for clients in session, Hubbard adds. It can be a relief to find that “they don’t have to walk into a session defending themselves,” she says. “They can learn that not every conversation has to be fight-or-flight. It’s a marathon, not a sprint, for sure, just as with any chronic illness. Help clients pace themselves.”

> Find the right words: An individual with food allergies (or the parents of a child with food allergies) will need to explain the allergy to everyone from school staff to well-meaning relatives who are hosting a holiday dinner. Be aware that there can be cultural and generational differences in levels of understanding and flexibility surrounding food allergies, Hubbard advises.

“This can be hard for people who aren’t comfortable speaking up. If they’re not a natural advocate, it will now fall to them to educate [others] and advocate,” she says. “A counselor can help them manage the feelings around that, [including] frustration, burnout and exhaustion.”

> Guide children (and parents) as they grow up: Parents may find themselves growing anxious as their child with food allergies ages, develops more independence and spends more time away from home. Counselors can offer support as these families navigate the child’s developmental milestones. This might include encouraging the family to gradually give the child more freedom and responsibility to make safe choices independently.

For example, teenagers who are beginning to date may have to inform their love interests that they shouldn’t kiss for a while after the person has eaten something containing an allergen. “For every phase of life, there will be an additional need to explain and educate [about the allergy], and that can be exhausting,” Hubbard says.

> Be aware that “relapses” are possible: Clients who have made progress on accepting a food allergy and managing the emotions that come with it can “go back to ground zero” anytime they experience an allergic reaction or exposure scare, Hubbard says. Counselors shouldn’t be disappointed if these clients sometimes backslide on the progress they have previously made in therapy.

> Work with the allergist: Professional counselors shouldn’t hesitate to contact a client’s allergist (if the client grants permission). Counselor practitioners can learn a lot about the specifics of a client’s needs from the allergist, Hubbard says. For example, some food allergies are milder, whereas others can cause a reaction even from airborne exposure (for example, peanut dust). “Each client will have a specific set of data [regarding his or allergy],” Hubbard explains. “It’s important to stay connected with their allergist and check in to help you better understand.”

> Be cognizant that allergy-related bullying does happen: Being aware of allergy-related bullying is especially important for counselors who work in school settings or with children and adolescents in their practice, Hubbard notes. Up to one-third of children with food allergies have faced bullying, according to FARE.

This can include overt bullying, such as taunting or threatening a classmate with an allergen. But allergy-related bullying can also come in less obvious forms, such as when an adult (teacher, sports coach, etc.) points out the individual with an allergy and labels them as the “reason” the class or team can’t have certain foods. This type of scenario can make individuals feel bad about their allergies and the inconveniences they may present, Hubbard says.

 

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The Food Allergy Counseling Professionals Networking Group

Started by Tamara Hubbard, this group is open to counselors who work with clients who are managing food allergies. Connect with them on Facebook: facebook.com/groups/FoodAllergyCounselingProfessionals/ to share resources and network with other professionals who specialize in this area.

 

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Contact Tamara Hubbard and find resources at her website: foodallergycounselor.com

Hubbard also writes a blog on allergy-related issues, including a series titled “Four things counselors should know about food allergies.”

 

 

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Related reading

Hubbard suggests the following resources for counselors or clients looking to learn more about food allergies and their connection to mental health:

 

 

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

 

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

 

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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.