Tag Archives: shame

What’s left unsaid

By Lindsey Phillips January 3, 2019

A child discloses that her grandfather has been sexually abusing her, and the mother’s response is shock that his abuse didn’t stop with her when she was a child. This scene is not uncommon for Molly VanDuser, the president and clinical director of Peace of Mind, an outpatient counseling and trauma treatment center in North Carolina. As she explains, adult survivors of child sexual abuse often assume that the offender has changed or is too old to engage in such actions again. So, the abuse persists.

Concetta Holmes, the clinical director of the Child Protection Center in Sarasota, Florida, has treated clients with similar intergenerational abuse stories. “In that unresolved trauma … what has happened is now a culture of silence around sexual violence that is ingrained in the family,” she says. “That [affects] things like your feelings of safety, security [and] trustworthiness, and it reinforces that you should stay with people who hurt you.”

Kimberly Frazier, an associate professor in the Department of Clinical Rehabilitation and Counseling at Louisiana State University’s Health Sciences Center, acknowledges that people often don’t want to think or talk about child sexual abuse, but that doesn’t stop it from happening. The nonprofit Darkness to Light reported in 2013 that approximately 1 in 10 children will be sexually abused before they turn 18.

Because of the culture of silence that surrounds child sexual abuse, it is safe to assume that the true number is even higher. Cases of child sexual abuse often continue for years because the abuse is built on a foundation of secrets and fear, Frazier points out. Survivors frequently fear what will happen to them (or to others) if they tell, or the shame they feel about the abuse deters them from disclosing.

Societal norms can also diminish a survivor’s likelihood of disclosing. For example, society has for decades implicitly sanctioned sexual interactions between boys who are minors and adult woman, but it is still abuse, says Anna Viviani, an associate professor of counseling and director of the clinical mental health counseling and counselor education programs at Indiana State University. Holmes adds that gender stereotypes such as this can cause boys to feel as though they shouldn’t be or weren’t affected by sexual abuse, which is not the case.

“I think the biggest fallacy [counselors have] is that [child sexual abuse] is going to impact people from a particular demographic more than another,” Viviani says. “Childhood sexual abuse cuts across every demographic. I think the sooner we can accept that, the sooner we’re going to be better at identifying clients when they have this issue in their history.”

Putting on a detective hat

Identifying signs of child sexual abuse is neither easy nor straightforward. Part of the difficulty lies in the fact that the signs are not clear-cut, says VanDuser, a licensed professional counselor (LPC) and an American Counseling Association member. Regressive behaviors such as bed-wetting can indicate abuse, but they might also be the result of other changes such as a recent move, a new baby in the family or a military parent deploying, she explains.

VanDuser also warns that child sexual abuse is insidious because a lot goes on before the offender actually touches the child. “Childhood sexual abuse sometimes leaves no physical wounds to identify,” she says. Some examples of noncontact abuse include peeping in the window at the child, making a child watch pornography or encouraging a child to sit on one’s lap and play the “tickle game.” Such activities are part of the grooming process — the way that offenders build trust and gain access to the child.

In addition to physical signs such as bladder and vaginal infections, changes in eating habits, and stomachaches, survivors of child sexual abuse also demonstrate behavioral and emotional changes. One major warning sign is if the child displays a more advanced knowledge of sex than one would expect at the child’s developmental stage, VanDuser says.

Other possible behavioral signs include not wanting to be alone with a certain person (e.g., stepfather, babysitter), becoming clingy with a nonoffending caregiver, not wanting to remove clothing to change or bathe, being afraid of being alone at night, having nightmares or having difficulty concentrating. In general, counselors should look for behaviors that are out of character for that particular child, VanDuser advises.

Viviani, a licensed clinical professional counselor and an ACA member, also finds that people who have experienced child sexual abuse have higher rates of depression, anxiety, panic disorders and posttraumatic stress disorders.

Because the signs of child sexual abuse are rarely clear-cut, counselors must be good investigators, Viviani argues. In her experience, adult survivors present with an array of symptoms, including health concerns, relationship problems and gaps in memory, so counselors have to look for patterns to discover the underlying issue.

If counselors notice any of these signs, VanDuser recommends asking the client, “When did this problem (e.g., bed-wetting, cutting, nightmares, acting out in school) begin?” Counselors can then follow up and ask, “What else was going on at that time?” The answers to these questions often reveal the underlying issue, she notes. For example, if the client responds that his or her depression or vigilance to the environment began around age 12, VanDuser says she will dig deeper into the client’s family relationships.

Frazier, an LPC and a member of ACA, suggests that counselors can also look for patterns in a child’s drawing — for example, what colors they use, how intensely they draw with certain colors, or if they scratch out certain people or choose not to include someone — or in the choices children make with activities such as feeling faces cards (cards that depict different emotional facial expressions). When Frazier asked one of her clients who had come to counseling because of suspected sexual abuse to select from the feeling face cards, she noticed the client consistently picked cards with people wearing glasses. Frazier later discovered that the child’s abuser wore glasses.

For Frazier, becoming a detective also involves going outside of the office to observe the child in different spaces, such as in school, in day care or at the park. Frazier includes the possibility of outside observations in her consent form, so the child’s parent or guardian agrees to it beforehand. She advises that counselors should take note of whether the child’s behavior is consistent across all of these spaces or whether there are changes from home to school, for example. In addition, she suggests asking the parents or guardians follow-up questions about how the child’s behavior has changed (e.g., Has the child lost the joy of playing his or her favorite sport? Is the child withdrawn? Is the child fighting?).

Speaking a child’s language

Young children may not have the words or cognitive development to tell counselors about the abuse they have been subjected to. Instead, these children may engage in traumatic play, such as having monsters in the sand tray eat each other or being in a frenzied state and drawing aggressive pictures, VanDuser says.

“One of the most important things for clinicians to remember when they’re working with kids and abuse is that it’s really critical to be working within the languages that children speak,” says Holmes, a licensed clinical social worker and a nationally credentialed advocate through the National Organization for Victim Assistance. “Children speak through a variety of different languages that aren’t just verbal. They speak through play. They speak through art, through writing [and] through movement, so it becomes really important that clinicians get creative in using evidence-based practices and different modalities to talk with children through their language. … Talking in a child’s language allows them to feel like the topic at hand is less overwhelming and less scary.”

For example, children can use Legos to build a wall of their emotions, Holmes says, with counselors instructing clients to pick colors to represent different emotions. If orange represents sadness and red represents frustration and 90 percent of the child’s wall contains orange and red Legos, then the counselor gets a better visualization of what emotions are inside the child, she says.

Next, counselors could ask clients what it would take to remove a red brick of frustration or what their ideal wall would look like, such as one that contains more bricks representing happiness or peace. Counselors can also ask these clients to rebuild their Lego walls throughout therapy to see how their emotions are changing, Holmes says. This method is easier than asking children if their anger has decreased and by how much, she adds.

Frazier, past president of the Association for Multicultural Counseling and Development, a division of ACA, also finds that working with children keeps counselors on their toes. Children are honest and will admit if they do not like an intervention, so counselors have to be ready to shift strategies quickly, she says. For this reason, counselors need to have a wide range of creative approaches in their counseling bag. She recommends drawing supplies, play school or kitchen sets, play dough and sand trays.

With sand trays, Frazier likes to provide dinosaurs and other nonhuman figurines for children to play with because it helps them not to feel constrained or limited. This allows them to freely let a dinosaur or car represent a particular person or idea, she explains.

Frazier also recommends the “Popsicle family” intervention, in which children decorate Popsicle sticks to represent their family members and support systems. This exercise provides insight into family dynamics (who is included in the family and who isn’t) and allows children to describe and interact with these “people” like they would with Barbie dolls, she says.

Frazier advises counselors to keep culturally and developmentally appropriate materials on hand. For example, they should have big crayons for young children with limited fine motor skills, and they should have various shades of crayons, markers, pencils and construction paper so children can easily create what they want.

Being multiculturally competent goes beyond ethnicity, Frazier points out. Counselors should understand the culture the child grew up in and the culture of the child’s current locality because what is considered “normal” in one city or area might differ from another, she says. For example, in New Orleans, where she lives, people regularly have “adopted” family members. So, if a child from New Orleans were creating his or her Popsicle family, it wouldn’t be strange to see the child include several people outside of his or her immediate family and refer to them as “cousin” or “aunt,” even if they aren’t blood relatives.

Thus, Frazier stresses the importance of counselors immersing themselves in the worldview of their child clients. “You can’t be a person who works with kids and not know all the shows and the stuff that’s happening with that particular age group, the music, the things that are on trend and the things they’re talking about,” Frazier says. “Otherwise, you’ll always be behind trying to ask them, ‘What does that mean?’”

With adolescents, Holmes finds narrative therapy to be particularly effective, and she often incorporates art and interview techniques into the process. For example, the counselor could ask the client to draw a picture of an emotion that he or she feels, such as anger. Next, the client would give this emotion a name and create a short biography about it. For example, how was anger born? How did it grow up to be who it is? What fuels it? Why does it hang around?

Next, Holmes says, the counselor and client could discuss the questions the client would ask this emotion if it had its own voice. Then, the client could interview the initial picture of the emotion and use his or her own voice to answer the questions as the emotion would. The answers provide insight into the emotional distress the client is feeling, Holmes explains.

Frazier will do ad-lib word games with older children, who are often more verbal. While clients fill in the blanks to create their own stories, she looks for themes (e.g., gloomy story) or the child’s response to the word game (e.g., eager, withdrawn). 

Long-lasting effects

Unfortunately, the effects of child sexual abuse don’t end with childhood or even with counseling. “Children revisit their trauma at almost every age and stage of development, which is every two to three years,” Holmes notes. “That might not mean they need counseling each and every time, but they find new meaning in it or they find they have new questions … or new emotions about it.”

Viviani, VanDuser and Frazier agree that recovery is a lifelong process. As survivors age, they will have sexual encounters, get married, become pregnant or have their child reach the age they were when the abuse occurred. These events can all become trigger points for a flood of new physical and emotional symptoms related to the child sexual abuse, Viviani says.

Often, an issue separate from the abuse causes adult survivors to seek counseling. In fact, VanDuser says she rarely gets an adult who discloses child sexual abuse as the presenting issue. Instead, she finds adult clients are more likely to come in because their own child is having behavioral problems or because they’re feeling depressed or anxious, they’re having nightmares or they’re married and have no interest in sex.

Adults survivors often experience long-term physical ailments. According to Viviani, who presented on this topic at the ACA 2018 Conference & Expo in Atlanta, some of the ailments include diabetes, fibromyalgia and chronic pain syndromes, pelvic pain, sexual difficulties, headaches, substance use disorders, eating disorders, cardiovascular problems, hypertension and gastrointestinal problems.

Another long-term issue for survivors is difficulty forming healthy relationships. Because child sexual abuse alters boundaries, survivors may not realize when something is odd or abusive in a relationship, VanDuser says. For example, if an adult survivor is in a relationship with someone who is overly jealous and possessive, he or she may mistakenly translate that jealously into a sign of love.

Child sexual abuse can also affect decision-making as an adult around careers, housing, personal activities and sexual intimacy, Viviani notes. For example, one of her clients wanted to attend a Bible study group but didn’t feel safe being in a smaller group where a man might pay attention to her. In addition, Viviani finds that adult survivors sometimes choose careers they are not interested in just because those careers provide a safe environment with no triggers.

To help adult clients make sense of the abuse they suffered as children and move forward, Viviani often uses meaning-making activities and mindfulness techniques. She suggests that counselors help these clients find a way to do something purposeful with their history of abuse, whether that involves sharing their story with a testimony at church, volunteering for a mental health association or participating in a walk/run to raise awareness of suicide prevention.

Finding self-compassion

Survivors of child sexual abuse often blame themselves for the abuse or the aftermath once the abuse is revealed, especially if it results in the offender leaving the family, the family losing its home or the family’s income dropping, VanDuser says. One of her clients even confessed to thinking that she somehow triggered her child sexual abuse from her stepfather.

“Sometimes the worst part is the dread [when the child knows the sexual abuse is] coming eventually. So, sometimes a teenager will actually initiate it to get it over with because the only time they feel relief is after it’s done,” VanDuser explains. “Then they know for a while that they won’t be bothered again.”

Counselors often need to shine a light on survivors’ cognitive distortions to help them work through their guilt and shame, VanDuser says. She tries to help clients understand that the sexual abuse was not their fault by changing their perspective. For example, she will take a client to a park where there are children close to the age the survivor was when the abuse happened. She’ll point to one of the children playing and ask, “What could the child really do?” This simple question often helps clients realize that they couldn’t have done anything to prevent the abuse, VanDuser says.

Viviani takes a similar approach by talking with clients in the third person about their expectations of what a child would developmentally be able to do in a similar situation. She asks clients if they would blame another child (their grandchild or niece, for example) for being sexually abused. Then she asks why they blame themselves for what happened to them because they were also just children at the time.

“As you frame it that way, they begin to have a little bit more compassion for themselves, and self-compassion is something that’s so important for survivors to develop,” Viviani says. In her experience, survivors are hard on themselves, often exercising magical thinking about what they should or should not have been able to do as a child. “As we help them develop self-compassion and self-awareness, we see the guilt begin to dissipate,” she adds.

Regaining a sense of safety

Safety — in emotions, relationships and touches — is a critical component of treatment for a child who has been sexually abused, Holmes stresses.

Counselors should teach clients about safe and unsafe touches, personal boundaries and age-appropriate sexual behavior rules, adds Amanda Jans, a registered mental health counseling intern and mental health therapist for the Child Protection Center in Sarasota. Counselors can also help clients “understand that they are in charge of their bodies, so even if a touch is safe, it doesn’t mean they have to accept it,” she says.

Hula hoops provide a creative way to discuss personal space boundaries with clients, Holmes notes. Counselors can use hula hoops of different sizes to illustrate safe and unsafe boundaries with a parent, sibling, friend or stranger, she explains.

VanDuser helps clients engage in safety planning by having them draw their hand on a piece of paper. For each finger, they figure out a corresponding person they can tell if something happens to them in the future.

Counselors can also take steps to ensure that their offices are safe settings. Jans, an ACA member who presented on the treatment of child sexual abuse at the ACA 2018 Conference, uses noise machines to ensure privacy and aromatherapy machines to make the environment more comfortable. She also has a collection of kid-friendly materials, so if a child starts to feel dysregulated during a session, he or she can take a break and play basketball or color.

Likewise, if clients are hesitant to discuss the topic, Jans allows them to take a step back. For instance, she has clients read someone else’s experience (either real or fictional) rather than having them write their own story, or she has clients role-play with someone else serving as the main character, not themselves. This distance helps clients move to a place where they eventually can discuss their own stories, she says.

Another technique Jans uses to ease clients into writing and processing their own stories is a word web. Together, Jans and a client will brainstorm words related to the client’s experience and put the words on a web (a set of circles drawn on a paper in a weblike pattern). Jans finds this exercise helps clients get comfortable talking about the subject and, eventually, these words become part of their narrative.

VanDuser also suggests getting out of the office. Sometimes she takes child and adolescent clients to a store to get a candy bar. On the way, she will ask them what they are feeling or noticing. If clients say that someone walking by makes them feel strange, VanDuser asks how they would address this feeling or what they would do if someone approached them. Then they will talk through strategies that would make the client feel safe in this situation.

Taking back control

Survivors of child sexual abuse often feel they can’t control what happens around them or to them, Frazier says. So, counselors can get creative using interventions that return control to these survivors and make them feel safe.

Viviani helps clients regain some sense of control in their lives by teaching grounding and coping skills. “Coping skills are so important to helping them begin to trust in themselves again so that they have the skills to really uncover and deal with the abuse,” she explains.

In sessions, counselors can help clients recognize what their bodies feel when they are triggered. Then they can help clients learn to deescalate through grounding skills such as noticing and naming things in their current surroundings or reminding themselves of where they are and the current date, Viviani says. Rather than reliving the incident — being back in their bedroom at age 5, for example — clients learn to ground themselves in the here and now: “This is Jan. 10, 2019, and I’m sitting in my office.”

VanDuser highly recommends trauma-focused cognitive behavior therapy (TF-CBT) for work with survivors of child sexual abuse. TF-CBT is a short-term treatment, typically 12-16 sessions, that incorporates psychoeducation on traumatic stress for both the child and nonoffending parent or caregiver, skills for identifying and regulating emotions, cognitive behavior therapy and a trauma narrative technique.

For a creative approach, VanDuser suggests letting children use crayons and a lunch bag to create a “garbage bag.” She first writes down all the bad feelings (e.g., fear, anger, shame) the client has about the abuse. As the child finishes working on one of the bad feelings, he or she puts the feeling in the garbage bag. When all the feelings are in the bag, VanDuser lets the client dispose of it however he or she wishes — by burning it, burying it, throwing it in the actual garbage or some other method.

Jans and Holmes suggest empowering clients by giving them some control in session. For example, if clients are feeling sad, the counselor can remind them of the coping strategies they have been working on (perhaps progressive muscle relaxation and grounding techniques) and ask which one they want to use to address this feeling. The counselor could also list the goals of therapy for that day and ask clients which one they want to work on first, Holmes says.

Holmes acknowledges that clients may never make sense of the abuse they suffered, but counselors can help them make sense of the abuse’s impact and aftermath. For Holmes, this meaning making involves clients being empowered to reclaim their lives after abuse rather than being held hostage by it, realizing that trauma doesn’t have to define them and learning to be compassionate with themselves.

The hero who told

Holmes encourages counselors not to shy away from discussing child sexual abuse. “If clinicians hesitate, clients will hesitate. If the clinician avoids it, the client will avoid it,” Holmes says. “It’s the clinician’s responsibility to take the lead on this topic. Sexual abuse is so widespread in our society that we do our clients a disservice when we don’t incorporate sexual abuse histories into our [client] assessments.”

Typically, however, counselors are not the first person a child will tell about the abuse. Often, children first disclose the abuse to a teacher or other school personnel, and their reaction is crucial in ensuring that the child gets help, Viviani says.

Thus, she advises counselors to partner with schools and child advocacy organizations to educate them on what they should do if a child discloses sexual abuse. “They need to know what to do,” Viviani emphasizes. “They need to know what to say to support that child because we may not get another chance, at least until they hit college age when they’re not under that roof anymore, or we may never get that chance again.”

Counselors must also empower survivors of child sexual abuse. “They shouldn’t be waiting for the therapist … or their best friend to ride in and save them. We want them to be the hero of their own story,” Holmes says. “And how we do that is through finding ways they can start to recognize and make safe and healthy decisions about different pieces of their life, and we want to model that even within the therapy environment.”

The end result of TF-CBT is the child writing his or her own narrative of the sexual abuse. VanDuser emphasizes that no matter how the child’s sexual abuse story begins, it always has the same ending: the hero — the child — who told.

 

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

Letters to the 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.

Standing in the shadow of addiction

By Lindsey Phillips October 30, 2018

Theresa Eschmann, a licensed professional counselor (LPC) and addiction family specialist in private practice in St. Louis, experienced firsthand the power of denial in adult children of parents with alcohol use disorders. All her life, Eschmann had witnessed her mother struggle with this disorder, yet upon finding her mother dead with a bottle of alcohol in her hand, Eschmann’s first response was denial. She couldn’t believe that her mother’s alcohol use disorder had caused her death, initially insisting that someone must have poisoned her.

“I … took a chemical dependency proficiency certification to try to get some understanding of what killed her because it couldn’t have just been alcohol,” Eschmann says, explaining her thinking at the time. “Alcohol made you sick. It made you have delirium tremens. It made you see things. But it couldn’t have killed you.”

Denial is often a strong coping mechanism for adult children of parents with alcohol use disorders, says Lisa Kruger, an LPC and psychotherapist and the owner of Stepping Stone Psychotherapy in the Washington, D.C., metro area. “They have to deny any feelings of sadness or anger that they might have in order to survive,” she says.

This denial extends to adult children’s own potential struggles with substance use disorders. Keith Klostermann, an assistant professor in the Department of Counseling and Clinical Psychology and the director of clinical training for the marriage and family therapy program at Medaille College, had a female client whose father chronically abused alcohol, and her own drinking often led to fights with her boyfriend. One of these drunken fights resulted in her breaking her foot. Even so, she maintained a permissive attitude toward drinking and brushed it off as a recreational activity.

The client was firmly in denial and not yet ready to address either her experience of growing up around substance abuse issues or her own drinking habits, says Klostermann, a licensed marriage and family therapist and licensed mental health counselor who maintains an active practice in New York. Counselors may be eager to push clients to explore these issues, but Klostermann warns that discussing the implications of this childhood experience before clients are ready is a recipe for disaster. Taking that approach may lead to problems establishing a therapeutic alliance or cause clients to end counseling prematurely, he explains. Instead, he advises, counselors can help clients connect the dots and arrive at an understanding that their behavior makes sense based on their experiences growing up.

Asking the right questions

Being an adult child of a parent with a substance use disorder is not uncommon. According to the National Association for Children of Addiction, 1 in 4 children in the United States (or approximately 18.25 million children) live in a family with a parent who is addicted to drugs or alcohol. Yet, Eschmann, a certified master addiction counselor and a member of the American Counseling Association, says it’s her sense that asking whether clients grew up in homes where addiction was present is often skipped over in clinical assessments.

In addition, because these individuals have frequently learned to minimize, discount or deny the implications of growing up in a home with substance abuse, they aren’t particularly likely to seek counseling for those issues.

Being a child of a parent who abused substances “may be the elephant in the room, but that may not be what brings them in. They may not recognize it,” says Klostermann, an ACA member. “The stuff that happens to us when we were younger, a lot of times we carry with us, [but] we don’t even realize why we do the stuff we do. We just sort of do it out of inertia.”

Klostermann and Kruger say that many of their clients present with relationship problems, anxiety, stress, depression and substance use. Often, the counselors note, these issues result from growing up with a parent who had a substance use disorder.

The environment of walking on eggshells around a parent who is under the influence of a substance creates and breeds anxiety for the child, Klostermann explains. When the child becomes an adult and engages in stressful situations in college (e.g., exams) or at work (e.g., deadlines), the person’s anxiety can snowball, he adds. Likewise, they may struggle with adversity and withdraw socially because they find it difficult to navigate relationships. This isolation can lead to depression, which is a real challenge, Klostermann says.

Counselors can look for possible warning signs that their adult clients were exposed to substance abuse issues in the home as children, Klostermann says. For instance, clients might engage in avoidant strategies (e.g., using alcohol as a way to cope with stress) or have a permissive attitude about substance use (e.g., “I don’t drink much. I only have a 12-pack a day.”).

Kruger, an ACA member who specializes in the areas of depression, anxiety, posttraumatic stress disorder, trauma and addiction, had a male client who came to see her for help with relationship issues and high anxiety. In his intake paperwork, the client wrote that he drank nightly, so she asked him how many drinks he had in a week. “It was 50 to 60 a week,” he replied, “but now it’s only 20 or 30.” This response was a big red flag, yet he didn’t realize that his drinking was a problem, she says.

To help clients recognize unhealthy behaviors, Kruger often uses motivational interviewing techniques. For example, with this client, a counselor might ask, “How is drinking 20 or 30 drinks a week working out for you?”

If counselors see potential warning signs, Klostermann advises asking questions about current substance use patterns, previous substance use, parental substance use and family attitudes around drinking. For example, counselors might ask the following questions: What was it like growing up in your home? What does drinking a lot or having a good time mean to you? What does that look like? What are the holidays and celebrations like in your family? What is a typical family dinner or birthday party like?

“Substance use is built around so many family functions and gatherings and celebrations,” Klostermann says. So, if a client comments, “My parents liked to party,” counselors could follow up by asking the client to explain what that means and what the implications are for the client’s life (e.g., increased violence after a parent drank, embarrassment when a parent became intoxicated at a social event). Klostermann explains that these types of questions help clinicians gain a better understanding of not just the acute nature of growing up in an environment with substance abuse but also the context of it — for instance, whether parental drug use led to a more permissive attitude at home or whether the child adopted unhealthy coping strategies.

In addition, adult children often find it easier to talk about others rather than themselves, Klostermann says. By asking these types of nonjudgmental questions (e.g., “Did drinking like that seem to work out for your mom?”), counselors can help clients create insight and awareness by changing the frame of reference, he explains. This technique helps clients gain an understanding about not only the severity of their parents’ alcohol or substance use but also the emotional implications of that behavior, he adds.

After counselors establish that awareness, Klostermann says, they can connect it to the client’s present situation (e.g., “Does drinking affect your relationships or grades?”). He suggests that counselors could also try to educate clients by saying something along the following lines: “Given what you described about your [parent’s] history, it’s not uncommon for people that grow up in these homes to sometimes exhibit certain behaviors. Sounds like that might be happening for you.”

Counselors are “planting the seed [and] leaving the door open but also helping [clients] to connect the dots and understand this is what’s going on and here’s why,” he explains.

In addition to asking about clients’ personal and family substance use histories, Kruger often focuses her questions on clients’ relationships with their parents. These questions can help bring out emotions such as shame, guilt or anxiety that stem from being a child of a parent with a substance use disorder, she says.

Emotional and attachment wounds

“Adult children of alcoholics … have difficulty identifying and expressing emotions,” Kruger explains, “because when they were kids, they had to set aside their own emotions — maybe they had to care for their parents. … They didn’t understand what their emotions were because what they saw in their parents’ relationship was inconsistent presentation or organization of emotions between them and maybe even between the parent and child too.”

To help clients who are having difficulty expressing their emotions, Kruger provides a sheet that shows 50 visual representations of emotions and asks clients to name the emotions that describe how they are feeling. She says this activity, which she refers to as an “emotional cheat sheet,” is “a good springboard … for clients who really don’t have the language [for their emotions].”

Kruger and Eschmann find that codependency is another common issue for adult children of parents with alcohol use disorders. Because these adult children grow up being sensitive to the needs of their parents — even to the point of ignoring their own needs — they often engage in approval seeking, which leads to codependency, Kruger explains. This need for approval and to avoid conflict can result in these individuals seeking acceptance from others who do not treat them well, which causes lower self-esteem, she says.

Often, clients who are codependent will assume they are OK because they are not the ones causing problems, Eschmann observes. She questions clients on codependent behavior by asking about their controlling behaviors, approval-seeking behaviors, anxiety, and distortion around intimacy and separation.

For Kruger, it all comes back to attachment — how bonds are created and broken. Parents who struggle with alcohol use disorders are typically inconsistent in their parenting and in their show of emotion toward their children. As she points out, this can create attachment wounds and be stressful for children growing up under these circumstances. Children may be doubly affected because they still depend on parents for care and for getting many of their emotional needs met. At the same time, these children often aren’t in a position to fight or to flee elsewhere, she adds.

Counselors can help adult clients gain awareness of how their current relationship patterns are affected by their childhood experiences, Kruger says. One technique she finds helpful involves taking the client’s experiences and imagining how those experiences would be perceived on The Brady Bunch. As a member of The Brady Bunch family, Kruger explains, the client would notice instantly if a partner or spouse were abusive because of the contrast with the sitcom family. However, growing up in a stressful environment with one or both parents suffering from an alcohol use disorder tends to distort a person’s perceptions of what is “normal” or acceptable.

For example, having a parent who drank and was inconsistently present when the client was a child would affect the client’s ability to evaluate his or her current relationships. If the client has a partner who sometimes withholds affection or emotion, is manipulative and comes around only when he or she wants something, the client won’t necessarily notice any red flags because those are the circumstances and relationship patterns the client knows from growing up, Kruger explains.

Kruger also gives short attachment assessments and finds that these clients often present with anxious attachments. “In relationships, [they cater] to the other person because that attachment anxiety comes up and that need for approval keeps them in relationships” — including bad ones, she says.

To help clients see the connection between their view of themselves and their relationships with others, Kruger will have clients write out how they view themselves, how they view other people and how they view the world. Then, they will discuss how these views are created, how clients are perpetuating these views and how they would like to see themselves in relationships.

The exercise is particularly helpful for clients who find themselves in toxic relationships, Kruger adds. “It’s really rare [for] somebody in a toxic relationship [who is] being manipulated to say, ‘I see myself in high regard, and I think I’m great.’ It’s usually the opposite,” she says.

Making meaning of conflicted feelings

Another crucial part of adult children’s recovery is sorting through their conflicted feelings of love, disappointment, anger and shame. In fact, both Eschmann and Kruger find that shame and guilt are common presenting issues.

Children often feel that a parent’s situation is their fault, and they find it difficult to process these multilayered emotions, Kruger notes. They simultaneously feel disappointment in and love for their parent. For adult children, processing and making sense of these feelings is a substantial part of recovery, she explains. Counselors should acknowledge that shame piece and how clients have “put that burden on themselves and carried that burden with them throughout adulthood,” Kruger advises. 

“Shames translates to I am bad,” Kruger points out. “Even if [clients] don’t present it on the outside, they’re usually coming in with some pretty damaged self-esteem and are already judging themselves.” In part for that reason, she emphasizes the importance of creating a nonjudgmental atmosphere in counseling.

When self-esteem, thoughts and feelings are involved, Kruger uses cognitive behavior therapy techniques. She says she has experienced a good deal of success with an exercise that blends cognitive restructuring and emotion identification. In the exercise, clients look at a triggering event and then identify their negative self-talk and automatic thought, the feeling that this thought creates, evidence to strengthen this thought, evidence against this thought and a new thought that they can believe.

The exercise allows clients to recognize their negative self-talk and its consequences and enables them to reconfigure these self-demeaning thoughts in a way that is believable to them, Kruger explains. For example, clients might think that they are “bad” and list all of the evidence they have for that thought. Next, they could counter that thought with the fact that they recently got a raise at work. Finally, they could create a new thought that sometimes they do good things, Kruger says.

“These clients need validation,” Eschmann emphasizes. “They didn’t get it growing up.” Instead, she explains, the parent who was abusing alcohol or other substances has often discounted the adult child’s feelings and experiences.

Klostermann also stresses the importance of normalizing these clients’ emotions and experiences. These clients may not realize — or, in some cases, perhaps don’t want to realize — the impact on them of their parents’ drug or alcohol use, he says. He notes how difficult it can be for clients to verbalize that their parents had or have a drinking problem, especially if they maintain a glorified version of their parents. For this reason, counselors need to help clients understand that it is possible for them to love their parents while still recognizing that their parents made mistakes.

Kathleen Brown-Rice, department chair and associate professor in the Department of Counselor Education at Sam Houston State University, agrees. Counselors must keep in mind that the family member is someone whom the client still loves and cares about, she says. Counselors can give clients the “space to say that you can love somebody and also be disappointed by their behaviors. You can love someone, and they can love you, and they can still hurt you,” she says. “[It’s] helpful for clients to understand that it’s more complicated than just [their parents are] bad or they don’t love [them].”

Eschmann helps clients focus on unresolved grief, which is common for adult children who grew up with parental substance abuse. Adult children are often hesitant to admit that their mom left them alone all night with a stranger or that their father came home drunk and had violent arguments with their mother, Eschmann says. They might not want to admit that these past events are why they get triggered today during certain situations.

“[Clients] have to accuse before [they] can excuse,” Eschmann asserts. “They have to go back and [ask], ‘What happened to me?’ This isn’t about [the parents] anymore. It’s about [the client].” If clients become more aware of what happened to them and what kind of environment they lived in that made them fearful and anxious today, then they can start healing, she adds. 

Mindful resilience 

Adult children who grew up in the same environment with substance abuse can respond very differently. One person may be angry, whereas another may be empathetic, and still another may end up also struggling with a substance use disorder. This raises the question of why some adult children of parents with alcohol use disorders are more resilient than others.

Resilience is “critical in terms of shaping kids’ development as they transcend into adulthood in terms of the choices that they make and the way that they deal with stress and conflict,” Klostermann points out. Based on his clinical experience, Klostermann suggests that having other healthy outlets (e.g., extracurricular activities such as sports, positive role models such as grandparents) and an ability to contextualize what is happening help to foster resilience.

Brown-Rice, an LPC and a member of ACA, acknowledges that there is more than simple genetics at play with resiliency. “Resiliency is not a moral characteristic. It’s a function of our brain,” she says. It’s “how our brain controls for those genetics … how that resiliency comes in and how we support that.”

Recently, she, along with Gina Forster (a lecturer in the Department of Anatomy at the University of Otago) and several other colleagues, conducted a study funded partly by a grant from the Center for Brain and Behavior Research at the University of South Dakota on college students who had similar experiences of being adult children of parents with substance use disorders. The participants identified as either engaging in risky substance use (the vulnerable group) or not engaging in risky substance use (the resilient group).

“Overall, their experience being raised by a parent who met the criteria for having a substance use disorder appeared similar,” says Brown-Rice, who presented the findings at the ACA 2017 Conference in San Francisco. However, “vulnerable individuals had lower scholastic performance … [and] reported poor overall psychological, physical and social health and more polysubstance use.”

The study also revealed another difference: The vulnerable group had a short allele of the serotonin transporter gene, which meant they were more likely to react to stressful events. “[This group] had a reduced uptake of their serotonin, which can increase depression and stressful life events,” explains Brown-Rice, associate editor of the Journal of Addictions & Offender Counseling.

Brown-Rice and the other researchers also measured brain activity while the participants viewed positive images (e.g., a cuddly bear), negative images (e.g., a crying baby) and neutral images (e.g., a chair). They found that the vulnerable group had altered brain activity when processing negative images. This group recognized the negative image but refused to store it, Brown-Rice explains.

Brown-Rice hypothesizes that this refusal to store negative images is an important factor in resiliency levels. To illustrate, imagine that you are walking outside and see a stick. Initially, your brain may think that the stick is a snake, so you jump back. As Brown-Rice explains, when you first see the stick, the amygdala activates and warns you because it looks like something that the brain remembers could hurt you. But after taking a closer look (i.e., storing the image), you realize it is just a stick, so you relax.

Resiliency depends on our ability to realize that the stick is not a snake. Some people, however, may be more likely because of brain functioning or genetic variations to see the stick and just react by running, Brown-Rice says. Thus, counselors can help certain clients by nurturing the parts of the brain that activate during stressful situations, she explains.

Brown-Rice incorporates this research into her clinical practice. She tells her clients that they have a resilient part of the brain — the prefrontal cortex — and that in session, they can work on controlling their brain and building their optimism and resiliency. She suggests that counselors use mindfulness techniques, such as guiding clients in breathing exercises and finding a safe place to go when triggered, because mindfulness is effective in calming the amygdala, which activates during stressful events.

Consistency also helps promote clients’ resiliency, Brown-Rice notes. If counselors are inconsistent, she says, that will put clients on edge.

Klostermann agrees. He finds that having a clear agenda helps to create a sense of safety and build rapport with clients. He informs them about his clinical approach and what to expect during the session and tells them there is no assumption on his part that they will schedule another appointment.

Kruger recommends using clients’ resiliency to help strengthen their internal sense of self. After all, she points out, adult children of parents with alcohol use disorders have already developed survival strategies, such as caring for siblings in areas in which the parent was lacking.

Instead of simply telling clients that they have strengths, Kruger uses motivational interviewing, which allows clients to identify and recognize their strengths themselves. For example, rather than telling a client, “You seem to be good at your job,” she might ask, “In what ways are you praised at your job?” This question helps clients reach the conclusion themselves, which builds their internal positive regard.

One more piece of advice for working with adult children of parents with substance use disorders: Counselors shouldn’t be afraid to change their approach if it’s not working. For example, Brown-Rice says, research has shown that people who have a short allele for serotonin may be resistant to cognitive behavior treatment. “If clients are not responding, we have to think maybe we need to change,” she says. “Maybe we need to move. Maybe we need to [incorporate] some of these mindfulness techniques. Maybe we need to do something else.”

Sometimes, it may be the counselor, not the client, who is being resistant, she stresses.

Halting the domino effect

The desire to get treatment for someone with a substance use disorder often overshadows the way that addiction affects the person’s family and others who care about the person. It shouldn’t.

In her educational video on addiction in the family, Claudia Black, an expert in addiction, highlights a child’s drawing of his experience living in a home where substance abuse is present. The child draws images of dominoes and writes, “Alcohol and drugs are like dominoes. They knock down the person, who knocks down everyone, including themselves.” The child’s words illustrate the way that addiction permeates and affects the entire family, not just the person with the substance use disorder.

For the first two years after her mother died from alcohol-related causes, Eschmann found herself crying repeatedly. Her grief and denial led her to learn more about chemical dependency, addiction and adult children of parents with alcohol use disorders. Counselors need to understand that the family has an emotional illness as well, Eschmann emphasizes. This illness is just as progressive as what the person with the substance use disorder is facing, she adds.

Brown-Rice reminds clients that they are not responsible for their substance use issues, but they are responsible for how they respond to these issues. For adult children of parents with substance use disorders, this means learning how their childhood experiences affect their current behaviors and choices.

Adult children of parents with substance use issues often feel isolated. Support groups such as Al-Anon and Adult Children of Alcoholics are helpful because they provide opportunities for people with similar experiences to share their stories and come to the realization that they’re not alone, Kruger says.

Counselors should also help clients understand that their parents’ substance use is not their shame to carry and substance abuse is not a legacy that they have to repeat, Brown-Rice says. Then, clients will realize that choosing a different path doesn’t mean that they are being disrespectful or dishonoring their parents, she explains.

The hope is that this different path will stop the domino effect of addiction, shame, depression and pain.

 

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

Letters to the 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 #MeToo

By Laurie Meyers August 31, 2018

In 2006, activist Tarana Burke founded the “me too” movement — a grassroots campaign to help survivors of sexual violence, particularly young women of color from low-wealth communities. Over time, the movement with a simple message — you are not alone — built a community of survivors from all walks of life.

In fall 2017, in the wake of allegations of sexual assault and harassment by film producer and entertainment mogul Harvey Weinstein and other powerful men, “me too” went viral — and global — with a single hashtag. Social media feeds were suddenly flooded with #MeToo, sometimes accompanied by personal stories or alternately issued as a statement in itself.

In the year that has followed this mass call for awareness, stories of sexual harassment and assault have continued to come to light. The discussions about how to achieve safety and equality show no signs of flagging. Some of these conversations are happening in counseling practices as counselors help clients process their own #MeToo stories.

For licensed professional counselor (LPC) Sarah Kate Valatka, a private practitioner in Blacksburg, Virginia, the most striking element of #MeToo has been the sense of community — albeit an unchosen one — the movement has created for survivors. That feeling of community not only helps clients feel less isolated but also engenders hope as they see other survivors navigating their own trauma, says Valatka, an American Counseling Association member whose practice specialties include addressing gender-based violence.

Other counselors say the movement is encouraging women who previously chose to remain silent about their experiences to seek help. “I absolutely believe this has empowered more women to come forward,” says Brooke Bagley, an LPC at the Sexual Assault Center of East Tennessee in Knoxville. “I have heard the narrative repeatedly — that many have been scared, isolated or unsure of the legitimacy of their own traumas, and this movement has given these individuals a voice.”

Indeed, Bagley says although the practice where she works has not seen a substantial increase in new clients, a number of people who had not previously thought of themselves as survivors have come in looking for help to process their experiences.

Charity Hagains, a licensed professional counselor supervisor who specializes in sexual trauma, says she and other counselors at the Noyau Wellness Center in Dallas have seen many new clients seeking help not for assault but for experiences they are just now realizing had crossed the line into sexual harassment. Hagains says she has commonly heard statements from clients such as, “It never occurred to me that this [behavior] wasn’t OK. Every boss I have ever had commented on my body.”

Hagains says the #MeToo movement has also caused many adult women to reconsider their younger experiences. Typical incidents these women have shared in session with Hagains include being pressured to show their bodies in a chatroom when they were preteens or being coerced into having sex as teenagers. At the time, they didn’t consider it coercion because they thought they were old enough to consent or had been drinking and thus excused the other person’s actions.

“It always made me feel awful,” clients have told Hagains. “I was ashamed, but I didn’t realize that it was something that other people would see as not my fault.”

Conversations such as these — both inside and outside of counselors’ offices — are long overdue, asserts Laura Morse, an LPC who specializes in relationship and sexual issues, including assault and trauma. Telling these stories has served to highlight how often sexual assault occurs, but clients are grappling with what comes next, she says.

“So much of the counseling journey with sexual assault survivors is figuring out the ‘and’ after identifying with #MeToo,” says Morse, a private practitioner in Lancaster, Pennsylvania. “Empowering individuals after assault to write their narrative, decide their legal choices and how or if they want to share their story, that’s the part of the conversation that #MeToo leaves us grappling with as a community.”

Moving on from #MeToo

The journey to healing from sexual trauma often begins with defining what has happened to the client, Bagley says. Using psychoeducation, she talks to clients about what constitutes sexual assault or harassment. She also explains common reactions and responses to sexual trauma. Once clients have a better understanding of what they have experienced, Bagley says she can delve into how their trauma is manifesting and work toward the management of symptoms.

Shame and guilt often accompany sexual assault and can be difficult to move past, says Trish McCoy Kessler, an LPC and owner of Empower Counseling, a practice in Lynchburg, Virginia, that focuses on the needs of women and girls. She starts by normalizing what clients are feeling and emphasizing that the sexual violence or harassment they have experienced is not their fault.

Kessler, a member of ACA, uses cognitive behavior therapy to help clients note when they experience a negative emotion and identify the thoughts that are evoking that feeling. She then challenges those thoughts, asking clients to consider whether any evidence exists to support their negative self-talk. Simply instilling hope in clients that their feelings of shame and guilt will lessen over time can help reduce their anxiety and stress, Kessler adds.

Kessler also focuses on coping skills with clients, she says, because many people who have experienced trauma use maladaptive coping skills such as substance abuse and emotional eating. Kessler teaches clients to instead use positive skills such as meditation, reaching out to friends (to avoid isolation), listening to music and writing or journaling. She has found it especially helpful to suggest that clients (and particularly teen clients) keep a list of effective coping skills on their phones to refer to when they are feeling overwhelmed. Kessler also emphasizes the importance of self-care, including getting adequate sleep, getting the proper nutrition and engaging in regular exercise.

Hagains notes that many of her clients lack compassion for themselves. She encourages them to identify as survivors rather than victims and attempts to teach self-compassion by holding a mirror up to the compassion that her clients show to others. For example, Hagains asks clients to consider what they would say to a friend going through the same experiences. “It’s usually not something like, ‘You’re awful,’” she notes wryly. “If you would give your friend a hug, give yourself a hug,” she urges.

Hagains also asks clients to identify the shame statements that they tell themselves. Then she helps them create positive, affirming messages to replace the negative self-talk.

Over time, Bagley has created a five-phase model that she uses for clients who have experienced sexual trauma. In the first phase, she assesses and identifies the client’s level of trauma through a symptom-based checklist. She then explores the emotional, cognitive, physiological and behavioral responses the client is experiencing.

Phase 2 focuses on building rapport and establishing the therapeutic relationship. Because clients who have experienced trauma are very vulnerable, it is imperative to provide a nurturing and safe environment, Bagley emphasizes. Once she has established a bond with the client and a sense of safety, Bagley focuses on the person’s present strengths and explores how the client can use those strengths to cope with the trauma.

Bagley begins cognitive-based interventions in Phase 3. Together, she and the client identify thought distortions attached to the trauma and start practicing ways of reframing negative beliefs.

In the fourth phase, Bagley focuses on identifying specific emotions. She teaches clients to practice mindfulness by noting where on their bodies they feel certain emotions and what is happening around them when they experience these feelings. Bagley says this helps clients identify triggers and also aids in bridging the mind-body disconnect that can occur with recent sexual trauma.

In the fifth and final phase, clients build a narrative surrounding their trauma. “At this stage in the therapeutic process, clients should be displaying more stability and management of symptoms,” Bagley says. “This is often apparent through changes in the language clients use to describe their trauma experience, as well as a shift in self-view.”

At this point, Bagley has clients retell their trauma to desensitize their trauma response and to empower them to feel more in control of their story.

It takes a village

Morse often works with other professionals, including law enforcement, to help survivors of sexual violence. She tells clients there are different paths they can take as part of their treatment and asks them what makes sense or seems helpful to them. Some clients are empowered by learning about their legal rights, and the possibility of pursuing justice gives them a sense of agency. For other survivors, gaining strategies to manage anxiety is critical to their daily functioning, Morse says.

When clients choose to seek justice through the legal system, Morse offers to go to the police station with them and sit in on a meeting with detectives. Beforehand, she prepares clients by explaining that they will be asked numerous questions about what happened to them. She also educates them about how lengthy the legal process can be and the emotional toll it may take.

Many of Morse’s clients have experienced harassment at work, and in these cases, they often choose to file a complaint through their employer’s human resources department. To prepare these clients, Morse goes through their employee handbook so they fully understand the company’s harassment policies.

Morse also strives to help survivors of sexual violence feel safe again, which often requires connecting them with outside resources. She frequently recommends self-defense classes, noting that in many cities, there are now free classes offered for survivors of assault. In some cases, reestablishing a client’s sense of safety may require a change in phone number or residence.

For those who struggle with overwhelming anxiety, Morse is a big proponent of eye movement desensitization and reprocessing (EMDR), and she refers these clients to a certified EMDR practitioner. If anxiety and depression are impeding her clients’ daily functioning, she has them meet with a psychiatrist to explore the need for short-term medication management of symptoms.

Morse says group therapy can also be a crucial therapeutic tool because it provides a way for survivors to share their stories with others who have experienced sexual trauma. Many community agencies and YWCAs offer free groups, she notes.

Morse also emphasizes the power of just being there for clients. “Many survivors of assault reflect that the most helpful part of the therapeutic process is simply having someone to listen and believe them on their journey,” she says. “Oftentimes, we’ll spend several sessions talking through the details and allowing a woman to rewrite her narrative as an assault survivor.”

When #MeToo is painful

Although counselors generally say that the #MeToo movement is socially necessary and can be personally empowering, they also note that for some survivors, the constant reminders of sexual trauma can have an unintended adverse effect.

“The movement can often feel like a double-edged sword in terms of awareness for survivors,” Bagley says. Although many survivors are grateful that the truth of the widespread nature of sexual violence is being made evident, the sheer volume of stories can be overwhelming. “It floods social media, news outlets [and] radio programs, leaving little escape for survivors,” Bagley explains. “Additionally, the backlash and negative media response to the movement has … a triggering and negative impact.”

Valatka agrees. “You [a survivor] may be on social media, and it’s just a normal day. Then someone shares, and it’s bringing it into your day — bringing it to survivors when they weren’t planning for it.”

Shaina Ali, an LPC and owner of Integrated Counseling Solutions in Orlando, Florida, says that when clients who are survivors of sexual assault or harassment bring up #MeToo, she uses an existential approach. “How does this affect your story? What does this mean for you?” Ali asks clients.

Her intent is to help clients focus on how hearing these stories affects their progress. In some cases, clients realize that they have handled potentially retraumatizing information better than they thought they might, says Ali, who specializes in trauma work. For others, their reactions are an indication that they have more trauma work to do. Ali notes that some of her clients who had come to her for issues unrelated to trauma realized that the #MeToo stories mirrored their own experiences — experiences they previously hadn’t recognized they needed to talk about.

Because #MeToo and other news stories related to mental health — such as the recent suicides of Kate Spade and Anthony Bourdain — can potentially have an effect on any client, Ali always raises such topics in session. She says this serves two purposes: to check in and head off trouble before it starts and to give clients an opportunity to bring up experiences they haven’t previously been ready to share.

Sometimes the triggering comes from the casual conversation of people clients are close to, Hagains points out. As people talk about #MeToo, sexual assault and harassment survivors hear a lot of opinions being shared, some of which are full of blame. It is not uncommon to hear people say things such as, “Well, she went to his apartment, so she deserved it,” Hagains notes.

Hagains tells clients that in these cases, they need to set boundaries by telling friends or family members that they do not wish to discuss the topic and that they will have to agree to disagree. In certain cases, such as with casual Facebook friends, Hagains urges clients to decide how important it is for them to stay in contact. It may be in a client’s best interests to mute those who are making hurtful statements. Sometimes setting boundaries means limiting contact; other times it may become necessary to cease contact altogether. 

What are men learning?

The larger goal of #MeToo is to change the way that men and society as a whole see — and treat — women. Is it working?

Hagains says the topic is definitely coming up in sessions with male clients. She says that about 90 percent of the men she counsels have asked her about behavior — as in what is OK and what isn’t.

“I think a lot of men are reexamining their roles,” she says. Many of them are realizing that what they thought was appropriate or complimentary to women can actually be offensive.

A familiar refrain that Hagains hears in session from male clients who are grappling with the implications of #MeToo: “I thought women liked to be complimented on their bodies.” She responds by telling them that it might be OK to say in a bar but definitely not at work.

Ali, an adjunct professor at both Central Florida University and the Chicago School of Psychology, has also heard increased discussion from men about the topic of sexual assault and harassment, both in her practice and in the classroom. Ali teaches clients and students about harassment, setting boundaries and establishing healthy relationships.

“The way I see it,” says Kessler, “is that #MeToo is not just for women. I want men to see, this is how you treat women.”

 

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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)

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

  • “Adult Child Sexual Abuse Survivors” by Rachel M. Hoffman and Chelsey Zoldan
  • “Intimate Partner Violence — Treating Victims” by Christine E. Murray

 

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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.

In search of an affirming faith

By Laurie Meyers July 25, 2018

One of Cyndi Matthews’ most vivid memories of growing up in a fundamentalist Christian church was watching the minister point at her brother’s best friend during a service and say, “You don’t belong here. Get out.” The reason? The boy was gay.

Matthews, a licensed professional counselor supervisor (LPC-S), says that incident was her first glimpse of a pattern of spiritual abuse directed at congregation members who identified as lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ). The animosity that leaders of the church held for LGBTQ members did not fit Matthews’ conception of Christianity. This religious cognitive dissonance would lead her to leave the church and subsequently focus her research and counseling practice on spiritual abuse.

Matthews, a member of the American Counseling Association, sees many LGBTQ clients in her Garland, Texas, private practice who struggle to reconcile their religious beliefs and experiences with their affectional orientation or gender identity. Many of these clients grew up internalizing a message that it wasn’t just their identity or orientation and behaviors that were wrong, but that there was something “wrong” with them as people, she says.

The LGBTQ community has frequently encountered intolerance from religious institutions. Although there are religious traditions that are affirming and open to LGBTQ people, many are not, says Misty Ginicola, lead editor of the book Affirmative Counseling With LGBTQI+ People, published by ACA. Nonaffirming religious groups usually have markedly rigid beliefs — there is wrong and there is right, and nowhere in between, she says. These are the voices that call for anti-LGBTQ legislation under the guise of exercising their religious freedom. As a result, even LGBTQ individuals who do not identify as religious are affected by nonaffirming religious beliefs, points out Ginicola, a member of ACA.

This conflict has produced not just a broader culture clash, but in some religious traditions, a pernicious history of rejection and outright abuse of LGBTQ individuals. Many of Matthews’ LGBTQ clients have been subjected to a wide range of religiously sponsored or endorsed abusive techniques intended to “cure” them. One client — a gay male — was not allowed to cross his legs or wear pink. He was directed to pray anytime he had “gay” thoughts and to replace “gay behavior” with Scripture reading or increased proselytizing. Other of Matthews’ clients were sent to church-sponsored “reparative” retreats where they were prayed over or even subjected to “exorcisms.” Matthews, an assistant professor of counseling at the University of Louisiana Monroe, has also been told about particularly horrific techniques such as forced ice baths and electroconvulsive therapy.

The emotional and even physical abuse that some LGBTQ individuals from strict religious traditions experience is so traumatic that Matthews says all of the survivors she has encountered in her practice were actively suicidal or had been suicidal in the past. At the same time, because clients from strict religious traditions have internalized the idea that what they are told in their churches is God’s word, it is often difficult for them to label their experience as abuse, she says.

Even LGBTQ individuals who break away from their religious traditions so they can fully embrace their affectional or gender orientation have a hard time discounting what they were taught. If someone who identifies as LGBTQ has been told from a young age that they are inherently wrong and immoral, it creates an inner message that lingers, says Ginicola, an LPC in West Haven, Connecticut, whose practice specialties include LGBTQ issues.

Brady Sullivan, a provisionally licensed professional counselor specializing in LGBTQ issues, has worked with clients who believed God hated them. “Every time they engage in sexual or romantic behavior or participate in pride activities, they feel an overwhelming sense of guilt,” he says.

Examining beliefs

Matthews says that, despite their experiences with spiritual abuse, some of her LGBTQ clients still want to find a way to reconnect with religion or at least retain a sense of personal spirituality. Others no longer want anything to do with religion; they come to counseling to untwine the message of being sinful or wrong from their sense of self and sexuality or gender identity.

The therapeutic relationship that is the core of counseling is especially crucial with clients attempting to navigate a conflict between their religious upbringing or current beliefs and their identity as LGBTQ, Matthews says. When people have been taught to seek comfort and strength from a religious tradition that then ends up rejecting them, it feels like a violation of trust, she says. Unfortunately, that sense of rejection can be further compounded when people in the LGBTQ community seek therapy from a practitioner who turns out to be nonaffirming. Matthews always asks clients if they have previously been in counseling and, if so, what that experience was like. This information helps her to address the therapeutic trauma that some LGBTQ clients have experienced.

Matthews screens for spiritual abuse as part of her intake process. She asks clients about their religious background and beliefs and if their experiences are something they would like to address as part of the counseling process. She says that LGBTQ clients from strict or fundamentalist religious backgrounds are highly likely to have experienced spiritual abuse, so the question usually isn’t “if” they will need to work through their experiences, but “when.”

These clients don’t always disclose or even perceive a history of spiritual abuse. However, counselors can look for a number of red flags, Matthews says. These include clients who:

  • Talk about how they are the cause of their own suffering and need to attend church more and to be more faithful and forgiving to alleviate their suffering.
  • Display magical thinking attached to “good” and “bad” behavior; they commonly believe that accidents, illnesses and other tragedies are the result of their “sinful” behavior.
  • Have a difficult time setting boundaries and saying no because of underlying guilt and shame.
  • Feel powerless to take action or make decisions because they fear repercussions from family members, church members, church leaders or their personal deity.

It is critical that counselors understand their role as helping professionals dedicated to providing a safe and affirming space for all clients, including those who are LGBTQ, says Ginicola, a professor of counseling and school psychology and coordinator of the clinical mental health counseling program at Southern Connecticut State University. Simply sitting with clients, supporting them in their pain and validating their experiences helps the healing process begin, she says.

Once clients are ready to talk about their conflicted views and feelings related to their sexual or gender identity and their experiences with religion, Matthews helps them explore the harmful beliefs they have been holding on to and works to dispel them. She is careful not to disparage clients’ faith traditions but does encourage them to question whether the condemnation they have been confronted with is actually the voice of God.

Lorrie Byrd Slater, a licensed professional counselor-mental health services provider in Chattanooga, Tennessee, who counsels many survivors of spiritual abuse, uses her knowledge of Christianity to help clients examine their beliefs. She urges clients whose religious communities have condemned or disparaged them to consider what the Scriptures say about the nature of Jesus Christ. She then asks them if their experiences are in line with Christ’s teachings. Slater, an ACA member, also reminds clients that their particular church is just one church out of many; other places of worship hold very different — and affirming — views of LGBTQ individuals.

Ginicola says cognitive behavior therapy is particularly helpful when confronting clients’ internalized beliefs that being LGBTQ is wrong or sinful. She asks clients to consider how those beliefs began and who taught them that they are inherently wrong. Ginicola exposes clients to religious viewpoints that are affirming to LGBTQ individuals through documentaries and bibliotherapy or putting them in touch with affirming pastoral help. She also encourages clients to explore a question for themselves: If God is love, as they have been taught by their faith communities, how could he hate them?

Practicing GRACE

Both Ginicola and Sullivan have found the GRACE model originally developed by counselor R. Lewis Bozard and pastor Cody J. Sanders — particularly helpful for guiding LGBTQ clients through the resolution of their conflicted religious views. Sullivan, who is practicing part time in addition to earning his doctorate in counselor education at the University of Missouri–Saint Louis, emphasizes that the model is just a guide, not a step-by-step process. For most clients, he uses only a few of the “stages.” The process involves:

  • Goals: Sullivan, an ACA member, talks to clients about their religious background, asking questions such as what faith tradition they grew up in (Christian, Muslim, Jewish, other) and whether they identify with a particular denomination or sect. He also asks how they feel about what they have experienced, both good and bad.

Ultimately, he wants to find out what clients are hoping to achieve by addressing the conflicts they feel between religious belief and who they are as a person. Sullivan asks: “If you woke up tomorrow and all these issues went away, what would that look like?”

As Sullivan guides clients through their background and goals, he stays alert for reactions, particularly any signs of trauma. If a client seems too upset in a particular session, he will back off and switch to another topic.

  • Renewal of hope: This stage involves uncovering shame and abuse and working through it, Sullivan says. For instance, some nonaffirming religious leaders individually confront LGBTQ congregants with questions about their affectional orientation or gender identity. These confrontations often take on the tone of an interrogation, culminating with  a reminder that “God hates those people.”

Sullivan tells clients that although a particular pastor might think that God hates LGBTQ people, many other religious leaders and faith communities do not hold that belief. If clients are amenable, Sullivan offers to help them make contact with an affirmative pastor to talk about religious views that do not condemn those who are LGBTQ.

  • Action: This stage represents decision time. Sullivan and the client have talked about the religious conflict for a while, and together they’ve processed the client’s trauma and grief. What does the client want to do now?

Sullivan says his role is to explain clients’ options to them and help them identify what they need to do to move forward. Some clients choose to remain planted in their current religious tradition, unready to move on from a community in which their spiritual roots were cultivated, even if that means continuing to wrestle with painful beliefs and practices. Other clients want to stay under the larger umbrella of their current religious faith but choose to find another church home or denomination that is more affirming of LGBTQ people. Still others decide to make a more drastic change, such as converting to a different faith system entirely. And, finally, Sullivan says, many clients decide that they no longer want anything to do with religion at all.

  • Connection: For some clients, processing their past experiences and finding a new place to worship isn’t enough, Sullivan says. Instead, they need to examine their personal relationship with God or whatever higher power they relate to. Ultimately, this involves clients identifying what God or that higher power believes about them and how that affects their view of their religion as a whole.

For instance, Sullivan might probe by asking clients what they believe God’s reaction is when they engage in sexual activity with someone of the same sex. He says that most clients are only able to develop the view that although they are sinning, God loves them anyway.

Sullivan does not like to end the GRACE process with this belief still intact. However, he says the pervasive sense of shame that many LGBTQ clients feel often makes it difficult for them to let go of the notion that living a life that embraces their true affectional or gender identity is sinful behavior. “It’s a struggle to get people to realize that God has made them this way and to accept that they are not sinners,” he says.

  • Empowerment: Sullivan acknowledges that he doesn’t see this stage achieved very often. It takes place only after clients have taken some kind of step such as attending a different church, joining a church-affiliated small group gathering or Bible study, or connecting with a church-sponsored social event, he says. Counselors have an obligation to help clients process these experiences, particularly if they are negative.

“The goal of the empowerment phase is to keep the client traveling down the path toward connection of spiritual and sexual identities, even if they have a negative experience,” Sullivan explains. “This is important because self-confidence and comfort with sexual identity are increased as a result of exploring the intersection between spiritual and sexual identities.”

In reality, Sullivan says, most clients who go through the GRACE model still struggle to reconcile their religion beliefs with being LGBTQ, but they are more at peace with the conflict.

Looking for aff irmative alternatives

One way that counselors can support LGBTQ clients who want to maintain their religious affiliation but feel conflicted is to help them find an affirming congregation, Sullivan says. However, he stresses that counselors must do their due diligence. It isn’t enough to read that the church is part of an affirming denomination or to see that it includes a rainbow flag on its website.

To ensure that he isn’t sending clients into a religious environment that appears affirming but actually isn’t, Sullivan makes a point of calling churches directly. He tells whoever answers the phone that he is a gay man and wants to know the church’s stance on the LGBTQ community. If the person tells him that he is welcome to attend the church and that the church will pray for him and support him in efforts to leave the gay lifestyle, Sullivan thanks them for their honesty but says the church is not for him. Although “welcoming” to LGBTQ people on the surface, churches that hold those types of beliefs do not make it on to Sullivan’s “recommended” list for clients.

Matthews notes that some faith traditions pose a specific and significant challenge to LGBTQ individuals who want to maintain a religious connection. Churches such as the Jehovah’s Witnesses and the Church of Jesus Christ of Latter-day Saints (the Mormon church) embrace particularism — the belief that their particular religious tradition is the only authentic path to God. These paths rest on tenets that are significantly different from what mainstream Christians believe.

For those raised in a church that embraces particularism (and is not affirming of LGBTQ individuals), pursuing their faith by switching denominations is akin to losing their religion entirely, Matthews says. When someone has been told all their life that there is only one path to becoming a Christian and gaining salvation, envisioning another form of faith and worship is almost inconceivable, she explains.

LGBTQ individuals struggling to align their personal and religious identities may look to their families for support. Unfortunately, families are sometimes part of the problem, Matthews says. Many families find it difficult to reconcile their religious beliefs with the reality of their child identifying as LGBTQ.

Matthews has worked with couples from strict religious backgrounds grappling with how to support a child who, according to what the parents hear in church, is living a sinful lifestyle. She provides these parents with psychoeducation by recommending books, giving them information about PFLAG (an advocacy and support organization for the friends, families and allies of those who identify as LGBTQ) and answering their questions, such as whether being LGBTQ is a choice. Matthews might also ask the couple to look for what the Bible actually says about being gay rather than relying solely on what their religious leaders say.

Counselors must also consider that particularly for LGBTQ people of color (POC) or those of low socioeconomic status (SES), leaving their religion behind may also mean losing their community, Ginicola says. “If you are a POC or have low SES, religion is not just a place you go sometimes; it could be a lifeline,” she says.

Losing a whole community can be devastating for anyone, but particularly for someone who has multiple marginalized identities, Ginicola continues. She gives the hypothetical example of a gay black man who, by coming out, loses his church. But when he turns to the LGBTQ community, he may encounter sporadic instances of racism. As a result, he ends up feeling like he is not fully accepted — and, thus, can never feel totally comfortable — anywhere.

Counselors need to let those with marginalized multiple identities know that counseling is one place where they can be fully themselves, Ginicola says. Counseling can encompass all of who these clients are — black, Christian, gay — without judging. Many people seem to think that they can identify either as LGBTQ or religious, but not both, Ginicola notes. She believes the idea that these two identities can’t coexist is harmful because faith — believing in something greater than ourselves, even if it isn’t a deity — is an integral part of life.

Given their negative experiences, some LGBTQ people lose all desire to return to organized religion. Regardless, spirituality can remain a significant part of who they are as people, says Slater, an assistant professor of counseling and associate dean of students at Richmont Graduate University. Spirituality is not the same as religion. In fact, an individual’s spirituality may not even encompass God. Spirituality is simply something that is bigger than us and that provides people with a sense of purpose, Slater says. For some people, that sense of spirituality and meaning can derive from nature, philosophy, personal ideology, science or even the belief in human rights for all, she explains.

Even when LGBTQ clients ultimately decide that they no longer identify with their past religious faith, Matthews tells them that it is possible to hold on to certain positive aspects and values of their religious upbringing that still resonate with them, such as practicing generosity and gratitude and loving others. Or, if these individuals previously enjoyed reading the Bible as literature, she might suggest that they explore other religious or spiritual texts outside of their faith tradition. If the ritual of prayer once provided clients with a sense of peace, she might encourage them to replace that experience with something nonreligious, such as a meditation practice.

Wearing blinders

Counselors who identify as religious know that imposing their values on clients is unethical, and most counseling professionals work hard to bracket their beliefs. Laura Boyd Farmer, an assistant professor of counselor education at Virginia Tech, has published numerous research studies on LGBTQ issues. She recently completed a research study that has not yet been published but that was presented at the 2017 ACA Conference & Expo in San Francisco. The study consisted of a survey that asked 455 mental health and school counselors how they thought their religious beliefs affected their work with LGBTQ clients.

Some respondents said that because their religious traditions were based on acceptance and the idea that Jesus loves everyone, their beliefs had a positive effect, helping them to provide LGBTQ-affirmative counseling. Other participants said their work was in line with their religious tradition, which calls on believers not to judge. Some counselors said that they disagreed with the LGBTQ “lifestyle” but chose not to judge. Others disclosed that their religious beliefs pose a conflict with which they struggle — striving to practice ethically despite their nonacceptance of LGBTQ individuals. Some respondents said that they agreed with the statement “love the sinner, hate the sin” and that this belief did not negatively affect their counseling of LGBTQ clients.

When counselors refuse to counsel LGBTQ clients because their religious beliefs tell them that doing so is wrong, that represents an obvious violation of the ACA Code of Ethics. But where things get tricky is with counselors who take a low-profile nonaffirming stance, says Farmer, an LPC who provides pro bono counseling for LGBTQ individuals in the Roanoke, Virginia, area. These are the counselors who say that they don’t agree with the “lifestyle” but wouldn’t refuse to counsel LGBTQ clients. These practitioners may think that no matter what their beliefs are, they can still maintain unconditional positive regard for their clients, but they might be operating with a big blind spot, Farmer contends.

To illustrate her point, she describes a recent casual conversation she had with a practicing counselor. This person talked about working with gay clients despite believing that being LGBTQ is a sin. The counselor said that they just tried not to judge. Farmer, an ACA member, asked how the practitioner was able to do that. Their response: “To be honest, it doesn’t come up.”

In providing counseling yet not fully accepting LGBTQ clients, this counselor was attempting to manage conflicts with their personal religious beliefs by avoiding pertinent topics. For example, Farmer says the practitioner was working with a gay youth struggling with depression, yet the challenges of identifying as LGBTQ “never came up.” Farmer says this makes her wonder how many other professional counselors are walking around wearing blinders.

Counselors like the one in Farmer’s story are not fully owning — or understanding — their bias, Ginicola says. A bias isn’t just, “I hate these people,” she explains. It’s also that working with someone who is LGBTQ doesn’t feel “right” and the counselor isn’t comfortable with it. By not confronting the discomfort, counselors are much more likely to miss signs (even if unintentionally), miscommunicate and project their worldview on the client rather than identifying the real issues, Ginicola asserts.

Disaffirming counselors resent that ACA’s ethics code requires them not just to set aside their personal beliefs to work with LGBTQ clients but to actually be advocates for them, Ginicola says. These counselors don’t view the experiences of LGBTQ clients as valid, she adds, and it is impossible to work effectively with clients unless you intrinsically embrace their value.

 

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Additional resources

To learn more about the importance of exploring aspects of religion and spirituality in clients’ lives, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Critical Incidents in Integrating Spirituality Into Counseling, edited by Tracey E. Robert and Virginia A. Kelly
  • Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice, second edition, edited by Craig S. Cashwell and J. Scott Young
  • Understanding People in Context: The Ecological Perspective in Counseling, edited by Ellen P. Cook

Journal of Counseling & Development (counseling.org/publications/counseling-journals)

  • “Psychological Safety and Appreciation of Differences in Counselor Training Programs: Examining Religion, Spirituality and Political Beliefs” by Amanda L. Giordano, Cynthia M. Bevly, Sarah Tucker and Elizabeth A. Prosek
  • “The Ways Paradigm: A Transtheoretical Model for Integrating Spirituality Into Counseling” by Joseph A. Stewart-Sicking, Paul J. Deal and Jesse Fox

Competencies (counseling.org/knowledge-center/competencies)

  • Competencies for Addressing Spiritual and Religious Issues in Counseling

ACA divisions

  • Association for Spiritual, Ethical and Religious Values in Counseling (aservic.org) and Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (algbtic.org)

 

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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.