Tag Archives: Sexual Wellness

The invisibility of infertility grief

By Tristan D. McBain September 30, 2019

In my work as an outpatient mental health counselor, I have encountered numerous clients over the years with stories about reproductive loss. Not only were these stories fraught with sadness and grief, but some of the individuals were still experiencing acute grief even several years later.

As I branched out into my role as a researcher during my doctoral study, these stories stayed with me. So, I began a line of inquiry on reproductive loss that started with infertility and the accompanying grief. Since then, my research on infertility and miscarriage grief has resulted in numerous professional conference presentations and guest lectures. The purpose of this article is to share information that I have learned about those with infertility and to provide methods for best practice in counseling with these clients.

Infertility is generally defined as a condition of the reproductive system that inhibits or prevents conception after at least one year of unprotected sexual intercourse. To account for the natural decline of fertility with age, the time frame is reduced to six months for women 35 and older. According to the Centers for Disease Control and Prevention (CDC), about 12% of women between the ages of 15 and 44 have “difficulty getting pregnant or carrying a pregnancy to term.” Infertility can affect both men and women, despite a common misconception that infertility is a woman’s condition. Infertility in men may be caused by testicular or ejaculatory dysfunction, hormonal disorders, or genetic disorders. In women, infertility may be caused by disrupted functioning of the ovaries (such as with polycystic ovary syndrome, a condition that prevents consistent ovulation), blocked fallopian tubes, or any uterine abnormalities (such as the presence of fibroids).

Infertility can be categorized into one of two subtypes. Primary infertility refers to when a woman has never birthed a child and thus has no biological children. Secondary infertility refers to when a woman experiences the inability to birth a child following the birth of at least one other child. Both forms of infertility produce a cyclical pattern of strong emotion that is often referred to as a “roller coaster.”

Medical interventions

A number of available interventions may be used to increase the chances of becoming pregnant. The best course of treatment will be different for each couple and may depend on considerations such as whether the infertility is male factor or female factor, the cost and availability of insurance coverage, and cultural customs or beliefs. Some couples decide that pursuing any kind of medical treatment is not the right course of action for them. For others, medical treatment may include any of the following interventions.

  • Medication may be prescribed to stimulate ovulation or follicle growth in the ovaries, increase the number of mature eggs produced by the ovaries, prevent premature ovulation, or prepare the uterus for an embryo transfer.
  • Surgery may be necessary, perhaps to clear out blocked fallopian tubes or to remove uterine fibroids.
  • Intrauterine insemination (IUI), also known as artificial insemination, is a procedure in which sperm are inserted directly into the woman’s uterus. The woman may or may not be taking medications to stimulate ovulation before the procedure.
  • Assisted reproductive technology (ART) refers to fertility treatments in which eggs and embryos are handled outside of the body. This excludes procedures in which only sperm are handled (e.g., IUI). The most common and effective ART procedure is in vitro fertilization (IVF).

Undergoing IVF treatment requires a strong physical, emotional and financial commitment. Generally, medications are prescribed to stimulate egg production and may include a series of self-administered injections. Eggs are removed from the ovary using a hollow needle, and the male partner is asked to produce a sperm sample (or a sperm donor may be used). The eggs and sperm are combined in a laboratory, and once fertilization has been confirmed, the fertilized eggs are considered embryos. About three to five days after fertilization, the embryos are placed into the woman’s uterus via a catheter in hopes of implantation. The CDC reports that women under the age of 35 have a 31% chance of conceiving and birthing a child with the use of ART; the chances are closer to 3% for women ages 43 and over.

The IVF process can be a highly emotional time for the woman and the couple, marked by moments of excitement, hope, disappointment or uncertainty. The IVF cycle may be canceled if certain problems develop along the way, such as having too few or no eggs to retrieve, the eggs failing to fertilize, or the embryos not developing normally. Any of these situations may produce a sense of loss for the woman or the couple. After the embryo transfer, it is generally recommended to wait 10-14 days before testing for pregnancy. In some circumstances, a chemical pregnancy takes place. This is when implantation happens that results in an initial positive result, but then the pregnancy does not progress. In other words, a very early miscarriage occurs.

This section on medical interventions is important to include because these interventions are part of the infertility experience and may affect the emotional or mental health of the client. This is true even for women and couples who choose to not pursue treatment; at the end of the day, a decision was made and they must cope with the implications of that choice. Professional clinical counselors who are knowledgeable about the available medical interventions will have better context for recognizing the myriad decisions that these clients face and the potential losses that may occur throughout the process.

The invisibility factor

Take a moment to think about the grief that occurred for you after the death of a loved one. The relationship you had with your loved one was probably clearly defined, and you have memories of that person to look back on. The loss is easily identified and articulated, not only by you but by others who were aware of the death. You most likely had many people express sympathy and give you their condolences, perhaps verbally or by sending flowers. You may have taken time off work for bereavement and attended a ritual such as a visitation ceremony, wake or funeral that helped to facilitate your grief. Your loss was likely recognized, acknowledged, validated and supported in a multitude of ways.

Now think about the losses associated with infertility. One of the major losses is that of the imagined or expected family. Women with primary infertility, who do not have biological children, face the loss of the entire life stage of parenting. This may include pregnancy, passing on family or holiday traditions, and passing on the genetic legacy or surname, plus the eventual loss of other life stages such as grandparenthood. Counselors should recognize that meaning is often attached to these losses which further compounds the pain. For example, not being able to experience pregnancy means that the woman is also excluded from cultural pregnancy milestones such as going to the first ultrasound visit, thinking of fun and exciting ways to announce the news to family and friends, participating in a baby shower, and throwing a gender reveal party. With infertility, the loss comes from an absence of something that has never been rather than the absence of something that used to be.

The stigmatization surrounding infertility contributes to an atmosphere of silence and invisibility. Infertility and its accompanying losses are not as outwardly visible and may not be well known or understood by others unless the woman discloses them herself. Many women who experience infertility feel a sense of failure or self-blame toward their bodies, and some may withdraw socially, isolate, or struggle with their identity and sense of self. The stigma surrounding infertility can make it difficult for women to reach out for support. As a result, they find themselves navigating the experience alone.

When a woman does talk openly about her infertility, other people may not respond in ways that are validating or compassionate, which may make the situation worse than if she hadn’t disclosed at all. For example, comments such as, “Just relax,” and, “Give it time,” minimize the woman’s pain and invalidate her grief. Asking, “Have you tried (fill in the blank)?” or “Have you considered adoption?” implies that the woman is not trying hard enough to find a solution or that what she has tried already is inadequate. Most of the women with infertility I have encountered over the years acknowledge that people generally mean well and offer such comments in an attempt to provide hope or to decrease their own feelings of discomfort when talking about infertility.

Facilitating the grieving process

Professional counselors have a responsibility to provide compassionate and competent mental health treatment. Each infertility journey is unique, and counseling interventions should be tailored to fit the individual needs of every client. Taking clients’ cultural, religious or spiritual backgrounds into consideration, several interventions may be used to effectively assist these clients through their grief.

  • Counselors, first and foremost, can be present and listen. Typically, this is what is missing when family members, friends, co-workers, doctors or strangers offer comments that end up being hurtful or invalidating to the person or couple experiencing infertility. We do not have to have the answers — even as counselors. Just be there.
  • Counselors can assist clients in articulating what they need from others around them. This may also incorporate methods for helping clients increase their assertiveness or self-confidence.
  • Counselors can help clients redefine their life expectations and conceptualizations of womanhood, family and mothering. This may also include processing how clients perceive lost embryos, chemical pregnancies or miscarriages to fit within the family unit.
  • Counselors can help clients manage the roller coaster of emotions and ongoing stress as they are trying to conceive, rather than focusing on finding closure. Closure usually implies resolution, which may not be possible with the prolonged nature of infertility and the treatment process.
  • Counselors can assist clients in developing their own rituals while trying to conceive, undergoing fertility treatment, or after making the decision to stop treatment. For example, a woman once told me that she threw a party after she and her husband decided to stop IVF treatments. The party signified taking control over their decision to remain child-free and served as a celebration of the effort it had taken to come that far. 
  • Counselors can explore appropriate methods of client self-care, including engaging in hobbies, participating in creative or social activities, and even taking breaks (as needed) from trying to conceive or pursuing medical treatment.
  • Counselors can connect clients with appropriate resources. It may be necessary to provide clients referrals to group counseling if they wish to connect with others who have similar stories, or to couples counseling if they are struggling in their relationships. In addition, location or cost can be barriers to clients obtaining the services that would work best for them, so counselors who are knowledgeable about online resources can provide these options. Collaborating with other health care professionals with whom the client is working can also provide more comprehensive treatment.

This is not, of course, an exhaustive list. Grief is a personal experience. Which methods are the best fit for your client should be explored in a therapeutic setting that considers both individual and cultural contexts.

What do counselors need to remember?

Imagine that you are working in a private practice when you meet a new client experiencing infertility. You are a master’s-level clinician and are fully licensed in your state. You have taken one class in your graduate program on grief and loss but have no further specialization or experience with infertility. The client has heard numerous comments, questions and suggestions throughout the years regarding her infertility. She is unsure of how counseling might help, but she feels the need to seek support.

This scenario, while general, is a realistic picture of a possible situation that any clinician could experience. As such, I will provide thoughts on what every counselor should keep in mind when it comes to the areas of infertility grief. I am not attempting to reinvent the wheel when it comes to essential counseling tools; rather, I am striving to provide context for effectively using these tools with clients affected by infertility.

>> Convey empathy and understanding. If I could share only one thing I have learned in my work with women affected by infertility, it would be that so many of them feel and believe that you cannot possibly understand what infertility is truly like unless you have been through it yourself. Many women have asserted to me that they just need someone willing to sit with them through the anguish. Counselors who are attempting to provide encouragement and hope may instead end up inadvertently dismissing their clients’ pain or minimizing their grief. It is also possible that counselors end up avoiding a deeper exploration of the experience completely because they do not know what to say. Do not underestimate your basic counseling skills when working with these clients. Acknowledge, reflect and empathize.

One way that counselors can suggest understanding is through the careful use of language. For instance, matching the client’s chosen language of “baby” or “child” is more appropriate (and accepting) than using the more medically correct terms of “embryo” or “fetus.” Language can also offer a reframe from a label of “an infertile woman” to “a woman affected by infertility.” This choice of words depersonalizes the condition and acknowledges that her identity is separate from the condition.

>> Become familiar with client issues related to infertility. Clients who talk about their infertility journey will use a variety of terms and acronyms. For example, you may have clients talk about the time they were “TTC,” which stands for trying to conceive. They may also mention medications, medical procedures or basic biological functions with the assumption that the counselor is generally informed on these topics. Although asking clarifying questions of clients can help paint a clearer picture of their experience, it is not the client’s job to educate the counselor. Take the initiative early in the working relationship with a new client to learn about infertility in areas in which you are deficient. That way, you will be able to understand the client’s journey and experience in greater context.

>> Validate the loss. The invisibility of infertility may cause some women to wonder whether their losses are real or valid. For example, I met a woman during my research who had elected to try IVF after three years of actively trying to conceive, and she gave birth to a healthy baby after just one round. Still, she felt a sense of loss over the fact that her memories of the conception did not entail a moment of passion and love, but rather recollections of shame and fear. She referred to her husband having to masturbate in isolation to provide the needed sperm sample and her experience of lying on a cold table waiting for the doctor to transfer the embryo. She did not feel that she could verbalize this sense of loss to others, however, because it might make her sound ungrateful. A counselor could validate the loss of the ideal conception story and help her articulate feeling both sad for that loss and grateful for her baby at the same time.

The invisibility of infertility also means that some women may not have the vocabulary to identify and articulate their losses. Women with primary infertility endure the losses of pregnancy, delivery, parenthood and eventual grandparenthood but may not be able to understand for themselves that they are mourning the loss of an anticipated and desired life stage. Counselors can assist clients with developing language for their losses if they are struggling to verbalize their grief.

>> Get comfortable. Discussions about infertility may overlap with other taboo topics such as sex, masturbation, miscarriage and abortion. Many of the women I have met who have been affected by infertility have had miscarriages along the way. This brings about an additional — but connected — situation of grief and loss. Talking about miscarriage can be difficult to do without also bringing up abortion, given overlapping language (e.g., spontaneous abortion) and medical procedures (e.g., dilation and curettage). These topics can be slippery territory for personal bias, but counselors should regulate their own reactions and practice reflection to maintain appropriate neutrality and support. Engaging in self-care can be particularly important when counseling those affected by infertility.

Challenging infertility stigma

More and more, childbearing is being viewed as a choice rather than a societal or marital expectation, yet not having children is still considered to be somewhat taboo. Women are socialized from a young age to prepare for eventual motherhood through childhood play that often fosters a nurturing and caretaking role. Other cultural narratives suggest that women have an ability and responsibility to control their fertility. This contributes to self-blame and shame when they are unable to conceive. Infertility is infrequently discussed publicly and thus carries a sort of social stigmatization. Counselors can contribute to destigmatizing infertility by normalizing conversations about infertility, challenges to conception, fertility treatments, and miscarriage.

Stories related to infertility gained widespread media attention throughout 2018. That March, a fertility clinic in Ohio experienced a technical malfunction that caused the destruction of more than 4,000 eggs and embryos, a loss that most certainly had potentially devastating implications for the affected families. Then, in August, a rare visual of the emotional and physical struggle of trying to conceive was captured in a photograph that went viral of a newborn baby surrounded by the 1,616 IVF needles that it took to conceive her. In the months that followed, actress Gabrielle Union opened up about her emotional fertility journey that included numerous miscarriages and surrogacy, and former first lady Michelle Obama revealed her story that included miscarriage and IVF to conceive her two daughters.

These stories bring visibility to infertility and normalize conversations about the challenges that can come with attempting to get pregnant. Counselors can contribute to destigmatization by engaging in discussions and posing curious but sensitive questions about how resources and support can be bolstered for affected women and couples.

Conclusion

Each infertility story is unique, and no one-size-fits-all solution exists when it comes to helping women and couples work through their infertility grief. Whereas an obvious loss from the death of a loved one usually includes rituals and social support, the invisibility of infertility makes it difficult to identify the losses, often leaving women affected by these losses to deal with them in silence and isolation. Counselors can help clients find the vocabulary to articulate the losses they are grieving, give voice to what they need from the people around them, and create ways to process their grief in a warm, nonjudgmental atmosphere.

 

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Tristan McBain is a licensed professional counselor and licensed marriage and family therapist. She is a recent graduate from the Counselor Education and Counseling Psychology Department at Western Michigan University in Kalamazoo. Contact her at tristanmcbain@gmail.com.

 

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

Letters to the editor: ct@counseling.org

 

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Related reading on this topic, from the Counseling Today archives: “Empty crib, broken heart

 

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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.

Touched by trauma

By Laurie Meyers February 22, 2019

Licensed professional counselor (LPC) Ryan T. Day often refers to himself as a trauma survivor turned trauma therapist. When he was 11, Day was molested several times by a family friend. He had also already endured serious bullying brought on by a temporary childhood speech impediment. Day eventually began to act out and get into trouble at school. At age 13, as punishment for this misbehavior, he was severely beaten by his father, a preacher in a Pentecostal African-American church who interpreted the saying “spare the rod, spoil the child” literally.

Once he was molested, Day says he began to feel that something was wrong — he was constantly angry and often used his fists to express that anger. Day knew he wasn’t feeling “normal,” but it didn’t occur to him that what he was feeling was tied to the molestation. He says there was simply no awareness of any kind about trauma in his community, which he describes as a rough area of Richmond, Virginia, where residents learned to ignore the sounds of gun shots and to turn away from domestic violence.

“I never knew that violence was an issue,” Day says. To him, it was just a normal part of life. Nor did Day know what sexual abuse was. Although he took a sex education class in high school, he says that sexual violence was never mentioned.

Day was also an athlete in high school, but instead of changing clothes in front of other students, he would retreat to a bathroom stall. “I felt uncomfortable around males. I didn’t trust men,” he says, adding that his feelings were not about homophobia but simply about not feeling safe. “Locker room shenanigans triggered me and made me want to fight or freak out.”

Still grappling with emotional and personal barriers as a young adult, Day earned his bachelor’s degree in information technology and then decided to become a counselor. He says his counseling program didn’t emphasize self-assessment, however, so it wasn’t until he confronted a crisis during his internship that Day finally made the trauma connection.

During this time, Day had become suicidal, in part because he realized he was married to someone he didn’t love. Day says he hadn’t learned how to establish personal connections growing up, so, as he puts it, “I married the first person to show me some affection and love.” The religious tradition in which Day was raised didn’t consider divorce an option. In addition, Day and his wife were expecting a child, so he didn’t see a way to escape the stress of his marriage.

Fortunately, one of Day’s supervisors realized that he was experiencing a crisis and referred Day to a therapist. Day was in therapy for five months before he started talking about his childhood. The therapist helped Day see how his traumatic childhood experiences had shaped him and, in some cases, held him back.

After Day earned his counselor licensure, his first few clients were adolescents who had experienced multiple traumas and were living in violent neighborhoods. Their experiences paralleled Day’s own, and he realized that his personal history with trauma gave him extra insight. And that was it — Day decided to become a trauma specialist, and he’s never looked back, including presenting an education session on complex trauma at the ACA 2018 Conference & Expo in Atlanta.

Like Day, many clients don’t initially present to counseling for trauma but rather for help handling other issues. “You have an individual coming in for treatment, coming in for depression, etc., but the further you get into [the person’s] history, there’s so much more story,” Day says, adding that it’s like unpeeling the layers of a client’s life.

Day doesn’t screen for trauma during a client’s first session — he prefers to reserve that for beginning to build the therapeutic relationship. But he does complete a screening within the first few visits, often using the Life Events Checklist from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Day says he also probes for trauma as he listens to clients’ stories, asking questions such as “Have you had trouble sleeping?”; “Are you having any relationship issues?”; “Have you ever been in a serious romantic relationship?”

Why the questions about relationships? Day explains that difficulty forming and maintaining personal relationships is a hallmark symptom of complex trauma, which is different from — and not as familiar to most people as — posttraumatic stress disorder (PTSD).

Complex trauma vs. PTSD

PTSD is typically considered to be the result of a single traumatic event that occurs at any point over the life span, whereas complex trauma is the result of repetitive trauma that begins early in life and endures for a prolonged period of time, explains Cynthia Miller, an LPC in Charlottesville, Virginia, whose practice specializes in trauma. Complex trauma might result from numerous occurrences of the same kind of trauma — such as ongoing physical or sexual abuse — but it can also develop from the accumulation of different kinds of trauma.

“It’s the difference between taking a single blow versus absorbing multiple blows over the course of years,” says Miller, an American Counseling Association member. “The accumulation of those blows causes a different kind of damage than what is caused by a single blow. The damage doesn’t impact just one system but multiple systems. With a single blow, I may have swelling and bruising and scarring, but that will be confined to one area. With multiple blows over time, I will have bruising and swelling in multiple places at different times and scar tissue all over.”

People with complex trauma or PTSD may experience some of the same symptoms, such as hyperarousal, disturbances in cognition, intrusive memories and avoidance of triggers, but there are critical differences between the two types of trauma. For instance, people with complex trauma have much more trouble with interpersonal relationships and their overall self-concept, Miller says. “In addition to all the usual PTSD symptoms, they will struggle with their sense of identity, with building stable relationships and with making meaning of the world and their lives,” she explains.

Miller says it is vital that counselors understand and recognize the differences between PTSD and complex trauma because misdiagnoses are common. Complex trauma is often mistaken for borderline or other personality disorders or, in some cases, diagnosed as PTSD with co-occurring mental health issues such as depression, anxiety and somatic disorders.

“People can end up with a bunch of different diagnoses which don’t really encapsulate and accurately formulate the total problem. The trauma gets lost in the various diagnoses,” Miller says.

In addition, the treatment approach for complex trauma is not the same as that for PTSD. “Treatment differs mostly in the sequence of interventions one might use, along with the length of treatment,” Miller explains. “Gold-standard interventions for PTSD typically involve the exposure and reprocessing therapies like EMDR [eye movement desensitization and reprocessing], prolonged exposure therapy, etc. Those treatments can be effective, but they can also destabilize clients, at least in the short term, and clinicians need to be really careful to ensure that clients have strong and varied coping skills in place before doing exposures.”

Although prolonged exposure therapy and EMDR are popular therapeutic methods that can be very effective, Miller believes clinicians should be more flexible in their approaches to treating trauma. “It’s great to be trained in EMDR or prolonged exposure therapy, but those approaches don’t work for every client,” she stresses. “Some clients are just dubious of them, others don’t want to do the exposure, and others just aren’t comfortable with it. [Also,] people don’t necessarily need to process the trauma in order to get better. I’ve had clients come into my practice who have stopped seeing other therapists because the therapist was too wedded to a particular approach and, when the client expressed discomfort with it, the therapist either couldn’t or wouldn’t adapt. You have to be able to tailor treatment to the client, not tailor the client to the treatment.”

Miller routinely uses cognitive behavior therapy (CBT) and psychoeducation to help clients understand what is going on with them, how trauma has impacted their life and what can be done about it. “This, in and of itself, is really helpful for clients,” she says. “They often believe that they are deficient in some way and have caused all their problems. Once I explain what [complex trauma] is and how it affects people, they really start to understand themselves better and feel less shame.”

Miller recommends workbooks such as Life After Trauma: A Workbook for Healing by Dena Rosenbloom, Mary Beth Williams and Barbara E. Watkins and Seeking Safety: A Treatment Manual for PTSD and Substance Abuse by Lisa M. Najavits. The workbooks “have great psychoeducational handouts and readings for clients that provide education on how trauma affects the body and the brain,” she says. “I typically use the first few sessions of therapy to go over the handouts and help clients notice ways in which what is described applies to them and does not apply to them.”

Regardless of the methods clinicians choose, the initial stage of any therapeutic intervention for complex trauma should focus solely on client safety, helping them remain in the present and build their coping skills, Miller says. She adds that this is usually the longest phase of treatment.

To help clients learn how to stop symptoms such as flashbacks and dissociation, Miller teaches grounding skills. “Groundings skills involve different ways of trying to get the brain’s attention, helping it focus on what is literally happening in the moment instead of focusing on a memory from the past or checking out entirely,” she explains. “Grounding skills can involve techniques that use the five senses or techniques that attempt to engage the cognitive portion of the brain.”

Exercises that involve the senses include tasks such as asking clients to feel their feet on the ground, inhaling a relaxing scent such as lavender or running cold water over their hands. “We [also] might teach them how to describe everything they are seeing around them in detail, as if they were trying to paint the picture of a room with their words,” Miller continues. “One of my favorite grounding skills for using in emergencies is holding an ice cube in the palm of your hand or against your cheek. The sensation of cold, and then nonharmful pain, tends to get the brain’s attention fairly quickly and help someone reorient.

“Cognitive grounding skills can include things like reciting the ABCs backward, or naming every state in alphabetical order or [naming] every make of a car that one can remember. These skills try to engage the frontal cortex, which tends to go offline when someone is having flashbacks or dissociating.”

Miller also helps clients reframe their cognitions, making them aware that their past is not continually playing itself out in their present. “We help them notice how today is just today,” she says. “For example, clients often have difficulty with the anniversaries of traumas that have happened to them. They get anticipatory anxiety and, as the date approaches, they will fall apart. We work in therapy to help them notice ways in which the upcoming date is different from the date of their trauma. The year is different, their age is different, the people around them are different, their life circumstance is different, etc. It’s helping them be fully in their present and in the reality of that instead of in their past.”

Counselors also need to be mindful of the accumulative physical toll of long-term trauma, Miller adds. Research has shown that experiencing trauma — especially when it is prolonged and repetitive — rewires the nervous system in ways that cause hyperarousal and persistent anxiety. This continuous stress causes the body to release cortisol, which can cause chronic inflammation. Over time, the inflammation leads to negative health effects. To help counteract this cascade of neurological and physical damage, practitioners can teach clients skills for calming their nervous systems, Miller says. Again, counselors should tailor the treatment to the individual client. Some clients may find yoga or meditation helpful, whereas others might benefit more from neurofeedback.

Triggers and trauma responses

Debbie Sturm, an LPC in Virginia and South Carolina, has extensive experience working with trauma survivors. Currently an associate professor and director of counseling programs at James Madison University in Harrisonburg, Virginia, at one point Sturm counseled clients through the state of South Carolina’s crime victims support service, which allows people who have experienced a crime to receive 20 state-funded counseling sessions.

Sturm’s clients had experienced a range of terrifying incidents. Among others, she worked with a bouncer who had been shot at work, a woman who had been stabbed and left for dead by someone trying to steal the cash from her paycheck, people who had witnessed a homicide and a client who had been held captive by an abusive family member. Some of her clients also lived in violent neighborhoods or had histories of adverse childhood experiences. “[All] of my clients, however, were just regular people going about their daily lives [who had] experienced something awful,” says Sturm, a member of ACA.

Most of the people Sturm counseled didn’t necessarily meet all the criteria for PTSD, but they all presented with numerous trauma symptoms. The core issue for these clients was that the distress of what had happened, combined with how unfamiliar, uncomfortable and often frightening these new symptoms were for them, caused them significant difficulties. Typical symptoms included anxiety, fear, hypervigilance, sleep and eating disturbances, a compromised sense of safety and, sometimes, anger, resentment, blame or self-blame, shame and helplessness.

“For those who experienced violence, the shock of the violence and the damage to [their] personal sense of safety, control or power could be profound,” Sturm says. However, the intensity of the trauma response did not necessarily line up in the expected way, Sturm continues.

Many people assume that the most “serious” or violent events are more traumatic than a less dramatic experience, but that is often not the case, she says. A person’s trauma response is always unique to the individual and the circumstances surrounding his or her traumatic experience. “It’s really important for the clinician to hold that belief and really honor whatever response each individual is having,” Sturm emphasizes.

The treatment path that Sturm followed with each client revolved around how that person was experiencing his or her symptoms. Sturm says that identifying clients’ triggers played an important role in their recovery. She did that in part by asking: “When do you feel like things are at their worst? What is happening around you? What do you do for comfort or reassurance? As you feel that sense of fear or hypervigilance welling up, how can you start to recognize it sooner and listen to what it’s telling you?”

“Helping people really recognize when their [sense of] fear and lack of safety is starting to elevate can also help them get out of a situation or connect to something or someone safe sooner,” she explains.

Interestingly, the triggers were not always tied directly to the client’s trauma. For example, one client who had been sexually assaulted at work would “lose time” whenever she saw a white truck. The vehicles had no connection to her assault, but for whatever reason, they triggered her, Sturm recounts. But for other clients, the triggers were connected to their previous traumas.

The search for what triggered trauma symptoms provided some therapeutic benefit in and of itself, Sturm says. The clients’ “discoveries” also allowed Sturm to suggest strategies for responding to their fears. For example, the client who feared white trucks connected a sense of safety to her mother, so Sturm suggested that when she was driving and spotted a white truck, that she pull over and call her mom.

Employing such strategies helped Sturm’s clients increase their sense of efficacy, power and control because they were no longer passive captives to their symptoms. Instead, they were armed with strategies that brought comfort and helped dispel their fear.

A person’s traumatic response is typically adaptive and can even be protective, Sturm says. “For example, consider hypervigilance. If something horrible has happened and your sense of safety is shattered, the most adaptive and protective thing you could do psychologically is to be on alert. After all, the world is now proven to be quite unsafe. So, be alert!”

At the same time, the state of alertness involved in hypervigilance is very uncomfortable, can be frightening and takes a toll on trauma survivors psychologically, neurologically and biologically, Sturm says.

Traumatic environments

In some cases, a certain place is the trigger for the person’s trauma response because it isn’t safe and will never become safe, Sturm says. Part of trauma therapy might involve talking with clients about the possibility of removing themselves from that environment. Unfortunately, leaving isn’t always an option.

ACA member Leah Polk, a licensed master social worker with Change Incorporated in St. Louis, asserts that trauma can never be treated separately from the environment in which it occurred. While some survivors of traumatic events go on to reestablish safety in their lives, others must continue living in places that are directly linked to their traumas or in environments that are violent or dangerous, such as unsafe neighborhoods, war zones or violent homes. Ultimately, practitioners must accept that they cannot prevent clients from experiencing or reexperiencing traumatic events, stresses Polk, whose specialties include helping clients recover from trauma.

However, to help clients cope, counselors can support the survival skills that these clients have while distinguishing the times and places in which those skills are useful or necessary, Polk explains. “For example, perhaps it’s crucial to be vigilant while walking home alone at night from the bus stop, but that same vigilance is not required at one’s place of work or a doctor’s office,” she explains.

Practitioners can also provide clients a safe place to express the emotions tied to the burden of living in an unsafe environment, Polk says. Clients can express the sadness and frustration of not having their needs met, the pain and anger caused by social and economic oppression, and the fear that comes from living in an unpredictable and chaotic environment.

Polk says counselors can become a safety resource for clients wrestling with trauma by modeling a consistent and predictable relationship within a contained environment. “Often … clients’ trauma is founded by a violation of trust, confidence or safety from what should have been a trusted figure in their lives,” she explains. “Without establishing an explicit alliance within the [therapeutic] relationship, much of this work is nearly impossible.”

Polk also works with clients to identify other sources of support in their lives, such as caring relationships or enjoyable hobbies and interests. To help regulate emotional arousal, she teaches clients relaxation techniques such as brief meditation, deep breathing, body scanning (to identify where in their bodies they might be holding tension) and progressive muscle relaxation.

Miller has also worked with clients who could not escape traumatic environments. “I would have loved to send my clients in prison to entirely different communities and home environments when they finished their sentences,” acknowledges Miller, who has previously worked with female inmates at correctional facilities. “It would have helped a lot, but it’s just not possible. So, what do you do when [clients] have to go back to the same environment?

“It’s not a great solution, but I think part of what you can do is help clients learn how to take control of what they can in an environment that feels uncontrollable. You can help them learn to set better boundaries around how they will allow themselves to be treated. You can teach them skills for asking for help when they need it. You can link them with supportive resources. You can also help them focus on their strengths and resiliencies and learn how to calm their system when there’s chaos all around them. Any little bit of control someone can feel is better than feeling no control at all.”

For many clients who have been through complex trauma, especially those who have been physically or sexually abused, the idea that they can have any say over how people treat them is a new concept, Miller says. “They are very used to being controlled by others and being told who they can and can’t talk to, what they can say and what they can’t, where they can go and where they can’t, even down to what they can eat or wear. They are also told that they must do whatever people want them to do. So, helping them set boundaries begins with helping them see themselves as people who have rights and who don’t have to tolerate any and everything.”

When counseling these clients, Miller says, “we work on building self-esteem and teaching assertiveness skills. Just helping them learn how to say ‘no’ can take time. We practice it in session through role-plays. We also focus on helping them learn ways to keep themselves safe when saying no to someone who might not take kindly to it. This can include having them take a personal safety class or a self-defense class that is geared specifically toward [assault] survivors. It can also include talking through how to determine how much risk is involved in a given situation.”

Body guards

When it comes to cases involving sexual trauma, the person’s own body can feel like the “unsafe environment.” Therefore, feeling safe in one’s own body constitutes the core of work with these survivors, says Laura Morse, an LPC and a sex and relationship therapist in Lancaster, Pennsylvania, who specializes in helping clients recover from trauma.

Morse starts by providing psychoeducation about the fight-or-flight response to trauma. This step helps normalize the symptoms that her clients are experiencing. Morse also teaches clients how to self-soothe and ground themselves. She pairs mindfulness and deep-breathing techniques with tapping, using either EMDR or self-tapping. During the tapping work, Morse has clients practice deep breathing accompanied by a calming scent, which gives them a method to ground themselves and self-soothe wherever they are.

Polk notes that clients with a history of complex trauma may never have possessed a sense of confidence or autonomy about their bodies. She uses mindfulness-based stress reduction exercises to help clients integrate the mind and body. This might include a guided meditation in which the client’s anchor of awareness is an upward scanning of the body, from toes to head. During the exercise, the client may notice that certain areas within the body elicit specific emotions or sensations.

“Once the client is discovering feeling in these areas, the client may offer compassionate thoughts or phrases to the impacted areas,” Polk says. “The client may also be encouraged to continue compassionate exercises such as offering gratitude for the ways in which their body has helped them survive trauma.”

Clients can also explore nonsexual touch, such as different temperatures (a cold compress versus a warm bath) or textures (a soft brush versus a silk ribbon) and journal about their experiences, says Polk, who is also seeking certification as a sex therapist.

“If the client wants to move toward reclaiming their sexuality, it may be important to discuss their sexual self-perception and relationship with themselves,” she says. “Are they able to achieve pleasure through masturbation? If not, what seems to get in the way? If certain touches are uncomfortable or triggering, the client’s sense of choice must be paramount — they can choose to try something different or set a limit around specific experiences.

“For example, while caressing and external stimulation may be pleasurable, penetration leaves the client feeling overwhelmed and tearful. Therefore, the counselor would encourage the client to observe their thoughts and feelings about their self-exploratory experience and determine what feels right for them in that moment. The sense of agency that comes with integrating the mind and body, along with rediscovering self-pleasure, can be a life-changing concept for survivors of chronic sexual trauma. Therefore, the counselor must give plenty of patience and space for these experiences.”

Sexual assault survivors also frequently experience problems with sexual intimacy. Says Morse, “I use the dual-control model for sexual intimacy to empower survivors to understand the ‘brakes’ that are keeping them safe [but] may be preventing them from enjoying experiences that they used to in the past. And then we begin to learn ‘accelerators’ of what is helpful.”

Brakes are sexual-inhibition factors such as a history of trauma, body image issues, relationship conflict, unwanted pregnancy, depression, anxiety or, as Morse puts it, “everything you see, hear, touch, taste, smell or imagine that could be a threat.”

Accelerators are sexual-excitation factors such as a partner’s smell or appearance, a sense of novelty, new love or “everything you see, hear, touch [or] smell that is a turn-on,” Morse says.

Morse also helps clients who are in relationships to create sexual scripts with their partners. “When creating a sexual script with a couple, I will do the exercise both with the couple [and] individually,” she says. “I ask the couple, with their permission, if we can create a line-by-line script of the actions that lead to intimacy. This may start with affection at breakfast or date night, well before intimacy in the bedroom begins.”

Creating the script encourages couples to reflect on their usual sexual patterns and, in individual sessions, allows each partner to express any barriers they may be experiencing or areas where novelty or changes could be incorporated.

Polk believes that when clients who have experienced sexual trauma say they are ready to reengage in partnered sex or physical intimacy, it is important for the counselor to assess how they came to that conclusion. “While being supportive of their desires, the counselor may want to ask if this interest arose from their partner, from their own interests or collaboratively. The client’s sexual self-efficacy, or ability to reliably communicate and have sexual needs met, is of paramount interest when approaching this topic.”

Sexual assault survivors who are already in a sexual relationship may also find that trauma symptoms create barriers to intimacy. Clients may experience psychological symptoms such as depression, PTSD, traumatic reenactment and anxiety. Decreased libido or arousal and painful sex are also common, as are sexual avoidance and conflict in the relationship.

To combat these negative impacts, Polk helps clients create a sexual consent model. “The sexual consent model is used to negotiate sexual boundaries and mutual agreements between partners,” she explains. “This is more than a ‘yes’ or ‘no’; [it] is explicit and entails ongoing dialogue between partners. Research currently tells us that men are more likely to see consent as a one-time event, so gender scripts must be considered when approaching this model.”

Polk provides examples of possible script dialogue:

  • “I know I said oral sex was OK last week, but right now, I am uncomfortable.”
  • “If we try this position, it doesn’t mean that you have to always do this.”
  • “After sex, can you make time to cuddle so that I am not left alone?”
  • “While having sex, I noticed that you got unusually quiet. Is everything OK?”

Morse recommends sensate therapy to her clients. She describes sensate therapy as a series of sex therapy exercises that allow for sensual touch to be achieved without anxiety. “Typically,
this will start with just having a couple carve out time twice a week where intimacy is not centered around the genitals and penetrative sex,” she says. “Masters and Johnson initially developed a series of exercises which are now commonly adapted based on a couple’s specific needs.”

Morse recommends the book Sensate Focus in Sex Therapy by Linda Weiner and Constance Avery-Clark for counselors who want to learn more.

Trauma education

Day believes there are still too many people walking around with trauma who have no idea that they can be helped. He says counselors need to be proactive in educating the public about trauma because many of the people who could benefit will never show up in their offices. Day also stresses the need for trauma education in schools but says that because school counselors have so much on their plates, clinical counselors need to step in and be willing to give their time.

“Counselors don’t always have to sit behind the desk,” he states. “Go to places where people are uncomfortable about having these conversations, such as schools, community centers, churches.”

One of the things that Day loves most about being a trauma counselor is getting the word out. He gives presentations, participates on panels and has even talked about trauma on the radio.

“Individuals have to have that conversation,” he says.

 

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Additional resources

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

Counseling Today (ct.counseling.org)

  • “Moving through trauma” by Jessica Smith
  • “The Counseling Connoisseur: The contour of hope in trauma” by Cheryl Fisher
  • “Informed by trauma” by Laurie Meyers
  • “Salutogenesis: Using clients’ strengths in the treatment of trauma” by Debra G. Hyatt Burkhart and Eric W. Owens
  • “Coming to grips with childhood adversity” by Oliver J. Morgan
  • “The toll of childhood trauma” by Laurie Meyers
  • “Traumatology: A widespread and growing need” compiled by Bethany Bray
  • “All trauma is not the same” by Tara S. Jungersen, Stephanie Dailey, Julie Uhernik and Carol M. Smith
  • “The high cost of human-made disasters” by Lindsey Phillips
  • “Lending a helping hand in disaster’s wake” by Laurie Meyers

Books and DVDs (counseling.org/publications/bookstore)

  • Disaster Mental Health Counseling: A Guide to Preparing and Responding, fourth edition, edited by Jane Webber and J. Barry Mascari
  • Youth at Risk, sixth edition, edited by David Capuzzi and Douglas R. Gross
  • Crisis Stabilization for Children: Disaster Mental Health, DVD, presented by Jennifer Baggerly

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Traumatic Stress and Marginalized Groups” with Cirecie A. West-Olatunji (CPA24341)
  • “Counseling Students Who Have Experienced Trauma: Practical Recommendations at the Elementary, Secondary and College Levels” with Richard Joseph Behun, Julie A. Cerrito and Eric W. Owens (CPA24339)
  • “Counseling Refugees: Addressing Trauma, Stress and Resilience” with Rachael D. Goodman (CPA24337)
  • “Dissociation and Trauma Spectrum” with Mike Dubi (CPA24333)
  • “Children and Trauma” with Kimberly N. Frazier (CPA24331)
  • “ABCs of Trauma” with A. Stephen Lenz

Podcasts (aca.digitellinc.com/aca/store/5#cat14)

  • “Treating Domestic Violence” with Tali Sadan (ACA282)
  • “Counseling African-American Males: Post Ferguson” with Rufus Tony Spann (ACA285)
  • “Harm to Others” with Brian VanBrunt (ACA248)
  • “Child Sexual Abuse Survivors, Their Families and Caregivers” with Kimberly Frazier (ACA200)

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Gun Violence
  • Trauma and Disaster

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

  • Traumatology Interest Network

 

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

 

Letters to the editorct@counseling.org

 

 

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

Talking about menopause

By Laurie Meyers January 7, 2019

Sleepless nights. Sudden temperature spikes and night sweats. Fluctuating moods. Brain fog. Sudden hair loss (head). Sudden hair growth (face). Dry skin, leaky bladder, pain during intercourse.

This litany of symptoms may sound like the signs of a mysterious and slightly terrifying disease, but they’re actually all possible side effects of a normal, natural life transition: menopause.

Menopause is an inevitable part of life for women — or, more precisely, people with ovaries — but chances are, many clients who show up to counseling know little about it. “The Change,” as it is sometimes called, isn’t taught in sex education classes and is rarely brought up by doctors. Even friends don’t always tell other friends about it. Unprepared for this disruption that usually coincides with a life stage already known as a major time of transition, clients may turn to counselors for help navigating this natural biological process.

Understanding the process

Therein lies the first lesson: Menopause is part of a process. Menopause refers to a specific point 12 months after a person’s last menstrual cycle. Perimenopause, which can begin up to 10 years before menopause, is the transitional time during which most menopausal symptoms occur. Perimenopause usually begins in a person’s 40s but can start as early as a person’s mid- to late 30s.

“During these years, most women will notice early menopausal symptoms such as hot flushes, night sweats, sleep disturbance, heart palpitations, poor memory and concentration, vaginal dryness and … depression,” says American Counseling Association member Laura Choate, a licensed professional counselor (LPC) who has written extensively about issues that affect women and girls.

According to the National Institutes of Health, other perimenopausal symptoms include irregular menstrual periods, incontinence, general moodiness and loss of sex drive. Some people also experience aches and pains and weight gain, particularly in the abdominal area, although experts are unsure whether these effects are tied directly to perimenopause or are instead caused by aging.

LPC Stacey Greer, whose practice specialties include assisting clients with issues related to perimenopause/menopause, says that many clients show up to her office because they’ve been feeling “off” or “not like themselves.” Some of these clients may even have received a perimenopause diagnosis, but most still are unaware of the symptoms and don’t understand the process, she says.

Both Greer and Choate believe that knowing what to expect in perimenopause can in itself ease some of the discomfort of the transition. Choate notes that for those who are unaware of the signs of perimenopause, many of the symptoms can be alarming. Some clients’ symptoms may be mild, but for others, they are severe and can significantly interfere with clients’ functioning and quality of life, Choate says. She adds that symptoms usually peak about a year before the last menstrual period and begin to ease significantly in the second year of postmenopause.

Is it hot in here?

Knowing what to expect from perimenopause is all well and good, but in this case, forewarned doesn’t mean forearmed. Clients still have to live through the symptoms.

Counselors can help with that. Greer says that charting is an excellent tool. She gives clients a chart listing perimenopausal symptoms and asks them to note all the ones that they experience over the course of a month. This allows her to identify and focus on a client’s specific problems.

Hot flashes, night sweats and trouble sleeping are some of the most common complaints. Choate says research has shown that cognitive behavior therapy (CBT) can help with hot flashes and night sweats. She recommends the techniques contained in Managing Hot Flushes With Group Cognitive Behavioral Therapy: An Evidence-Based Treatment Manual for Health Professionals by Myra Hunter and Melanie Smith. The book highlights the importance of identifying and reframing thoughts that occur during a hot flash.

When hit with a hot flash, instead of thinking, “Not other one!” or “I am going to pass out” or “This will never end,” clients can tell themselves, “It will pass” or “Menopause is a normal part of life” or “The flashes will gradually go away over time,” Choate explains.

“In addition to changing self-talk, it is helpful to have an attitude of calm acceptance, mindfully accepting the hot flash instead of trying to push it away or become upset by it,” she says. “There is evidence that mindful acceptance and allowing the flash to ‘fall over you’ helps women cope more effectively. Also, using paced breathing to elicit the relaxation response helps women cope as they focus on their slowed breathing instead of the discomfort that accompanies a hot flash.”

Many people also experience problems sleeping during perimenopause. According to the National Sleep Foundation (NSF), this is not only because of nighttime hot flashes but because of decreasing levels of progesterone, which promotes sleep. The NSF recommends the following for menopause-related sleep problems:

  • Stay cool. Keep a bowl of ice water and a washcloth near the bed for quick cool-offs when awakened by a hot flash. Also maintain a cool, comfortable bedroom temperature (ideally between 60 and 67 degrees), and keep the room well ventilated.
  • Choose the right bedding. Skip thick, heavy comforters and fleece sheets and go for bedding made from lighter materials, such as breathable and fast-drying cotton. This prevents overheating.
  • Eat soy. Eating soy products such as tofu, soy milk and soybeans may help combat dropping estrogen levels. Soy products contain phytoestrogens, which have weak, estrogen-like effects that may ease hot flashes.
  • Consider a natural remedy. Natural hot-flash helpers include botanicals such as evening primrose and black cohosh. Make sure that clients consult a physician before taking these or any other supplements because they are not regulated and may interfere with other medications.
  • Try acupuncture. This ancient Chinese remedy uses tiny needles to unblock energy points in the body and may help balance hormone levels to ease hot flashes and trigger the release of more endorphins to offset mood swings.
  • Balance hormones. Clients should consult a physician for sleep problems that last for more than a few weeks. A physician might recommend hormone replacement therapy (HRT), which helps stabilize decreasing hormone levels and lessen the severity of hot flashes. Other medication options such as low-dose antidepressants and even some blood pressure drugs have also been shown to alleviate menopausal symptoms.

Good sleep hygiene habits are also important. The NSF recommends the following:

  • Get earplugs or a sound conditioner to maintain a quiet environment. Extraneous noise in the bedroom can disrupt sleep.
  • Keep overhead lights and lamps in the home dim (or turn off as many as possible) in the 30 to 60 minutes before going to bed.
  • Position the alarm clock so that it’s difficult to see from bed. Watching the seconds and minutes of a clock tick on and on while trying to fall asleep can increase stress levels, making it harder to get back to sleep when awakened.
  • Keep a consistent sleep schedule. Going to bed and waking up at the same time every day — even on the weekends — reinforces the natural sleep-wake cycle in the body.
  • Develop a bedtime routine. Running through the same set of habits at night helps the body recognize that it is time to unwind.
  • Stay away from stimulants such as nicotine and caffeine at night. Avoid drinking tea or coffee, eating chocolate or using anything containing tobacco or nicotine for four to six hours before bedtime. Alcohol can also disrupt sleep, so avoid more than a single glass of liquor, beer or wine in the evening.
  • Get regular exercise, but not too close to bedtime.

Greer also recommends relaxation techniques. She works with clients to help them focus on the things they can control and let go of the things they cannot control.

Many people find significant relief from hot flashes, sleep problems and mood disturbances by taking HRT or antidepressants, but clients often need help sorting through their options, Greer says. It’s not uncommon for clients to come to counseling with a whole sheaf of information from their OB-GYN, much of which can be difficult to understand. Greer helps clients navigate the material and identify any follow-up questions they have for their physicians. “This can help them feel more empowered and have a voice in their treatment,” she says.

“Speaking to a trusted medical and mental health professional is important at this time,” says Joanna Ford, an LPC whose practice specialties include assisting clients with issues related to menopause and perimenopause. If her clients don’t already have a physician, she suggests that they ask family members and friends or even consult social media for recommendations. In fact, some of Ford’s clients have created circles on social media that offer recommendations on physicians and treating menstrual issues.

Depression risk

Choate, who is currently writing a book on depression in women across the life span, says that depression is a common perimenopausal symptom. “There is an increase in depressive symptoms, first-time episodes of major depressive disorder (MDD) and … risk of recurrence of MDD in women who have a history of MDD,” she says. “Symptoms of depression occur at a 40 percent greater rate [among perimenopausal women] than in the general population, and the prevalence of depression increases 2-14 times in women during perimenopause versus the premenopausal years.”

Interestingly, perimenopausal depression presents slightly differently than depression as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. In perimenopausal depression, clients are more likely to be irritable or hostile, have mood lability or anhedonia, and have a less depressed mood than is commonly seen in MDD, Choate explains. “Therefore, without a predominantly depressed mood, depression during the transition can be overlooked or misdiagnosed,” she says.

“Counselors can help women focus on self-compassion and self-care during this time, as studies show that there is an increase in negative life events for midlife women compared to other times in their lives,” Choate continues. “This could include children leaving home, caring for aging parents, the death of parents, personal illness, divorce or separation, [and] loss of social or financial support. With the increase in stressful life events, paired with the biological changes of perimenopause, women are more likely to experience distress.”

But all hope is not lost, Choate says. “I think it is helpful to be aware of studies that indicate that while women do experience a decrease in their mental health during these years, recent longitudinal studies show that depressive symptoms decrease as women age out of the perimenopausal years and enter their late 50s, 60s and 70s,” she says. “It is helpful to view this time as a window of vulnerability that does dissipate as women age and as they learn to view mid- to later life as a time of renewal and vitality.”

Sense of self and sexuality

It is not uncommon to feel grief about the menopausal transition. Greer says that some of her clients describe feeling “old” and struggle with their identity as women. “I try to help them work through the grieving process and work toward an acceptance of what is happening to their body,” she says. “It [the transition] does not change who they are, just how they see themselves.”

It isn’t difficult to understand why perimenopausal women feel old. As Choate notes, in Western cultures, youth is viewed as highly desirable, particularly for women, who continually receive the message that signs of aging should be avoided and obscured as much — and as long — as possible.

“The anti-aging industry is designed to perpetuate the myth of eternal beauty — that women can and should maintain a youthful, thin appearance regardless of their age,” Choate says. “The myth implies that women should exert the energy needed to conceal signs of aging, and if they don’t, then they are to blame.”

Women are socialized to prevent or repair skin changes such as wrinkling, sagging and age spots, all of which are natural signs of the aging process. Thinning and graying hair and weight gain are other results of aging that are considered undesirable, Choate notes.

Women “are taught that as they lose their youth, they will also lose their physical beauty, their sexual appeal, their fertility and their overall use to society,” she says. “In contrast, in cultures in which older age is revered, women report fewer symptoms during the menopausal transition. Cross-cultural studies show us that when older women are valued for their wisdom and contributions, they have more positive expectations about aging and menopause, and they also experience few menopausal symptoms. The message from these cross-cultural studies is that when women welcome aging as a natural process, not a disease, and accept naturally occurring changes to their weight, shape and appearance, they are less likely to experience negative symptoms associated with menopause.”

Women may know all of this intellectually, but the societal message is hard to ignore: Youth = beauty = power. Even women who habitually kept these weapons sheathed may feel the shift as they enter the perimenopausal transition.

“Body issues are important to address during this transition time,” emphasizes Ford, a member of ACA. “Aging is part of every life. The culture that we are surrounded by may impact our image of ourselves and our self-value. If we can increase our awareness about how we speak to ourselves about our bodies, it is possible we can accept the changes instead of fighting them.

“People may feel invisible before entering perimenopause, and it can increase feelings of depression and isolation. It is imperative to find a support system that encourages an individual’s values based on a variety of things, such as personal interests, skills, spiritual or religious beliefs, occupation, artistic or creative pursuits or any topic people can connect through.”

Body image issues can become part and parcel of the sexual changes that accompany perimenopause. “Menopause is reached upon the cessation of a woman’s menstrual cycles for 12 consecutive months. This means that menopause culminates in the loss of fertility,” Choate says. “For many women, this is a difficult role transition, particularly if they have based their identity upon a youthful appearance, which is often associated with fertility. For other women, the end of the childbearing years is a welcome change, as they become free from monthly menstrual cycles and also gain freedom from the need for birth control and other pregnancy concerns. They may experience negative biological sexual changes but may be more motivated to seek treatment for these changes as they begin to explore their sexuality apart from its association with childbearing.”

“Women often report a decrease in libido during this time,” Choate continues. “Some of this is due to physical factors — pain during intercourse, vaginal dryness — and some is due to psychological factors, including poor body image, beliefs and expectations about aging and sexuality, stress, fatigue from night sweats, and sleep disruption.”

Estrogen replacement therapies can help with many of the physical factors, but addressing the psychological factors is equally important.

“CBT is also helpful in examining a woman’s expectations for menopause, aging and her sexuality now that her sexuality is no longer linked to fertility and youth,” Choate says. “She might need to change her beliefs about women and aging, viewing menopause as a natural process that occurs to all women but does not indicate a disease, nor does it necessitate a view of herself as an aging, asexual woman. She might benefit from discussing her concerns with her partner to clear up any miscommunication about her partner’s expectations or attitudes toward the changes that are occurring in her body.”

It is essential — but sometimes difficult — to talk about those negative biological sexual changes, Ford notes. “Testosterone and estrogen levels are decreasing at this time and can lead to a change in libido or discomfort during intercourse,” she explains. “I do think people have to ‘re-envision’ their sexuality because hormonal changes are always happening.”

Of course, sex does not mean just intercourse, Ford continues. Embracing different ways of sexual expression can be helpful if intercourse becomes painful. People for whom intercourse is painful may also want to consult their physicians about lubrication or hormonal therapies, she says, adding that she recommends clients read The V Book: A Doctor’s Guide to Complete Vulvovaginal Health by Elizabeth G. Stewart and Paula Spencer.

Ultimately, counselors can help clients see not just the losses associated with menopause but also the opportunities.

“Now that you are entering a new life stage, what new opportunities do you want to seek out for yourself?” Choate asks. “What can you explore and enjoy during this next life phase? Research shows that while women do experience increased unhappiness during their early 50s, longitudinal studies show that they are happier than ever in their mid-50s and into their 70s and benefit from decreased caregiving and work responsibilities in their later years.”

Greer reassures clients that even though the menopausal process may sometimes seem as if it will go on forever, the stage is temporary. “There is life after menopause,” she emphasizes.

 

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

Letters to the editor: ct@counseling.org

 

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

 

Addicted to sex?

By Amanda L. Giordano and Craig S. Cashwell August 7, 2018

Sex and sexuality are necessary, healthy and, arguably, sacred aspects of the human experience. What happens, though, when sex is used not to enhance intimacy and connection with others but, rather, becomes out of control? What happens when a person describes a clear set of personal values around sexual behavior yet consistently crosses his or her own boundaries and compromises personal sexual values? What happens when a person continues a pattern of sexual behavior despite detrimental consequences? Can a person be addicted to sex?

Although most forms of sexual expression are healthy, the sex addiction model posits that some individuals may develop compulsive, dependent relationships with sex. Critics of the sex addiction model suggest that the addiction label pathologizes nonnormative sexual behaviors (e.g., fetish, kink), yet true proponents of the model do not claim to define morally appropriate forms or frequencies of sexual acts. The focus, rather, is on one’s relationship with sex.

Just because a sexual behavior violates an individual’s personal values, religious or spiritual beliefs, or societal norms does not make it an addiction. Instead, sex addiction has specific defining characteristics:

  • Loss of control
  • Continued engagement despite negative consequences
  • Mental preoccupation or cravings

Thus, rather than being sex-negative, advocates of the sex addiction model work to identify those who are unable to control their sexual behavior, are experiencing distressing outcomes and are mentally preoccupied or craving sex. Once sex addiction is determined, individuals then can get the treatment and support they need to establish healthy sexuality. 

A topic for debate

The notion that sex can be addictive still is debated among mental health professionals. Instead of addiction, alternative explanations for problematic sexual behaviors include impulse-control issues, obsessive-compulsive disorder, neuroticism, learned behavior, a form of sensation seeking, internalized sex-negative messages or manifestations of a mental health issue such as bipolar disorder.

The addiction model, however, purports that the primary issue is an out-of-control relationship with sex resulting from changes in chemical messengers in the brain. Specifically, naturally reinforced behaviors, such as eating and sex, are linked to the release of neurotransmitters (i.e., dopamine) related to pleasure and reinforcement. A naturally rewarding behavior such as sex can become a supernormal stimulus leading to dysregulation in the dopaminergic system. The resulting neuroadaptations affect reward, memory, attention and motivation. Thus, from an addiction model perspective, sex can hijack the natural functioning of the reward pathway in some individuals, leading to addictive behavior.

The sex addiction model contends that in addition to being positively reinforcing through the release of dopamine and other neurotransmitters, sex can be negatively reinforcing. Over time, sex can become addictive when it is used as the primary or, sometimes, sole method of regulating undesirable emotions. In other words, sexual behavior can be negatively reinforcing when it functions as an avoidance strategy and is used to escape emotional pain. In a negative feedback loop, however, the individual often feels shame as a result of his or her out-of-control sexual behavior. Paradoxically, this shame may become part of the undesirable emotions that the person then strives to regulate through sexual acts. From an attachment perspective, it is likely that these individuals never learned to coregulate emotionally and, instead, try to autoregulate emotions.

Scholars who primarily emphasize the negative reinforcement of sexual behavior often argue for terminology other than sex addiction, such as compulsive behavior or hypersexuality. However, the fact that sex provides both negative reinforcement (i.e., escape) and positive reinforcement (i.e., pleasure) seems to give credence to the addiction model.

Although controversy remains, the mental health field is steadily embracing the notion that behaviors can become addictive. For example, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included the diagnosis for gambling disorder in a chapter titled “Substance Use and Addictive Disorders.” In addition, internet gaming disorder and nonsuicidal self-injury (which some conceptualize as a behavioral addiction) were included in Section III as conditions in need of further study.

A diagnosis of hypersexual disorder was considered for the DSM-5 but ultimately was not included. The American Society of Addiction Medicine, however, revised its official definition of addiction to include both chemicals and naturally reinforcing behaviors. Furthermore, within the World Health Organization, the Working Group on Obsessive-Compulsive and Related Disorders for the 11th version of the International Classification of Diseases has recommended a diagnosis of compulsive sexual behavior. The organization determined the need for additional research to classify sexual behavior as addictive but clearly recognizes that out-of-control sexual behavior is a public health issue.

In addition, the recent surge of public concern related to pornography use and related erectile dysfunction among relatively young men (as evidenced by high traffic on websites dedicated to helping individuals “reboot” or discontinue use of pornography) has contributed to the influx of neuroimaging studies exploring addiction to pornography. Researchers have confirmed that the same regions of the brain activated by drug stimuli also are activated by online sexual stimuli and that addictive sexual behavior may be associated with decreased gray matter and diminished connectivity in the brain.

Types of sex addiction

Scholars conceptualize two types of sex addiction. The profile for the classic type includes early attachment wounds, family-of-origin issues and trauma histories, culminating in insecure attachment strategies in adulthood. Research shows a clear link between problematic sexual behavior and insecure attachment styles, and the majority of individuals in treatment for sex addiction have experienced trauma. For individuals with classic sex addiction, their sexual behavior may have been a primary means to fulfill attachment needs or escape emotional pain. Over time, however, the behavior became compulsive and out of control as the natural longing for sex became a need and then an addiction. 

Recently, a second contemporary type of sex addiction has been identified among individuals without the classic profile of trauma or attachment wounds. Instead, the contemporary type emerges as a result of chronic, excessive exposure to sexual stimuli, especially in the form of pornography or cybersex, made more readily available when the internet became ubiquitous. Sex researcher Alvin Cooper referred to cybersex as a triple-A engine, offering affordability, anonymity and accessibility to users.

Online sexual images and videos are pervasive, and current estimates suggest that the average age of first exposure to pornography is 11. This initial exposure is often accidental on the part of the child, with pornography sites known to purchase domain names of commonly misspelled children’s websites (referred to as cybersquatting). Over time, however, pornography becomes a supernormal stimulus reshaping the brain by repetitive experiences of pleasure associated with online sexual images. The brain responds to this hyperactivity in the reward pathway by decreasing natural dopamine production and receptors. Consequently, with decreased natural dopamine production, those with sex addiction may feel mildly depressed at baseline, inducing cravings for sexual behavior to alleviate the negative mood. Thus, whether classic or contemporary, sex addiction leads to changes in brain circuitry, which, in turn, perpetuates the addictive cycle.

The nature of sex addiction

Among individuals for whom sex has become addictive, the condition is all-consuming. When those with sex addiction are not engaging in sexual behaviors (acting out), they likely are thinking about them (fantasy and mental preoccupation), getting ready for them (preparation and ritualization) or recovering from the consequences (physically and emotionally).

Sensitization caused by neuroadaptations may lead individuals to seek novel or more intense sexual stimuli to achieve the desired effect (otherwise known as tolerance). For example, an individual may shift from nonviolent to violent pornography or change from streaming cybersex to partnered anonymous sex. Those with sex addiction begin to live a double life as they hide their out-of-control sexual behaviors from others, withdraw and isolate. Furthermore, many people with sex addiction lose sexual interest in their romantic partners and experience sexual dysfunction because of classic conditioning in which arousal is paired with alternative stimuli such as a computer. The addiction affects the individual physically, psychologically, spiritually, relationally and emotionally. Although sex addiction begins to control these individuals’ lives, they often are reluctant to tell anyone about their experience because of intense feelings of shame and self-loathing.

Addictive sexual behavior can manifest in a variety of ways, from compulsive masturbation, anonymous sex and prostitution to compulsive sexual relationships, voyeurism or rape. Indeed, some sexual acting-out behaviors can cross the legal line and fall into the realm of sexual offenses, but the majority of those with sex addiction do not offend; rather, they engage in legal forms of compulsive sexual behavior.

Sex offenders generally have distinct profiles from sex-addicted nonoffenders. Specifically, sex offenders are more impulsive; engage in more intrusive behaviors; respond to offenses with hatred, anger and entitlement; and have low remorse. This profile differs from the progressive trajectory of sex addiction that tends to include more frequent, yet less intrusive, acting out; triggers shame, despair and powerlessness; and is met with high remorse. When sexual acting-out behaviors cross the line of legal offense, those who are sexually addicted are legally responsible for the consequences of their actions despite having an addiction (much like someone with alcohol addiction who injures another person while driving under the influence).

Although individuals with addiction are not responsible for “giving themselves” sex addiction, they are responsible for their recovery through seeking help and working a treatment program. Increasing public awareness about sex addiction can help promote early access to professional treatment, with the hope being that this step will aid in avoiding decades of negative consequences both for individuals with sex addiction and for others who may be affected.

Clinical considerations

Given that sex addiction can include myriad sexual behaviors, it is important for clinicians to assess and screen appropriately. Most sex addiction emerges in late adolescence and young adulthood, so school counselors and community clinicians working with young clients can provide early intervention by regularly screening for sex addiction. Counselors are encouraged to broach the subject of sex in counseling and explore clients’ relationships with their sexual activities, such as masturbating, sexting, hooking up, using pornography, engaging in cybersex, using sexual apps and engaging in compulsive sexual relationships.

Despite the fact that sex addiction emerges early, most individuals do not seek professional treatment until later in life as a result of experiencing often extreme negative consequences (i.e., “hitting rock bottom”). Accordingly, all clinicians should be screening for a loss of control over sexual behaviors, continued engagement in sexual behaviors despite negative consequences, and mental preoccupation or cravings. Along with informal screening and exploration, many formal assessments for sexual compulsivity and addiction exist, including the Sexual Addiction Screening Test, the Sexual Compulsivity Scale and the Sexual Dependency Inventory. The use of these instruments can help clinicians better understand their clients and coconstruct appropriate treatment goals.

Once counselors identify the presence of sex addiction, they have many tools and treatment programs to assist in helping clients reach long-term recovery. Unlike recovery from chemical addictions, the goal of sex addiction treatment is not abstinence from all sexual acts, but rather the development of healthy sexuality. It is the compulsive, detrimental sexual behavior that counselors and clients work to eradicate.

To help clarify recovery from sex addiction, many clinicians and 12-step recovery programs (such as Sex Addicts Anonymous) use the three-circles activity. With a sponsor or counselor, those with sex addiction draw three concentric circles. In the innermost circle, the client lists all unhealthy sexual behaviors that have led to negative consequences and over which the individual has lost control. These are the behaviors from which the client is choosing to abstain.

In the middle circle, the client lists behaviors that may lead to sexual acting out. Identifying middle-circle behaviors is important from a neurological perspective. The amygdala is responsible for emotional memory; thus, it remembers stimuli associated with the experience of pleasure. After years of sex addiction, individuals likely have associated specific locations, sounds, sights, smells and actions with sexual pleasure. The middle circle, therefore, includes any stimuli, such as excessive fantasizing, cruising or sexually objectifying others, that may trigger the amygdala and lead to sexual craving.

Finally, the client uses the outermost circle to identify healthy behaviors that will support the individual’s recovery. These behaviors might include participating in 12-step groups, engaging in counseling, fostering spiritual practices, exercising, eating healthy, keeping home and work spaces nonchaotic, spending time doing recreational activities and increasing healthy social support.

Many counseling approaches and interventions, including cognitive-behavioral approaches, psychodynamic approaches, acceptance and commitment therapy, motivational interviewing, art therapy, group counseling, couple and family counseling, and even psychopharmacology, are appropriate for work with sex addiction. It is important to note that recovery from sex addiction often spans years rather than months. Clients, family members and partners may erroneously believe that recovery occurs within a matter of weeks and can become disheartened when initial attempts to change behavior are unsuccessful. Providing psychoeducation about the neurobiology of sex addiction can offer a more accurate perspective and create realistic expectations. Clients can find hope in the fact that, in time, the brain can heal and resolve dysregulation in the reward circuitry. This healing process takes time, however, and the completion of specific tasks such as those outlined in Patrick Carnes’ 30 tasks of recovery.

Additionally, sex addiction may not be the only concern addressed in treatment. Given the common mechanisms underlying addiction, it is not surprising that coaddictions to gambling, food, gaming, the internet or substances often exist among those with sex addiction. Furthermore, research supports the prevalence of comorbid mental health problems, including bipolar disorder, major depressive disorder and attention-deficit/hyperactivity disorder, among those with sex addiction. Finally, a trauma-informed perspective may be necessary to help clients resolve trauma to improve emotion regulation.

Clinicians should take an integrated approach to address all addictive and mental health concerns in treatment. Integrated care may be more complex than addressing one concern at a time, but diverse treatment teams, supplemental or adjunct resources, and holistic recovery plans can best help clients reach long-term health and wholeness.

Advocating for clients

One of the most necessary forms of advocacy for this population is increased awareness related to sex addiction. During the Masters Tournament in 2010, roughly six months after the story broke concerning Tiger Woods’ sexual behavior and treatment for sex addiction, someone flew a plane over the Augusta National Golf Club with a banner reading, “Sex addict? Yeah. Right. Sure. Me too.”

It is inappropriate for anyone outside of Woods’ personal and professional circle to try to determine a clinical diagnosis for his case, but the plane and banner reflect a popular public sentiment: Sex addiction is not real. Advocates can work to increase public knowledge relating to sex addiction and dispense critical research about the condition.

Additionally, mental health professionals can take several practical steps to advocate for clients who are sexually addicted. Currently, many counseling centers do not include information about sex addiction on their websites or relevant items on their intake forms. This lack of acknowledgment may inadvertently communicate to clients that sex addiction is not an appropriate topic for counseling. Thus, one of the simplest forms of advocacy is to include the experience of compulsive sexual behavior on websites, advertisements and client intake forms.

Another important advocacy effort is to acknowledge that individuals of all genders can have sex addiction. Specifically, when community groups, media spokespeople or well-meaning educators leave women out of the conversation about addiction to sex or pornography, they add a layer of stigma for these individuals. Although prevalence rates may differ among genders (about 1 in 7 of those with sex addiction are women), it does not discount the salience of sex addiction among female populations.

Finally, the most recent standards of the Council for Accreditation of Counseling and Related Educational Programs require educators to teach students about theory and etiology of addictive behaviors. Therefore, counselor training programs can advocate for future clients by infusing relevant, up-to-date information regarding sex (and other behavioral) addictions in the counseling curriculum.

Conclusion

Much work is needed to decrease the stigma and shame associated with sex addiction. Although stigma exists with any addiction, it seems particularly poignant with regard to compulsive sexual behavior. In the cycle of sex addiction, shame serves as both a precursor and a consequence of sexual acting out. Raising public awareness regarding the nature of sex addiction can help combat this shame.

Rather than conceptualizing compulsive sexuality as a moral failing, the addiction model provides a framework to empower clients to manage their condition while offering effective tools for recovery. Controversy may always exist regarding the conceptualization of sex addiction, but it is imperative to continue the conversation, increase empirical evidence and engage in advocacy efforts to serve and support this population.

 

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

Amanda L. Giordano is an assistant professor at the University of Georgia. A licensed professional counselor, she specializes in addictions counseling and multiculturalism. Giordano serves on the executive board for the Association for Spiritual, Ethical and Religious Values in Counseling and the editorial review boards for the Journal of Addictions & Offender Counseling and Counseling and Values. Contact her at amandaleegiordano@gmail.com.

Craig S. Cashwell, a professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, is an American Counseling Association fellow. Additionally, he maintains a part-time private practice focusing on couple counseling and addictions counseling. He serves as editor-in-chief of Counseling and Values.

 

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.

It’s not about ‘clean’: Dismantling the language of HIV stigma

By J. Richelle Joe and Sarah B. Parkin June 5, 2018

Words matter. The language we use when discussing sensitive, controversial or stigmatized topics reflects and shapes our attitudes and beliefs about those topics. Such is the case with HIV and AIDS. Since being widely identified in the 1980s, HIV and AIDS have been perceived negatively by the general public, resulting in the pervasive use of language that characterizes those living with the virus or the disease as undesirable and even dangerous.

The counseling context is not immune to such damaging language, and it is reasonable to infer that words have a powerful influence on mental health and counseling outcomes for people living with HIV. Counselors must beware of the power of language; outdated information about HIV and AIDS can intersect with the inadvertent use of stigmatizing language and undermine the ethical principles of nonmaleficence and beneficence that form the foundation of our profession. We also have a responsibility to actively oppose HIV- and AIDS-related bias and stigma by educating ourselves about HIV and AIDS and changing the language we use when discussing them.

Let’s start by offering a quick guide to HIV and AIDS terminology:

  • HIV: Human immunodeficiency virus; people can be diagnosed with HIV and not have an AIDS diagnosis
  • AIDS: Acquired immunodeficiency syndrome; caused by HIV
  • CD4 cells: Cells that are a part of the body’s immune system; also known as T cells
  • Viral load: The amount of HIV particles in the body
  • Opportunistic infections: Illnesses, including certain types of cancer, that occur more often when someone has a weakened immune system
  • ART: Antiretroviral therapy, a common treatment for HIV
  • PrEP: Pre-exposure prophylaxis, daily medication that can reduce one’s risk of contracting HIV
  • PEP: Post-exposure prophylaxis; prescribed use of ART within 72 hours of a possible exposure to HIV
  • Viral suppression: When the amount of HIV particles in an individual’s system decreases to the point that the virus is not detectable by current tests; occurs when an individual is adherent to treatment; also known as having an undetectable viral load

The changing face of HIV and AIDS

In the United States, AIDS was originally called GRID (gay-related immune deficiency), and the illness was most commonly associated with gay white males. Although the name of the illness changed as it became apparent that minority sexual orientation was not a determinant of HIV transmission, AIDS continued to be viewed as a “gay disease,” with multiple layers of associated stigma.

Although the stigma remains, the demographics of individuals living with HIV have shifted and increasingly include women and individuals of color. According to the Centers for Disease Control and Prevention (CDC), women account for approximately 20 percent of new HIV diagnoses, and among African American women, the estimated lifetime risk of an HIV diagnosis is 1 in 54 (compared with 1 in 941 for white women). African American and Latinx communities are disproportionately affected by HIV and AIDS. This is largely as a result of social determinants of health such as access to accurate information, preventive methods and health care, which are influenced by geographic location, cultural and social beliefs, socioeconomics, and stigma about sex and sexuality.

As the demographics related to HIV and AIDS have changed since the 1980s, so has the scientific knowledge, leading to key advancements in HIV prevention, diagnosis and treatment. Today, people with HIV can live long, healthy lives, provided that they adhere to treatment and monitor other aspects of their health.

Unfortunately, much of what is commonly known about HIV and AIDS is outdated and inaccurate. For instance, recent surveys conducted by the Kaiser Family Foundation indicated that some Americans still believe that HIV can be transmitted via mosquito bites, shared eating utensils and toilet seats. Many Americans also instinctively associate HIV with death, despite critical advancements in HIV care.

HIV is not a death sentence. For individuals living with HIV, the key to their health is the strength of their immune systems as measured by their CD4 cell count and viral load. Ideally, the goal for people living with HIV is to have a high CD4 cell count and a low viral load. Fortunately, as a result of significant medical advances over the past few decades, individuals with HIV who are consistent in their adherence to ART can have a viral load that is undetectable. Studies have shown, and the CDC has affirmed, that individual with undetectable viral loads have almost zero chance of transmitting HIV to another person even if other protective measures are not present. Never before in the history of HIV and AIDS has there been such hope for HIV prevention generally and people living with HIV specifically.

Unfortunately, not all individuals living with HIV access care and have an undetectable viral load. According to the CDC, approximately 1.1 million Americans are currently living with HIV, with 85 percent of these individuals aware of their HIV status. However, only 62 percent of Americans living with HIV are engaged in care, and only 49 percent of individuals living with HIV have an undetectable viral load. Multiple factors, including public health policies and social determinants of health, contribute to these statistics.

Unaddressed mental health needs might also be at work. People living with HIV may experience adjustment difficulties, depression, anxiety and trauma — all of which can affect an individual’s willingness and ability to seek medical care and remain adherent to treatment. In the past, HIV care focused primarily on the medical needs of people living with HIV. Today, there is growing awareness of the need to address the psychological and emotional aspects of HIV and AIDS because those factors may affect overall wellness.

The power of language

Despite the hope that science has given us with respect to HIV prevention and treatment and the increased awareness of the need for mental health support for people living with HIV, the language frequently used to describe HIV and AIDS continues to bolster the stigma associated with the illness.

Whereas phrases such as “clean bill of health” are benign with respect to other illnesses, when used in connection with HIV and AIDS, they can have a much different connotation. For instance, use of the word “clean” to describe someone who does not have an HIV diagnosis can send the message that those who are HIV positive are somehow unclean and dirty, or even impure and sinful. But HIV is not about clean. Not having an HIV diagnosis is not a determinant of cleanliness or good moral character. Equally, having an HIV diagnosis has nothing to do with being dirty or having loose morals.

Similarly, referring to HIV “infections” rather than HIV diagnoses or transmissions conjures thoughts of contamination, impurity and even death. Simply put, the dichotomy of “clean” versus “infected” breeds stigma, negativity and hopelessness. These negative connotations make getting tested, disclosing one’s HIV status, discussing methods of protection, and accessing and staying in care more difficult.

When counselors inadvertently use stigmatizing language in reference to HIV and AIDS, they risk harming clients by perpetuating stigma and reinforcing barriers to both physical and mental health care. By reducing stigma through intentional language choices, counselors can better help individuals explore their options for entering care or identify potential barriers that may prevent them from staying in care in the future. Additionally, helping clients identify protective factors such as support systems, positive coping strategies and individual strengths can be beneficial to their growth and development.

Regardless of HIV status, and in the name of balance, it is also important for counselors to inquire about aspects of their clients’ sexual wellness when the topic arises. As previously mentioned, with clients who are living with HIV, counselors can discuss getting and staying in care. With clients who are not living with HIV, counselors can use psychoeducation to identify appropriate prevention methods, including PrEP, PEP and proper condom use.

 

 

Say this, not that

Recognizing the negative impact that stigmatizing language has on individuals is only the first step toward defusing the taboo of HIV and AIDS. The next step is to identify specific stigmatizing phrases and replace them with appropriate alternatives.

On a foundational level, counselors can make an easy change in their communication about HIV and AIDS simply by using person-first language. Saying “person living with HIV” rather than “AIDS patient” does several things. First, it builds the therapeutic relationship and helps to externalize the diagnosis rather than fusing it with the client’s identity. Second, person-first language decreases stigma by emphasizing the possibility of living, and living well, with HIV.

The use of “person living with HIV” rather than “AIDS patient” also reflects a more accurate understanding of the illness and its progression. Often, HIV and AIDS are used interchangeably, despite an important medical distinction between the two. For counselors, it is essential to accurately differentiate between an HIV diagnosis and an AIDS diagnosis.

An HIV diagnosis follows a reactive test for the HIV virus; however, a diagnosis of AIDS is given by a physician only if an individual’s CD4 cell count is below 200 or if the individual develops certain opportunistic infections. Given that effective treatment is available for individuals who have been diagnosed with HIV, it is likely that someone who is adherent to treatment will never receive an AIDS diagnosis. By ignoring the difference between these two diagnoses, a counselor might appear to be invalidating, deterministic and incompetent to a client who is living with HIV.

Additionally, the phrase “full-blown AIDS” needs to be retired from our collective vocabulary. This phrase — which bolsters fear, reinforces HIV stigma and conjures thoughts of death — is wholly inaccurate and is no longer used among medical professionals. Along the same lines, stating that someone “died from AIDS” is also unproductive and inaccurate. If HIV progresses to the point that an AIDS diagnosis is given, an individual is vulnerable to opportunistic infections, which could be fatal. Hence, an individual might die from an opportunistic infection or an AIDS-related illness but not from AIDS itself.

Accuracy in our language when discussing this particular illness is critical. Errors in our word choices can communicate misinformation and harm clients, adding to the barriers that often prevent clients with HIV from seeking medical and mental health care services.

Conclusion

Understandably, discussing HIV and AIDS can be awkward or uncomfortable for some individuals, including counselors. However, equipped with the right language, counselors can engage their clients in vital conversations about their sexual and mental health. By discussing HIV transmission rather than infection, we can destigmatize the illness and the conversation. We can disrupt the pervasive narrative that equates HIV and AIDS with death, uncleanliness and immorality. And most important, we can be bridges rather than barriers so that people living with HIV will feel encouraged and empowered to access care and live well.

 

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J. Richelle Joe is an assistant professor of counselor education at the University of Central Florida. Her work focuses on HIV prevention and culturally and ethically sound services for people affected by HIV or AIDS. Contact her at jacqueline.joe@ucf.edu.

Sarah B. Parkin is a master’s student in clinical mental health counseling at the University of Central Florida. Her research interests focus on intersectionality and marginalized communities.

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.