Tag Archives: stigma

Pushing back against fatphobia

By Bethany Bray November 30, 2022

“I feel fat today.”

This is a phrase that Justine Trumbetas, a licensed professional counselor (LPC) in Pennsylvania, says she often hears from clients who live in bodies of all kinds of shapes and sizes. And this seemingly simple statement contains a lot for counselors to unpack with clients. 

More often than not, this thought stems from weight stigma or bias that the client has internalized from external sources. This can include anything from an offhand comment a friend makes about needing to work out to “earn” her slice of birthday cake to a medical doctor who advises weight loss for a presenting concern that is unrelated to the patient’s body size.

Trumbetas, who specializes in helping female clients with anxiety and body image-related issues, says that when clients use language such as “I feel fat” or “I feel gross,” she uses it as an opening to help them begin to recognize their emotions and negative thought patterns as well as how these thoughts affect their value and self-worth. The first step is to replace the word “fat” with a more factual, accurate word, she notes.

“I tell them that fat is not an emotion, so we can’t feel it. And we work to replace that, find the word they need … and tap in to what they’re feeling, [such as] defeated, let down, sad. And then we dig into why they feel that way,” says Trumbetas, an American Counseling Association member who has a counseling practice providing online sessions to clients in Pennsylvania and Florida. “There’s much more than feeling fat. There is a lot more underneath it. Are they comparing themselves to other people [or reacting to] something that they saw or heard from others? Typically, when we dig in, I find that their worth is tied to their body and how others view it.”

Pervasive weight stigma 

Thin bodies have been idealized and prioritized in U.S. culture and society for centuries. This shows up in everything from themes in advertisements and television to the overuse — and misuse — of the body mass index (BMI) as a benchmark for health by medical professionals and others.

Weight stigma carries the message that “there’s something wrong with your body simply because of the size of it,” says Jennifer DiGennaro, an LPC with a private practice in Grand Rapids, Michigan. And it’s traumatic for an individual to be bombarded by a lifetime of messaging that implies that their worth is tied to their body size or ability to lose weight, she adds.

“We live in an eating disorder culture and a body-shaming culture,” says DiGennaro, who specializes in helping clients heal from trauma, body shame and eating disorders. “We carry this myth that everyone can control their weight,” she continues, but “there are many, many, many reasons that someone is living in a larger body, and it may have nothing to do with what they eat or how much they’re moving.”

When talking with clients and colleagues, DiGennaro finds that using different words to name this phenomenon can help others understand the stigmas surrounding weight, depending on the context and their familiarity with the issue. Weight stigma can also be described as fatphobia, fatmisia, sizeism, weight bias, weight-based discrimination, fatism or size bigotry. No matter what it’s called, fatphobia is “thinking you know things about a person simply by the size of their body, and we don’t,” DiGennaro says. “And arguing on that point is reinforcing weight stigma.”

When unpacking and dismantling weight stigma, it’s important — both for counselors and clients — to consider the full context of the messaging they receive about weight loss, nutrition, body size and related issues, says Kaitlyn Forristal, an ACA member and licensed professional clinical counselor who studied fatphobia’s influence on diagnosis decisions made by counseling graduate students in her 2018 doctoral dissertation. This includes the fact that many companies stand to benefit from keeping this stigma alive and prevalent, she adds, noting that the weight loss industry in the United States was worth $72 billion in 2018.

Trumbetas says that nearly all her clients use language in sessions that indicates they have been negatively affected by weight stigma. This ranges from describing feelings of worthlessness to noting that they had a “bad” weekend because they indulged and ate a slice of pizza, she says.

Her clients have often internalized microaggressions and messaging they’ve received from a number of sources, but she finds that the most influential are social media, their family of origin and the medical profession. Many clients talk about being raised in an atmosphere where the adults were always on a diet roller coaster, Trumbetas says, so it was common for them to make comments such as “You shouldn’t be eating that.”

She has also worked with clients who have stopped going to medical appointments because they don’t want to be judged and have assumptions made about them based on their weight. Because weight bias is deeply embedded in the medical profession, some doctors’ initial and go-to recommendation for larger-sized patients is to lose weight without finding out the context surrounding what’s bothering them, she explains. 

Reconnecting to self

The counselors interviewed for this article agree that clients who have been negatively affected by weight stigma often need a combination of counseling work that focuses on quelling negative thought patterns, tolerating discomfort and reconnecting to a body that external forces have caused them to disconnect with and hate.

An important first step is educating clients on what weight stigma is and how prevalent it is in our society as well as offering the message that “your worth, your identity and your value is not in your appearance,” says Stephanie Dutson, an LPC who specializes in helping adult clients with trauma, anxiety and body image-related issues.

Dutson says she often emphasizes to clients that a body is for living in, not for looking at.

She finds that weight stigma often causes clients to feel guilt or shame about what they are or are not doing to maintain their appearance. And that guilt or shame “affects a person’s health so much more than an extra 20 pounds does,” says Dutson, who lives in Birmingham, Alabama, and has a counseling practice providing online sessions to clients located in Utah, Wisconsin and Alabama. “The research shows time and time again that social life, stress management and moving your body in a joyful way — not weight or size — are what promote health. Diet culture really squashed that intuition for most people, and [unlearning weight stigma] comes back to trusting themselves and finding connection to intuitive knowing.”

Many of Dutson’s clients have strong feelings of shame or disgust associated with their bodies, especially with parts that are often sexualized or idealized in popular culture and media (such as the abdomen, chest and arms), she notes. Dutson focuses on helping clients who feel this way regain comfort and feelings of safety with their body, including “tuning in” to parts of their body that they’ve “tuned out” or disconnected with because of weight stigma, she says. 

For example, she may ask a client to gently touch or look at parts of their body that they have tuned out (e.g., a soft belly post-pregnancy) in a mirror at home. Then Dutson processes the experience and emotions the client felt at their next session. She also encourages them to spend more time doing this exercise as they become increasingly comfortable with their body. The aim, Dutson says, is to help clients gradually reconnect to their body.

Many clients have such negative feelings associated with their body that they aren’t able to look at their entire body in the mirror at first. She encourages them to start small with a handheld mirror to view one part of their body, such as an arm or leg, and eventually add additional areas.

“I tell clients to expect some feelings of discomfort, but to try and find an area of the body or [amount of] time that is moderately uncomfortable while still tolerable so they don’t become flooded or overwhelmed,” she explains.

A powerful aspect of these exercises, Dutson notes, is helping clients recognize and begin to fully feel emotions — including discomfort — in their body. “I don’t know a client with body image issues that is entirely comfortable with their emotions because emotions are so often experienced within the body,” she adds.

Trumbetas also finds mirror work helpful, and often suggests that clients focus on learning to thank their bodies for its strength. She prompts clients to think of things that their body has done for them, such as allowing them to smell their favorite scent or heal from sickness or surgery.

This is quite a perspective flip for individuals who have harbored animosity toward their body for a long time, she notes.

If a client makes a comment such as “I hate my thighs,” Trumbetas says she would prompt the client to spend time looking in the mirror and thanking those thighs for getting them where they want to go and being able to do things like climb stairs or walk their dog.

“Being kind to yourself in this way can be a foreign concept,” she acknowledges. “I tell my clients consistently that to get comfortable, you have to become uncomfortable.”

As clients practice looking at their body in the mirror, she suggests they take an empowering stance she calls the “Wonder Woman pose.” To do so, the client meets their own gaze while standing with their hands on their hips, holding their head high, chest out and shoulders down. Trumbetas will model the pose for clients during sessions and encourages clients to try it with her. Standing in this way can decrease anxiety and boost confidence, she says.

Trumbetas says she receives a lot of positive feedback from clients about the Wonder Woman pose, and many report that it’s helpful to do whenever they’re feeling anxious or need to feel better about themselves and reconnect to their own power.

Identifying triggers

Reconnecting to oneself in counseling allows clients not only to better understand their own emotions but also to pinpoint how it feels when they are affected by negative messaging about body size and appearance, notes Dutson, an ACA member.

“Understanding the core emotion of what a trigger brings up for you gives you a better road map of how to deal with that emotion,” she explains. “Most of the emotions that come up around body image are disgust, shame, anxiety or guilt. And when clients have that [emotional] self-awareness, they can ask, ‘What is the core emotion that I’m feeling?” 

She then guides them to find ways to care for themselves when shame and other painful feelings arise, such as focusing on empathy and self-compassion.

For example, a client may be visiting an aunt who makes a comment that the client has gained weight since she last saw her or talks incessantly about her own weight loss behaviors or successes. Dutson will process this interaction with the client and prompt them to identify the emotions they felt and how they would like to handle a similar situation in the future.

She finds it helpful to prompt clients to track the moments that produce a visceral or intense emotional reaction regarding body size. Depending on the client’s situation and preference, she has them recount triggering situations to her verbally or write down details in a notebook or journal. She then guides clients to think about who was there, what was said, what emotions rose to the surface, what they were doing and feeling leading up to the interaction, and other aspects surrounding this triggering experience. Clients who reflect in this way eventually notice common threads of people or topics that activate them, she notes.

It can also be helpful, Dutson says, to suggest that clients write out a script or statements they’d like to use the next time they are in a triggering situation. Depending on where they are in their healing, this can include asking the other person not to talk about weight or body size in that way.

Trumbetas also helps clients identify and manage triggers, and one of the first things she does with clients who have been affected by weight stigma is to suggest they do an “audit” of their social media accounts to unfollow people and pages that spread body-negative messaging.

DiGennaro adds that helping clients talk about messaging related to weight stigma also requires counselor practitioners to suppress the urge to reassure or comfort clients who make statements such as “I feel like people are judging me.” A counselor’s role, DiGennaro emphasizes, is to be honest because people may very well be judging the client. Instead of offering reassurance, counselors can help the client unpack how they feel about such thoughts, recognize their origins and become intentional about the relationship they have with these thoughts and the way they affect their mental health, she says. Then they can help clients find and set boundaries to keep from internalizing harmful messaging going forward.

DiGennaro often helps clients plan for social interactions or family gatherings by guiding them to explore their values and identify what they are and are not willing to disclose or talk about.

“It’s a huge piece of healing work to first know what you need and want, then be able to put it into words and ultimately decide to share it with the appropriate people,” she says. 

DiGennaro sometimes invites clients to constructively use the anger they may feel about issues related to body weight and size. “There is a lot to be angry about with the way our bodies and feelings about food have been manipulated by diet culture,” she says. “One pattern I often see is when a client takes the unconscious anger evoked by weight stigma and turns it against themselves with punishing or chaotic food behaviors. So once the anger becomes conscious [through counseling,] I tell clients to channel that appropriately outward. Feeling and acknowledging rightful anger allows for the setting of essential boundaries to protect from further harm from weight stigma.”

Rethinking restriction

Helping clients identify and work toward goals is often an important part of counseling. But what if a client is focused on a goal to diet or lose weight?

The first thing to remember is that it is outside of a professional counselor’s scope of practice to advise clients on nutrition, exercise, weight loss or other topics related to physical health. (For more, see Section C of the 2014 ACA Code of Ethics at counseling.org/ethics.)

Weight loss is not a behavioral or mental health issue, DiGennaro stresses. Whenever a client mentions a goal of weight loss in a counseling session, she uses that opportunity to dig into why they want to set that goal — and what outside influences might have contributed. She uses motivational interviewing and asks questions such as “What would it mean to you if you lose weight?” to explore the client’s underlying reasons.

Knowing the reasons behind their weight loss goal will also help counselors determine the best approach for the client. Maybe the client says they want to lose weight because of negative comments they’ve heard from family members. “If you dig into it, they might be actually fine with their body, but they’re sick of hearing comments at family gatherings,” DiGennaro says. “In that case, we need to work on boundaries.”

Another client, however, may realize that their core reason for wanting a smaller body size is a desire to feel more confident. In that case, DiGennaro says she would focus on counseling techniques that boost the client’s self-confidence without attaching it to their weight or body image.

“Food and body issues are often the tip of the iceberg,” DiGennaro says. “I have never worked with a person who discovers their heart’s desire is to be thin. It’s always more along the lines of finding peace, receiving love and finding meaning in life.”

Similarly, Trumbetas says that when a client mentions in session that they’ve lost a certain number of pounds, she avoids praising or encouraging them, which would reinforce weight stigma. Instead, she responds with a question such as “How does that make you feel?” to explore the context of the client’s statement.

Trumbetas uses these conversations to emphasize that weight and health do not mean the same thing, and that “fixating on one aspect of health leads to unhealthy thinking,” she says.

Clients sometimes tell her, “If I can only lose this amount of weight, I’ll be happier.” But she reminds clients that being thin will not magically make them into someone they will love. Instead, she focuses on helping them learn to avoid comparing themselves to others and strengthen their self-love (both love of their body and their whole self).

DiGennaro is a certified intuitive eating counselor, so she also offers clients who talk about dieting psychoeducation on intuitive eating and explains that research indicates that most people who diet eventually gain the weight back, plus extra.

“Trying to control your body [via dieting] often comes from a place of punishment and restriction. I see it as ultimately a disconnection from self,” she says. “Instead, I help clients get curious about what it might be like to reconnect to themselves from a place of nourishment, self-care and truly listening to their body. And this is complex work because often … there were protective reasons they had to disconnect from their bodies and reconnection must be done in a trauma-informed way.”

DiGennaro acknowledges that this perspective shift does not come easily for clients, and it often takes many sessions before they begin to replace the unhealthy thought and behavior patterns they’ve adopted to cope with a lifetime of weight stigma.

Dutson also focuses on helping clients shift their perspective away from a restrictive view of taking things away (including food) to one that allows them to consider adding supportive elements to their life. To do this, she often prompts clients who are healing from the effects of weight stigma to identify and add things to their life that bring them joy, nourishment and comfort. This can be anything from dancing to their favorite song to connecting with a supportive friend.

There is so much more to wellness than body size, and the importance of social support is often one of the biggest contributing factors that clients overlook, especially those who have negative feelings about their bodies, Dutson adds.

“Asking ‘how can we add meaning, nourishment and joy to the body?’ is a more realistic and hopeful approach [to wellness] than restriction and taking things away,” she says.

Unlearning bias as a practitioner

Hilary Kinavey and Carmen Cool, co-authors of the 2019 Women & Therapy journal article “The broken lens: How anti-fat bias in psychotherapy is harming our clients and what to do about it,” note that researchers and mental health clinicians alike have reported on the “prevalence and negative implications of weight stigma in psychotherapy” since the 1980s.

“It is our lens, our gaze and the assumptions behind it that are the problem,” wrote Kinavey and Cool, who are both LPCs. “Diagnosis by sight is inaccurate and essentially biased. We simply cannot know who engages in overeating and who engages in restrictive eating based on the size and shape of the body in front of us. As professionals, it is our ethical duty to unpack and address this prejudice and to shift our focus and commitment to the human being who inhabits the body.”

The counselors interviewed for this article also recommend that counselors consider their own internalized weight bias to ensure they don’t inadvertently reinforce those biases in their interactions with clients.

“No one deserves to be treated badly because of their body shape, size or ability,” Trumbetas says. “If a counselor has their own negative views, they need to look inward and work on themselves — with another therapist if needed.”

Weight bias creeps into counseling, Dutson says, when a practitioner makes assumptions about a client based on their body size, such as how active clients are, how they feel about their body or what they might need to address in therapy. In turn, this can influence the questions clinicians ask (or don’t ask) and the issues they cover with the client.

staras/Shutterstock.com

“We have to recognize as counselors that we live in a society that values certain bodies over others, which can be ableist and elitist,” Dutson says. “We need to understand how marginalizing it can be to leave those beliefs unchecked. It’s not a stretch to say that our culture believes that certain genes, illnesses and conditions [that affect body size] are somehow inferior.”

Forristal, an assistant professor of clinical mental health counseling at New England College in Henniker, New Hampshire, agrees counselors need to do their own work to recognize and unlearn harmful beliefs about weight and body size. “Unless we intentionally and actively unlearn fatphobia the way we do with unlearning racism and other stereotypes, we are at risk for perpetuating this harm to our clients and communities,” she stresses.

A good first step counselors can take to combat this, Dutson says, is to decouple morality from food and body issues — both in the language counselors use in session with clients and in the way they think about things personally. This includes the questions a practitioner asks during the intake process with new clients, she adds.

Food is not good or bad, and it can be a comfort without inducing guilt. Counselors should refrain from talking about their own body or weight loss in sessions or asking leading questions of a client that reinforce weight stigma, Dutson says.

Instead, she advises counselors to borrow from mindfulness techniques and approach food and body issues from a nonjudgmental, observational lens. “We’d all benefit more from that,” Dutson acknowledges, “and modeling that for your clients is very powerful.” 

Forristal says that refraining from making assumptions — either positive or negative — about a client based on their body size or shape is a good start toward ridding professional counseling of weight bias. Weight stigma is a barrier to care and help seeking, so counselors who want to combat this should mention on their website and other promotional materials that eradicating fatphobia is a goal of their clinical practice, she adds.

In their article, Kinavey and Cool suggested that counselors ensure that their office space is accessible and welcoming to larger clients, which includes having chairs that accommodate a larger person comfortably and a waiting room that does not include decor or reading materials that reinforce fatphobia, such as fashion magazines.

Forristal also encourages practitioners to address any power imbalance that can affect the therapeutic relationship such as the counselor having a larger body than the client or vice versa. A client with a thin body, for example, may not feel comfortable reporting the extent of their issues with a counselor who is larger out of fear of offending them.

Counselors should not hesitate to check in with clients and ask how they feel about discussing body image issues with a practitioner who is a different size from them to ensure that they are comfortable, Forristal adds.

“We can never address these issues if we’re too uncomfortable or unwilling to broach them in the room with clients,” she says. “If a fat client expresses body image concerns to a thin counselor, the counselor can name that they hold privilege as a thin person and check in with the client about their reactions around that. Much like it doesn’t help to take a ‘colorblind’ approach when working with BIPOC [Black, Indigenous and people of color] clients, it isn’t helpful to ignore the differences in body size and power in the room.”

 

****

Resources for counselors who want to learn more:

  • The National Eating Disorders Association’s page on weight stigma: nationaleatingdisorders.org/weight-stigma
  • The Association for Size Diversity and Health: asdah.org
  • The National Association to Advance Fat Acceptance: naafa.org (Visit the “learn” menu to download a brochure with suggestions and guidelines specifically for therapists.)
  • Hillary Kinavey and Carmen Cool’s 2019 Women & Therapy journal article, “The Broken Lens: How Anti-Fat Bias in Psychotherapy is Harming Our Clients and What To Do About It”: org/10.1080/02703149.2018.1524070

****

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

****

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

Fatphobia: How can counselors do better?

Compiled by Bethany Bray November 23, 2022

Stop and think for a moment: Have you ever seen a plus-size Barbie doll or rooted for a romantic hero who wasn’t thin?

Kaitlyn Forristal, a licensed professional clinical counselor, poses this question to illustrate the way fatphobia and weight stigma saturate our culture and society.

“We are programmed from a very young age to associate fatness with bad things … [and] counselors are not immune from socialized viewpoints and messages,” says Forristal, an assistant professor of clinical mental health counseling at New England College in Henniker, New Hampshire.

It’s up to counselors, therefore, to examine their own feelings and assumptions about weight and body size to keep from passing them on to clients in therapy, she stresses.

Forristal studied fatphobia’s influence on diagnosis decisions made by counseling graduate students in her 2018 doctoral dissertation; fatmisia is an area of research and specialty for her. Counseling Today sent her some questions via email to learn more about how weight stigma can show up in the therapy room and what counselors can do to dismantle it — both in themselves and in their clients.

How might fatphobia and weight stigma show up in counseling? Misdiagnosis is one area, but what else?

Yes, misdiagnosis is a concern due to a societal belief that “obesity” is a medical disease. Aside from diagnosis and treatment, counselors are also at risk for projecting their own (potentially negative) beliefs about their bodies and health status onto their fat clients. Despite what a clinician may assume, many fat clients are comfortable in their bodies and have no intention of changing them.

It could also be dangerous for counselors to assume that a fat person’s presenting issues, such as body image struggles, anxiety, depression or other mental health concerns, will be alleviated if the client loses weight. It is likely that fat people have internalized fatphobia — a set of negative beliefs about themselves because they are fat — and believe that losing weight will help them to solve their problems. While this may be true to some extent, losing weight cannot repair relational issues or make up for [brain] chemical imbalances.

If a person is struggling with the stigmas associated with being fat, or expresses hatred of themselves for being fat, attempting to change their body is not the solution. We eradicate prejudice by addressing the socialization of fatphobia and working to make our society safer and more inclusive for everyone.

What would you want counselors to know about approaching the assessment and intake process in a nonstigmatizing way? How can counselors ask about weight or weight loss, eating habits, etc., without a client feeling they are being shamed or judged?

Using the same intake measures and assessments with both fat and thin clients is the best way to approach this; don’t assume that a fat person overeats or that a thin person exercises regularly.

Consider why you may want to ask about weight loss or eating habits: Is it to confirm your suspicion that a fat client doesn’t get enough cardio or because you [assume] that their weight loss/gain is a symptom of depression?

If a fat client reports on an intake form or during an interview that they struggle with self-esteem due to their body size, want to lose weight or have poor body image, counselors should address that the same way they would with a thin client. If a new client doesn’t mention struggling with these things but happens to be fat, they are probably there for other reasons and you don’t need to ask about weight loss or eating habits.

Counselors don’t need to be afraid to discuss body size, fatphobia and marginalization with fat clients, but they also don’t need to broach this with a client just because they think someone may have an issue solely because of their body size.

How might counselors be making assumptions that someone who doesn’t fit society’s norms for shape and size is unhealthy and/or somehow to be blamed for their challenges? How might this bias creep in without counselors realizing?

It is an unfortunate societal belief that we can tell someone’s health status by looking at them. We see this all the time with news coverage of the “obesity epidemic” (spoiler alert: fat people have always existed!) and dehumanizing b-roll [news footage] of [faceless] fat people walking around and living their lives.

Something that is really strange about society if you think about it is the notion that others’ bodies are for us to comment on or have an opinion about. How often do you see someone who has changed size (lost or gained weight) and made an assumption about them, whether they have “let themselves go” or are now healthier due to a smaller body? When you run into someone you haven’t seen in a while and they are smaller, do you automatically congratulate them or tell them how great they look? Each time you do this, you are making an assumption that they lost weight intentionally and that it is worth celebrating that there is now less of them.

There are many medical conditions that are often attributed to fat people (diabetes, heart disease, sleep apnea) that medical research doesn’t support. The average size person in the United States is “overweight,” so it is likely that many findings that fatness is a cause of these medical conditions are misinterpreted when fatness is correlated to these conditions. It is important to be good consumers of research and pay attention to who is putting out studies that demonize fatness (I’m looking at you, Weight Watchers!) and who the intended audience is.

Researching the history of the body mass index (BMI) can help as well. Considering that the BMI is still used in western medicine for pathology and treatment of patients is baffling and is not rooted in accuracy or health outcomes. The BMI is unnecessarily vague (e.g., “overweight” — over what weight?) and doesn’t account for muscle mass or many other confounding factors. Some of the most elite athletes in the world are “morbidly obese” according to the BMI.

It was never created to be used the way that it is now, and aside from the harmful labels it puts onto people’s bodies, it creates real issues for mental health care treatment. For example, due to the BMI categories, many fat people have difficulty receiving treatment for eating disorders, which is detrimental to client and community health and to the profession of counseling.

What do counselors need to do to check themselves and unlearn old patterns and assumptions about weight and body size? How can counselors do better?

Unlearning negative beliefs about fat people is a similar process to unlearning socialized beliefs about other marginalized identities (LGBTQIQA+ community, BIPOC [Black, Indigenous and people of color], disabled people). There is nuance to this in the United States as we are an individualistic society who believe that for the most part, people get what they deserve or work for.

Therefore, fatphobia falls into a category with other social issues like poverty where we feel more comfortable attributing blame to individuals that we believe can change their status if they only tried and worked hard enough for it. Poor people can just work harder or get better jobs to “pull themselves up from their bootstraps,” or fat people could lose weight if they only had more self-control. Obviously, neither of these things are true for the vast majority of people facing this discrimination, but the societal belief that we can change our circumstances continues to harm those in our communities.

Counselors can do better by speaking out about these things and advocating for the rights and dignity of fat people. It should come as no surprise that bias against fat people is rooted in racism and xenophobia.

Fatmisia is also rooted in capitalism; the weight loss industry was worth $72 billion in 2018. Selling weight loss programs, weight loss surgeries and weight loss-focused fitness programs is a business that is only viable because people buy into the notion that fatness should be avoided at all costs (literally).

Having this information is helpful for counselors to (a) reconceptualize the way they feel about their own bodies, (b) provide validation and psychoeducation for clients struggling with body image or other weight-related issues and (c) advocate for changes in the way that others in society view and relate to fat people.

How can counselors support a client who names weight loss as a goal in counseling? What should a counselor’s role be in this situation?

A counselor’s role is always to support their client in treatment, and there are many valid reasons for clients to want to lose weight: to be safer in society by living in a smaller body, because a family member has expressed concern for their weight, a medical provider suggests it for overall health, or as a requirement for a certain procedure, etc. However, counselors are not medical providers, physical therapists, dietitians, etc., and should refrain from providing any medical advice as this is outside of our scope of practice and unethical.

It can be easy to automatically support a client who wants to lose weight because we believe that a fat body is always an unhealthy one, but this is not the case and could cause harm. Most research on dieting shows that intentional weight loss does not work and that only 5% of dieters maintain their weight loss for an extended period of time; most dieters gain back the weight they lost and more due to the metabolic disruption of putting one’s body into starvation mode.

Counselors can, of course, ask about the reasons the client is bringing this up in session: Are they having body image concerns, experiencing disordered eating or relational problems? These are issues that counselors are trained and qualified to help with. Exploring these issues may reveal the deeper issue that a client has an eating disorder or is being verbally/emotionally abused by a partner. A counselor’s role in either of these cases would be to explore options for the client and set goals in treatment. If a counselor has training/knowledge in this area, this is a good opportunity to self-disclose their own body image concerns and ask the client if they would like [the counselor] to share with them some information about weight loss, the diet industrial complex, etc., that may help them reframe these issues.

What should counselors avoid doing or saying in sessions with clients to keep from harming them with weight stigma?

The easiest way counselors can know how to speak about clients’ bodies is by asking them! Some people prefer to describe themselves as fat because it is merely a descriptive word like tall, dark-skinned, etc. For others, there is such a negative connotation with the word fat (and a lot of harm associated with it) that they prefer other ways to describe themselves.

Counselors should avoid making assumptions about fat clients that they wouldn’t make about their thin clients, such as [whether] they overeat or binge eat, do not exercise enough, hate their body, etc. Practicing weight neutrality, or making no assumptions (good or bad) about a client’s weight or body size, is a great start.

It is also imperative that counselors resist the notion that fat people can or should lose weight to avoid stigma and marginalization due to their body size. We would not expect a little person to just grow taller to access the world with more ease, and we should not project this onto fat people either. Humans have always come in all shapes and sizes and being fat is just one way of having a body — it is that simple.

Michael Poley/canweallgo.com

****

See more on this topic in a feature article, “Pushing back against fatphobia” in Counseling Today’s upcoming December magazine.

****

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

****

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

‘Not a monster’: Destigmatizing borderline personality disorder

By Scott Gleeson October 3, 2022

Rose Skeeters, a licensed professional counselor in Eau Claire, Michigan, said she’s been in a room full of counselors who scoffed at the mention of treating an often-dreaded diagnosis: borderline personality disorder (BPD). 

The contemptuous response among clinicians is one Skeeters is used to. It’s also a common scenario that’s being replicated in private practices and agencies across the country. In a 2022 literature review of mental health workers’ attitude toward people diagnosed with BPD (published in the Journal of Personality Disorders), Karen McKenzie and colleagues found that mental health professionals have largely negative views of BPD — ultimately impeding proper treatment.

“BPD doesn’t just have a stigma in society; it’s in our profession too,” says Skeeters who was diagnosed with BPD in her early 20s before her mental health career fully launched. “Part of why I tell my story and experience with BPD is because it’s a diagnosis that is seriously misunderstood, and the mind of someone with borderline personality isn’t empathized with enough. There are clients out there struggling with this who need our help.”

Skeeters, who hosts the podcast From Borderline to Beautiful, is among a growing wave of clinicians who specialize in the treatment of BPD, which has become one of the most common personality disorders. BPD was first conceptualized as a mental illness by Otto Kernberg in 1975, and then it was officially introduced as a disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980. This disorder is characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self and strong emotional reactions. 

The high suicide risk and explosive emotional behavior often associated with BPD are among the many concerns that can prompt eyebrow raises among clinicians and a high referral rate. BPD is also frequently underdiagnosed, largely because it has varying and dynamic symptoms that can initially present as other disorders. Societal stigma doesn’t help either, with BPD being a diagnosis closely tied to hostile behavior in popular culture. During the recent controversial trial between former couple Amber Heard and Johnny Depp, for example, Heard was assessed and diagnosed with BPD by a forensic psychologist and portrayed as angry and impulsive, which was used as a way to discredit her by Depp’s legal team. 

Skeeters has the unique perspective of viewing this disorder from an “in recovery” client purview as well as from a clinical lens now as a professional counselor. She notes that despite the distorted perception of the diagnosis, recent research on the effectiveness of psychological treatments for BPD (such as Sophie Rameckers and colleagues’ article published in the Journal of Clinical Medicine in 2021) illustrates BPD to be highly treatable and the most healable among personality disorders.

“The biggest misconception about borderline personality is that it isn’t treatable,” Skeeters says. “It may be difficult to treat because emotions can rev up from 0 to 60 very quickly for someone with BPD, and in those moments, the logic of reality just isn’t there for that person. But this is not a life sentence and it’s not hopeless to get better. With proper treatment, clients can become self-aware and recover.” 

A trauma-informed approach 

Alisha Teague, a licensed mental health counselor in Jacksonville, Florida, says she’s seen the stigma associated with BPD perpetuate or even exacerbate symptoms for clients because of the damageability to one’s self-esteem. That’s why when working with clients, she makes determined attempts to redefine the disorder’s meaning by zeroing in on its symptomatology.

“Clients with borderline personality are so much more used to being rejected of love than actually healing,” notes Teague, the founder of the private practice Out of the Box Counseling. “When you call it ‘abandonment disorder,’ that helps them grasp a key part of the disorder while empathizing with themselves. I’ve seen clients say, ‘Oh, that’s why I have low self-esteem.’ Then when you tie in attachment theory, a client with BPD can see their behavior is tied to [a] fear of losing the closest person [to them]. That helps us move right into paths to push for secure attachment.” 

Lauren Lucas, a licensed clinical social worker for Fox Valley Institute in Naperville, Illinois, says she also treats BPD by first exploring the deepest root of the behavior. And trauma is often an underlying concern. In a 2021 literature review published in Frontiers in Psychiatry, Paola Bozzatello and colleagues found that up to 90% of clients diagnosed with borderline personality have experienced some type of childhood trauma or neglect. Similar studies have determined BPD is more prevalently linked to trauma than genetics. 

Lucas recommends counselors take a trauma-informed approach when working with these clients. “Nine times out of 10, a trauma is present for someone with borderline personality,” Lucas says. “Even if it’s ‘little t’ trauma, when clients can understand how their past pain shaped their world, it frees them up for self-acceptance. So often with BPD, there’s this reaction to fear of abandonment that’s driving their behavior.” She finds that being direct about what could be causing some of this plays a crucial role in the client’s movement and growth.

Lucas adds that a client experiencing BPD is often  plagued with self-hatred or self-loathing emotions, making a psychodynamic approach a direct pathway for clients to have empathy for themselves. “Sometimes the biggest hurdle can be a client’s self-shaming,” she says.

Shame is also a core feature of BPD, as noted by Tzipi Buchman-Wildbaum and colleagues’ 2021 meta-analysis published in the Journal of Personality Disorders. Christine Hammond, a licensed mental health counselor in Winter Park, Florida, says that for clients with BPD, feeling “seen and heard” with their root trauma (and in general) can help to offset those lurking shame emotions and accelerate their empathy for others. 

One way for clients to feel seen is by using a family systems approach — whether it be exploring upbringings or reconciling with family members directly and indirectly in session. “My approach for most personality disorders is to not necessarily treat the individual but the family as a unit itself,” Hammond says. Roles and dynamics within the households, she explains, often provide a blueprint for what’s happening in present day. 

“A lot of times, in a family dynamic, clients are used to matching volume for volume or verbal assault with verbal assault. It’s the only way to survive or be heard,” Hammond says. “Seeing that some of this isn’t their fault can lead to more empathy for themselves. The goal isn’t to hang out in the past or stay in trauma-land for too long, though. It’s to find paths forward.” 

An alliance based on patience and transparency  

As with any client, a therapeutic alliance is necessary for one’s emotional safety and well-being. Because people with BPD often struggle with mistrust, Hammond acknowledges that counselors may need to build trust gradually. 

“Part of the challenge as a therapist is accepting clients constantly pushing back and sometimes trying to sabotage because that can happen when they’re attempting to undo the deepest wounds of mistrust,” Hammond says. “No matter how safe therapy can be in their mind, trusting someone … takes building that stability over time because they’ve maybe never had it in their entire life.”

Because a lot of counselors are afraid to work with someone diagnosed with BPD, clients are used to constantly changing clinicians, Hammons notes, which only adds to the feeling that nobody understands or relates to them. But counselors can work against that pattern by simply being there, she adds. 

Sara Weand, a licensed professional counselor in Philadelphia, says that offering clients a safe haven through an alliance can be essential when they may be consumed with emotional turbulence. 

“The biggest thing you can do to build trust is honoring that their feelings are real,” Weand advises. “So many times, therapists can get lost in the facts, but that merely perpetuates invalidation. It takes a special skill to be able to meet the person where they’re at and accept them there before launching into work.”

Weand views the therapeutic alliance as a partnership where she and the client are working together toward a goal. This partnership, she says, relies on two things: the counselor understanding that they do not know everything and the client realizing that what they’ve been doing isn’t working. 

She often explains this concept to clients by comparing this alliance to being in a rowboat together with the goal of reaching the other side of the lake. “It’s not my job to row a certain way if it [the responsibility of rowing] is theirs. And it’s also not me rowing back if there’s a hole in the boat,” she says. “It’s important to have mutual responsibility. That may be fostering a healthy relationship of push-pull for the first time in their life because they can see I’m not going to ditch them or abandon them like maybe they have been in other parts of their life. But I’m also going to push them regularly.”

Lucas echoes Weand’s point about client accountability, noting that she’ll often be transparent from the start so clients know what they’re in for. 

“The need for a sense of safety and security is paramount, and as a clinician, you’re not going to make any progress without that,” Lucas explains. “I personally find that being direct can be really refreshing for clients with BPD when forming the alliance. We talk about how coming to therapy is not always going to be comfortable and pleasant. I can still provide unconditional positive regard while also not always agreeing or saying yes. Finding a way to articulate that with care and security can help work against the fear of abandonment or black-and-white thinking.” 

A proper barometer for diagnosis 

Transparency is also important when it comes to diagnosing BPD. Yet another casualty of the stigma tied to BPD is a reluctance among some clinicians to properly assess and diagnosis this disorder. In particular, practitioners who work with an eclectic mix of clients often have trouble determining if and when to diagnose a client with BPD, especially if another diagnosis such as posttraumatic stress or major depressive disorder exists, Skeeters says. 

Skeeters strongly believes a diagnosis, if accurate, is necessary to convey to a client for their well-being and stresses that clinicians shouldn’t sway away from delivering one.

“It’s always important to give clients [the] truth. If a clinician is afraid of how a client may act, then that is their own stuff coming up,” she says. “You wouldn’t tell someone who has diabetes they have something else or that ‘you maybe or could have diabetes.’ If you’re walking on eggshells because you don’t want to hurt the person, it will likely make it worse in the long run because one thing someone with BPD is craving more than anything is trust. Telling them the truth, even if it’s hard, will help toward that.”

In fact, Skeeters admits that one of her biggest complaints is that her BPD wasn’t diagnosed earlier. “In some ways I feel like I lost out on years of my life because therapists misdiagnosed me or were too scared of delivering the diagnosis. I was told that I had bipolar II and was treated for an eating disorder when the underlying issue was tied to borderline personality,” she says.

Hammond, however, cautions clinicians to consider the client’s age and development before giving them a diagnosis. She says timing is everything and resists assigning a BPD diagnosis to her teen clients because, as she points out, a client’s maladaptive behavior can more thoroughly be inspected in adulthood. “I hate adolescent diagnoses,” she stresses. “I go to Erik Erikson’s eight stages of personality development, and a client needs to be developed enough before diagnosing in my opinion.” 

Lucas also pays close attention to the delivery of the diagnosis, and she trusts her intuition on when the right time may be to discuss this with clients. 

“The approach I take is first having a discussion on what a diagnosis means to them,” Lucas explains. “Then I’m acknowledging their trauma and how it affects their behavior in the here and now. If they experienced neglect growing up and are struggling with their partners in relationships today, then I might say, ‘Here’s what we may call that.’ It’s never an easy conversation. But to my surprise, there’s a tremendous amount of relief that can come when a client is able to name why they’re acting the way they are. The language in the delivery matters just as much as the diagnosis.” 

Skeeters takes time to explain the diagnosis to her clients. She begins by saying, “This is what I’m theorizing with a diagnosis,” and then she describes why and how it applies to treatment. A diagnosis, when delivered from a collaborative sense, can bolster self-awareness and, as a result, improve a client’s work ethic in therapy, Skeeters notes.

DBT as the ‘gold standard’ treatment method 

The method of choice for BPD is undoubtedly dialectical behavior therapy (DBT), which combines standard cognitive-behavioral techniques for emotion regulation and reality testing with concepts of distress tolerance, acceptance and mindful awareness that largely spawns from meditation practices. Marsha Linehan, the psychologist who developed DBT in the late 1970s as a result of her own mental illness, defined the dialectical component of DBT as “a meditation-focus,” which is accepting things the way they are while simultaneously pushing for change to achieve happiness. Allowing clients to engage in both of these experiences at once paves the way for an increased emotional and cognitive regulation by helping them learn the triggers that lead to undesired explosive and reactive states. 

Weand, a DBT instructor in Philadelphia, describes DBT as a balance between meeting a client where they’re at while also pushing for change. DBT is all about building a client’s skill set to face their inner conflict in a way that projects outward in a healthy manner, she explains. 

“DBT is the gold standard of treatment for BPD for a reason, and that’s because it works,” Weand says. “It allows the therapist the opportunity to validate the client and really connect on a human level. The skills are all practical, but the meditation-focus creates room for slowing it down and honoring feelings as real. CBT [cognitive behavior therapy] can work as a standard therapy, but for people with BPD who feel so deeply, sometimes, painful shit is just painful shit and you can’t necessarily reframe that.”

“DBT can be effective with suicidal ideation,” Weand adds, “but it’s important to have proper boundaries as a therapist and refer to advanced care because DBT is not suicide prevention.” 

One treatment that is often complementary to DBT is eye movement desensitization and reprocessing (EMDR), which, as Lucas points out, can help with the dissociation a client with BPD may experience when they are unable to regulate intense emotion. 

“One of the biggest things EMDR can help with is the acceptance piece of regulation,” she says. “We cannot change what happens to us, but we can change how we react” to it. 

Hammond says that DBT’s focus on mindfulness can help to bolster a client’s self-awareness and therefore improve their ability to control or manage explosive and eruptive behavior. The overall gain from DBT isn’t necessarily removing a behavior; it’s slowing things down so that triggers can be managed and dysregulation can be altered, she explains. 

“We usually don’t see the behavior completely go away,” Hammond adds. But it provides clients “with a higher level of awareness and really knowing themselves.”

Untangling black-and-white emotional thinking

A common symptom of BPD is black-and-white emotional thinking (i.e., splitting), which involves seeing people or situations as all good or all bad. Skeeters says that type of intense relational trauma is a byproduct of an “emotional playground” that clients with BPD can find themselves trapped in and reactionary to when reenacting old wounds with partners. For that reason, if clinicians are working with a couple and one of them has BPD, then that individual’s treatment must come before couples therapy can begin. 

Nopphon_1987/Shutterstock.com

“Growing up, I viewed the world through a hyperbolic lens,” Skeeters recalls. “I was very sensitive and assumed that others viewed it that same way too. In my effort not to become abandoned, I ended up becoming this tyrant with dysfunctional beliefs. It can feel like other people are making you out to be a monster and that just makes it worse. I didn’t know that other people weren’t hyperbolic or lacked empathy the way I did. When it came to my relationships, to even start the path to recovery, I had to be brutally honest with myself and know how my behavior affects others around me when I’m on that emotional playground.”

Lucas says that the best way to address black-and-white emotional thinking and encourage accountability is through preventive measures and psychoeducation. 

“Because folks with BPD have more extreme experiences with emotions, it’s important to provide tools of regulating and grounding for moments of being triggered,” she notes. “When it’s showing up in a relational aspect, it’s [about] helping clients understand the way their brain may be operating in those moments [and] why they might fixate on how things should be or need to be. When someone is splitting or seeing in black and white, it can be difficult to see the gray area or the nuance of an argument or situation in a relationship. When we look at those patterns, not naming them as good or bad per se, but honor where they’re coming from and why they’ve served someone, then they can be adjusted better.” 

Weand says she’s noticed that most of her client’s black-and-white thinking comes after a big fight or a relationship failure. “I’ll have a client come in and their biggest pain is that ‘people think I’m crazy’ and [they] just want to feel like they’re not a monster,” she said. “They truly fear they’ll be doomed to be [perceived] this way their entire lives. The reality is they may be doing [and saying] things that look crazy [and that affect or hurt others]. … But once you show them where it comes from and that it can be regulated, there’s hope.”

Confronting countertransference 

Transference and countertransference can be ongoing issues when treating clients who have BPD, so counselors need to do their own work by becoming more self-aware and going to therapy themselves. 

Teague acknowledges that her own personal experiences with a family member who has BPD once challenged her ability to work with clients who are diagnosed with the same disorder. It took personal tragedy to push her to do her own self-work to develop the self-awareness and emotional availability that she now uses in helping clients with BPD.

“In 2020, I was smacked in the face by so many terrible things: a tragedy with a client happened, a friend from high school died [and] then everything with George Floyd came about,” Teague recalls. “I didn’t realize it right away but all of my own personal trauma was coming up. If I didn’t go back to therapy to do my own work and forgive myself to become self-aware, then I wouldn’t be able to work with this type of population. You need to have that awareness because countertransference is bound to come up for some types of cases. You need to have the tools within yourself first.”

Weand acknowledges that she needs to keep her caseload low and have only 10 clients so that she has full emotional availability for clients with BPD. “We have to be honest with our own limitations,” she said. “Mood-dependent behavior is tiring, so by setting those limits and having those boundaries, we’re giving our clients the best fit in a therapist.” 

Hammond said she’s seen therapists fret when working with clients experiencing BPD, and she can often trace it to their own inner struggles that may need to be worked out elsewhere. 

“Obviously, if you have countertransference that makes it unhealthy for the client, then a referral is necessary,” she says. “But I see too often therapists might have their own issues or misconceptions with BPD or don’t have the right education on it so they’re very quick to toss them [the client] to somebody else.” She acknowledges that this tendency is not helpful, and she hopes clinicians will develop healthier attitudes toward clients with BPD moving forward. 

“When you look closer, you can see that BPD clients are some of the most creative, imaginative and passionate people we have in the world,” Hammond says. “That’s why it’s so sad they’re misconstrued because I greatly enjoy working with them — seeing them fight to improve and then [eventually] get there is one of the most healing and powerful things you can do as a therapist.”

 

****

Scott Gleeson is a licensed clinical professional counselor in the Chicago suburbs, specializing in trauma and relational dynamics. He spent over a decade writing for USA Today, where he won national writing awards from the Associated Press and NLGJA: The Association of LGBTQ Journalists. His debut contemporary novel, The Walls of Color, and its sequel, Spectrum, will hit bookshelves in 2024 and 2025, respectively.

****

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

The unacknowledged stigma of mental illness

By Tina C. Lott July 5, 2022

Jorm S/Shutterstock.com

There is a 900-ton elephant in the counseling room, and it is often not acknowledged by the counselor or the client. As sessions go on and therapeutic alliance builds, this elephant results in a missed opportunity for the counselor to truly know their client. This elephant is known as stigma. 

Although stigma associated with mental illness is a well-researched area, there is a paucity of the literature that teaches counselors how to 1) identify stigma and 2) process and address stigma to decrease its impact on the client. This elephant cannot continue to boast proudly from the corner of the counseling room. Counselors must call it out. But how? Now, you’re asking the right question!

Stigmas exist nearly everywhere. Sometimes stigma is associated with things we can see such as ethnicity or a set of behaviors, and other times, it is present in things that are not so obvious such as within systems or laws. Either way, stigma is harmful. 

There are two primary types of stigmas: public stigma and self-stigma. According to an article by Graham Davey published in Psychology Today in 2013, public stigma forms from negatively held beliefs that society has about a particular group of people. These beliefs often entail stereotypes, discrimination and prejudice. In a 2002 article published in World Psychiatry, Patrick Corrigan and Amy Watson postulate that self-stigma occurs when an individual internalizes the negative beliefs that society has about them. For example, it is a common belief, and myth, that people with mental illness are dangerous. Self-stigma means the individual believes this narrative even if they are not dangerous and even when there is no evidence to support this claim. Self-stigma is usually a result of public stigma. Both kinds of stigma have been documented to exacerbate symptoms. Stigma also creates an “us versus them” divide between those who have a mental illness and those who do not.

Counselors have been charged with many responsibilities within the counseling session. We attune to the client’s mood, process emotions, help to create the goal of third-order change and create a safe space for clients to explore their most vulnerable selves. One skill, however, that we are not specifically trained to do is to recognize stigma and how it impacts our client’s lives. Furthermore, most counselors are ill-equipped to know how to address stigma once its presence has been recognized. Clients come to session and talk about how their symptoms have created obstacles in their relationships, work and career, but they do not usually name stigma as one of the main culprits. Counselors who are aware of what stigma is, how it presents and how to alleviate it have a better chance at addressing those presenting issues and offering their client a more well-rounded counseling experience by acknowledging stigma’s detrimental role.

Tips for addressing stigma with clients

For the past 10 years, I’ve worked with individuals who have been diagnosed with severe and persistent mental illnesses. Specifically, I have extensive experience working with individuals diagnosed with schizophrenia. Throughout my career, I have learned a great deal about the plague of stigma and how it can often destroy a person’s will to recover. During my doctoral studies, I conducted a case study where I investigated the impact of stigma on self-stigma attitudes of an African American man diagnosed with schizophrenia. This project was profound because it allowed me to witness firsthand how detrimental stigma can be for people who have a mental illness, and most important, I learned how to recognize and address it. This study also put me on a path to share what I know about stigma. Here are three simple tips for how counselors can recognize stigma in the counseling session. 

1) Remember that counselor education and awareness are essential components of the counseling process. Stigma can form from biases, so counselors must be aware of their own prejudices. We all have them, and the sooner we can own them, the sooner we can use that information to address the elephant in the room. Ask yourself, “How do I feel about my client and their diagnosis?” Then, ask yourself how others may feel about your client. How would you feel if your partner or parent had this diagnosis? Would there be feelings of shame? Embarrassment? Denial? This process may help to reveal stigmatizing thoughts that perhaps were not as apparent. Stigma can be found in the language that the client uses to describe their mental illness, in the nonverbal communication that the client displays, or in myths and stereotypes that the client unknowingly shares with the counselor. To have the most profound impact on dismantling stigma attitudes, counselors need to have a good understanding of what stigma is and how it may present in a counseling session. Counselors should educate themselves on stigma and then listen attentively for any of these signs so that they can be addressed. 

2) Name the elephant in the counseling session. This calls for the counselor to use immediacy to recognize stigma. Calling the elephant out strips it of its power. Identifying stigma and processing how it has an impact on the client not only allows the client to tell their full story but also helps the counselor better understand the obstacles that their clients face. You understand clients in context. This force that lurks in the corner is now identifiable, and when something is identifiable, it can be addressed.

3) Create a collaborative and safe space. A collaborative, safe space is essential for good therapeutic work to happen. When the client and the counselor are working toward the same goal, the synergistic efforts become a force to be reckoned with. This partnership is necessary to effectively address negative stigma attitudes. A safe space is crucial for any therapeutic alliance to blossom, but a space cannot be safe if counselors have not done their part to identify the stigmas that make the client’s condition worse. Clients need to trust their counselor in order to be a change agent in their own recovery. Counselors who address symptoms and the stigma attached to the client’s condition create a comprehensive approach to treatment.

Addressing stigma from a theoretical framework

Some counselors may not feel equipped to try these tips. Perhaps it seems daunting to address something that the counselor only recently realized. Because counselors learn to conceptualize and treat clients using a theoretical lens, this approach might be one of the best ways for counselors to meet the responsibility of addressing negative stigma attitudes.  

My theory of choice is rational emotive behavior therapy (REBT), which was developed by Albert Ellis in the 1950s. One of the primary premises of REBT is that we are not disturbed by life events. Instead, it is our belief about the event that makes all the difference. If our beliefs are irrational, then our emotions and behaviors will be irrational as well. Counselors who use REBT aim to change faulty beliefs into beliefs that are more productive and aligned with reality. The result is less self-disturbance. 

I tested this theory in my doctoral case study that I mentioned earlier. In this study, I applied REBT techniques to the negative self-stigma attitudes of an African American male, Ike (pseudonym), diagnosed with schizophrenia. I found that many of the techniques that are unique to REBT also helped the client gain awareness of the impact of stigma. Ike learned ways to discount irrational ideas that stemmed from stigma. 

Universal acceptance 

REBT is built on the philosophy of universal acceptance, which means that we accept things for how they are. This does not mean we have to like the situation. It does not mean we agree with it. It does not mean it is fair or we condoned it. It just means that in this moment, the situation is the way it is and we have little to no control to change it. There are three primary types of universal acceptance: universal self-acceptance, universal other acceptance and universal life acceptance. 

Universal self-acceptance acknowledges that we are all a work in progress, and even with our human flaws, we are still worthy. We have to be kind and patient with ourselves as we continue to work toward self-improvement each day. Excepting one’s flaws and shortcomings without criticism but with the goal of improvement is the premise of universal self-acceptance. When clients struggle with this concept, I ask them to think of their most favorite person. Then, I have them envision telling this person the things they say to themselves in times of high criticism and negative self-talk. Most clients admit they would never say such things to the other person. So, I ask clients to think of that person every time they engage in negative self-talk. I create a rule: If they would not say these things to that loved one, they are not allowed to say it to themselves. Over time, the goal is that the client learns to talk to themselves with kindness and compassion without the need to imagine they are speaking to their loved one. Many of my clients have found this approach to be effective, and it is how I begin the process of teaching clients about universal self-acceptance. 

Universal other acceptance posits that we meet people where they are and accept them “as is.” We cannot control others, and it is not our jobs to judge them. Each person has their own way of going through life, and if we can just learn to accept this (even if we don’t necessarily like it), then we can avoid feeling overly upset when others do not behave in the ways we think they should. When clients learn to practice universal other acceptance, they can also accept other individuals who may have the same or similar mental health challenges. Practicing universal other acceptance has both indirect and direct advantages toward negating negative connotations and stigma attitudes around mental illness. 

Universal life acceptance suggests that life is going to happen whether we want it to or not. This does not mean that we should just “lie down and take it” and that our problems will be solved by inertia. Instead, universal life acceptance stresses that we have to change our thinking about the life event because being upset and angry about it will not change the circumstances. Rather than experiencing intense emotions such as rage or deep depression, we can accept the situation and strive to change it by doing so within our locus of control. We cannot control life events; we can control only our reactions to them. Essentially, we can control only ourselves, not anything or anyone else. Universal life acceptance helps clients learn to focus on what they can control (primarily themselves) and relinquish control of everything else.

Counselors can gain a comprehensive understanding of universal acceptance by practicing it themselves. Firsthand experience puts counselors in a better position to teach these concepts to clients. Additionally, understanding how universal acceptance works in their own lives gives them insight into how to apply this to a client’s presenting problems. Counselors can teach clients to apply universal acceptance to negative stigma attitudes that emerge from deep exploration into stigma’s presence and impact. 

REBT interventions for addressing stigma

As mentioned previously, REBT has the potential to be a go-to theory for addressing self-stigma attitudes. Although REBT has a plethora of interventions, I want to suggest three interventions that I personally used in my research and found to be effective in addressing Ike’s self-stigma attitudes and beliefs that caused him significant stress. 

1) The ABC situational model. The ABC situational model, which is a foundation of REBT, allows for clients to see how their irrational thinking leads to self-disturbance. If they can change their thinking, then the emotion that follows will change as well. The A in the ABC situational model stands for activating event, which is the incident or event that happened. The B stands for belief or what you tell yourself about the event. The C stands for consequence, which is how you feel as a result of the belief that you have about the event. 

Ellis believed that this formula captures how most people get to the point of distress. People get overly distraught when their belief is faulty or illogical. For example, Ike had been at the same company for the past three years. He felt good about his work and was finally making ends meet. When he was hired, Ike self-disclosed that he had a mental health diagnosis of schizophrenia disorder. He figured it was good practice to let his employer know just in case he experienced any challenges managing symptoms. One afternoon, the executives called for an emergency meeting, and Ike learned that he and several others would be laid off from their jobs. The executives said it was due to the hardships brought on by the pandemic. Ike took in the news and had a panic attack. He was convinced that this was the worst thing that could ever happen to him and that he was chosen to be let go because of his mental illness. He was sure word would spread among future employers and he would be excluded.

If we apply Ike’s situation to the ABC situational model, the activating event in this scenario is Ike being laid off. The belief is Ike thinking that he was let go because of his illness and that things could not get any worse. Ike was convinced that there was no way he would be able to find another job. He generalized the situation and thought to himself, “This always happens to me. I’m never going to keep a job if I tell people I have this condition.” The consequence in this scenario is extreme anxiety — to the point of panic — and thoughts of hopelessness.

Ike’s self-disturbance comes from his irrational beliefs. If Ike believes he was laid off because of his mental illness but there is no real evidence, proof or situation that corroborates this idea, then his emotional response would be at the same level of severity as his thoughts. This leads to self-disturbance. Counselors can intervene at the belief level and help clients to change their irrational beliefs into thoughts that are more aligned with the reality of the situation. Challenging Ike’s unfounded thoughts about being fired because of his mental illness would be a good place to start. The clinician could help Ike realize that although the situation is not ideal and will be hard, it is not the end of the world, and it is not the most terrible thing that could ever happen. He has no concrete reason to believe he was laid off because of his illness. He was not the only person the company let go, and he did not know whether others had mental illnesses. Furthermore, there is no evidence to support that his employer will share his condition with others. This approach can help to reduce the severity of emotions and bring about a different, less traumatic, emotional experience. Ike would learn to see the layoff as an unfortunate event, but a bearable one. His distress would be more aligned and more in proportion to the actual circumstance, which would likely reduce self-disturbance. 

The ABC situation model is the cornerstone of REBT. Counselors can use this approach to gain an understanding of the origins of the clients’ faulty thinking. It is also a useful teaching tool for clients as well. The more they understand how to use this model, the more they can begin to use it outside of the counseling room, leading to third-order change. 

2) Disputation. Another technique used in REBT is disputation. Ellis believed that we must vigorously and consistently challenge irrational thoughts through disputation. Not only must we challenge them, but we must also replace them with ones that are more realistic. In my case study, Ike believed he was not capable of being loved or cared for by anyone because he had a diagnosis of schizophrenia. Although he felt this way often, I was able to get Ike to share about many instances where he experienced good relationships with others who knew about his condition. These relationships were the exception, but when there is an exception, the irrational beliefs are hard, if not impossible, to uphold. Disputation helped Ike to recognize that not all his relationships were bad and that he had experienced healthy relationships with others. Counselors who use REBT believe that the more we get into the habit of identifying and then challenging our faulty thinking, the easier it will be to replace those beliefs with thoughts that are more in proportion with reality. 

3) Reality testing. Reality testing is another fundamental intervention used in REBT, and it helps the client to use evidence to negate thoughts that are irrational. Ike, for example, often did not feel safe because of the way society had treated him in the past because of his mental illness. These negative experiences led Ike to believe that others in the community could tell he had schizophrenia just by looking at him. The stigma of what someone with a mental illness is perceived to look like was prominent in Ike’s worldview. 

Ike practiced reality testing by putting his theory into practice. I gave him a homework assignment to go for a short walk in the community and identify who had a mental illness and who did not based solely on how the person looked. After completing the assignment, Ike reported that he was not able to say for sure who had a mental illness. He said he could not tell by just looking at them and that the other person would have needed to “do something” for him to make that decision. Ike and I applied this new information to his own thoughts about how he is perceived by others. He concluded that if he were just going to the store or taking a stroll in the neighborhood, there was no way someone could pinpoint that he had schizophrenia. This exercise was repeated many times to help Ike to disprove his thoughts about this idea. 

In summary, stigma continues to wreak havoc upon those with mental illness. There is not enough focus on this issue within most counseling programs, so many counselors are not aware of stigma’s impact on symptoms and clients in general. Counselors can be change agents by gaining an understanding of the impact of stigma. And then they can educate the client by addressing stigma and its impact on the client in the counseling session. Counselors can also offer interventions to help clients learn to cope with and combat negative self-stigma attitudes. Stigma can make a condition that is already hard to manage worse, but if counselors can learn to recognize it, they can empower their clients to do the same with the added benefit of teaching clients how to cope.

 

****

Tina C. Lott is a licensed clinical professional counselor, certified alcohol and other drug counselor, national certified counselor, approved clinical supervisor, and board-certified telemental health provider. She is a core faculty member with Walden University. In addition, she is an independently contracted therapist at PATH mental health, a mother of two fantastic kids and a life partner to her fiancée. Contact her at tina.lott@mail.waldenu.edu. 

 

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

****

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

Building trust with reluctant clients

By Bethany Bray June 22, 2022

The Washington Post’s “Dear Carolyn” advice column recently fielded a question from a person who was unsure if they were ready to seek counseling to cope with a strained relationship with a parent. Although the person was aware that counseling could be helpful in this particular situation, they were still reluctant to seek services. “I can’t bear the thought of sharing any sort of emotions or history with a complete stranger, especially when I hear people have to reshare as they try two or several counselors to find the right one,” they wrote.

In her response to this letter, advice columnist Carolyn Hax advocated for the person to try counseling and addressed their hesitancy by saying, “The ‘total stranger’ is actually the point. … That extra, disinterested, trained, and informed set of eyes can help any of us see things we’re too close to see.”

The author of this letter is hardly alone in their hesitance. Data from the National Alliance on Mental Illness indicates that roughly one in five American adults experienced mental illness in 2020, yet less than half received treatment.

And part of this reluctance may stem from the fact that counseling does involves being vulnerable to a stranger — albeit a professional stranger — and working through emotions, trauma and issues that can be painful, sad or fear-provoking. When combined with feelings of shame, stigma or bad memories of a past therapy experience, it’s no wonder that clients are often nervous, fearful or hesitant to start counseling.

Counselors understand the importance of the therapeutic relationship. But when a client is hesitant or reluctant, practitioners need to make trust and relationship building the central focus of counseling work, along with a little extra patience and unconditional positive regard.

An extra dose of validation

Bri-Ann Richter-Abitol, a licensed mental health counselor (LMHC) in New York and a licensed clinical mental health counselor and supervisor in North Carolina, has worked with clients who were so apprehensive about trying counseling that they were visibly shaking in their first few sessions.

Richter-Abitol owns a private practice in Wake Forest, North Carolina, that specializes in counseling for anxiety disorders. She and her staff offer individual and group counseling with a focus on creating a welcoming, nonintimidating environment.

When a client’s body language indicates that they’re nervous or hesitant as they begin counseling, Richter-Abitol uses it as an opportunity to acknowledge their concern and validate that what they’re doing is hard. Her focus becomes normalizing the therapy process, rather than jumping into any kind of assessment or intake regimen.

“This [hesitancy] is extremely common, even for clients who have been in counseling before. … If I notice that a client is really anxious, I use immediacy and point out that it is scary to be here, and I applaud them for coming in,” says Richter-Abitol, an American Counseling Association member.

Clients who are hesitant to try counseling need transparency, patience and an extra dose of validation from their counselor, agrees Megan Craig, an LMHC who counsels clients at a community mental health agency in the Boston area. She often emphasizes to clients that they’re not doing something “wrong” if they are having trouble opening up or aren’t immediately comfortable in therapy. Applauding a client’s bravery to walk through the door also creates an opportunity to ask them what motivated them to make that first appointment — and, in turn, helps the counselor learn more about the client, Craig adds.

Validation played a key part in fostering connection with a female client Craig once worked with who kept being referred to different clinicians within Craig’s agency because of staff turnover.

By the time she was put on Craig’s caseload, the client was “exhausted” and fearful of losing yet another practitioner. So, she had spotty attendance and would often cancel appointments.

“She felt like she hardly wanted to be there [in counseling sessions]. She had told her story so many times, only for her clinician to leave. She kept having to start over from scratch and be vulnerable with a new person,” Craig recalls.

Craig was honest with the client and broached the subject directly, validating that her exhaustion was understandable and warranted.

Craig also realized she needed to slow the pace of therapy with this client. Their early counseling sessions focused on lighter topics, such as work stress. It was one year into counseling before the client was comfortable enough to begin talking about heavier topics, including her trauma history.

The client’s attendance eventually improved but not until Craig spent months building a relationship with her.

“At first, I second-guessed myself and wondered if this [early work] was ‘therapeutic enough.’ But that’s what she needed. That was what was therapeutic for her,” Craig says. “She needed to establish the trust that I wasn’t going to leave and would stay with her. Just me showing up [to counseling sessions] is exactly what this client needed.” 

Fear of judgment

Counselors are no strangers to the importance of the therapeutic relationship, and decades of research show how central and essential it is to client engagement and growth, says Michael Tursi, an LMHC in New York. Counselors, however, must make relationship building an utmost priority for clients who are hesitant. They have an opportunity to display nonjudgment every time they respond and interact with a client, he notes.

“It’s one thing to say, ‘the therapeutic relationship is essential,’ but there are some clients who really might not be willing to engage at all until they see certain things, especially nonjudgment, in their counselor,” he says. “When counselors meet with clients, right from the beginning, they have an opportunity to display nonjudgment.” 

Tursi, an assistant professor in the mental health counseling program at Pace University’s Pleasantville, New York campus, has done research on client experiential avoidance (i.e., when a person is resistant to experiencing strong or adverse sensations, emotions or thoughts) and engagement in counseling. For his doctoral dissertation, Tursi interviewed a cohort of clients in counseling who self-identified as experiencing this phenomenon, and he, along with two other colleagues, published the findings in a 2021 Journal of Counseling & Development article.

Tursi measured his study participants’ level of avoidance by having them complete the Multidimensional Experiential Avoidance Questionnaire developed by psychologist Wakiza Gámez and colleagues.

According to Tursi, one data point in his research quickly became very clear: Each and every one of the participants talked about fear of judgment from their counselor. The study participants acknowledged that they became more engaged in counseling once they established that their counselor was trustworthy and nonjudgmental.

In fact, the participants viewed counseling as a potentially harmful or threatening relationship until their counselor had fostered a trusting relationship with them and eased their hesitancy, Tursi adds.

Some participants talked about “testing” their counselor by intentionally saying something to elicit a response to gauge how trustworthy the counselor was. Even if a client does not do something like this intentionally, Tursi notes, they are very aware of how a counselor is responding to them.

“Nonjudgment is central to working with any client. But these clients might need a counselor who is quite in tune with [the fact that the] client is concerned about judgment and be patient with that,” says Tursi, an ACA member.

A key aspect of creating an atmosphere of nonjudgment is for counselors to be aware of a client’s comfort level, he says. This includes keeping an eye out for indicators that a client is anxious, such as body language, and checking in regularly with the client to talk about how they feel things are going.

A client should never feel pestered or pushed into talking about issues; they should come to the decision to disclose on their own, Tursi emphasizes. Counselors need to temper the expectations of what they think or expect a client will need or be willing to do. 

“Attending to where your clients are is important. We shouldn’t go into therapy and assume clients are going to disclose right away rather than do the therapeutic work that we think they need to do,” he explains. “Counselors should make sure they’re focusing on providing conditions for these clients to engage. … The client is never going to get there [make progress], in any kind of meaningful way, unless they’re engaging in sessions.”

Tursi hopes his research spreads awareness among counselors that experiential avoidance is very common and that some clients may come into counseling believing — for a variety of reasons — that it could be a relationship that is potentially harmful. Tursi draws on the work of Barry Farber, a professor of psychology and education at Teachers College, Columbia University, when he emphasizes that it’s easy to have unconditional positive regard for clients who come in ready to trust and work with their counselor. But it’s equally important to provide that regard for clients who are hesitant, although it may be more difficult. Patience should be a counselor’s watchword, Tursi adds.

“As counselors, we have to be aware of situations in which we have difficulty providing positive regard and continue professional development to improve our abilities to provide nonjudgmental acceptance at times that it is difficult,” Tursi says.

Check yourself 

As a practitioner who specializes in counseling clients with anxiety, Richter-Abitol finds that rapport building with clients who are hesitant must involve self-awareness on the part of the clinician. This includes keeping her own wants, expectations and assumptions about work with clients in check, she says, and asking for client input on the pace and direction of their treatment.

Richter-Abitol is transparent with her clients: She lets them know that they are “in control” of what they want to talk about in sessions and emphasizes that she won’t “make” them talk about anything they’re not ready to.

“You have to meet the client where they’re at and let them set the agenda. I have had clients who have taken months to build rapport, and if you [the counselor] are not patient, you may never get to that point,” Richter-Abitol says. “You have to constantly check yourself outside of sessions and tell yourself that even small successes contribute toward long-term goals. Small things add up.”

polkadot_photo/Shutterstock.com

Richter-Abitol, like Tursi, argues that the therapeutic relationship must take priority with these clients, rather than diving into a treatment plan based on their diagnosis or what the practitioner thinks they need. Counselors should get creative to find ways to bond with the client prior to moving into heavier work, she suggests. For young clients, this might be therapeutic games or activities; for adults, it might be a discussion of lighter topics that help paint a picture of who they are, including things that they like, dislike and what motivates them.

“Those conversations can lead to deeper ones,” she says. “It’s not helpful to be too rigid. You can have things that you’d like the client to work on, but ultimately it has to be up to them. Flexibility is important.”

Richter-Abitol has found that clients feel more empowered when she lets them take the reins in this way. And many begin to open up naturally when they don’t feel pressured to do so.

This approach requires counselors not only to be in touch with and sensitive to their client’s needs and level of readiness in counseling but also to check their own inclination to take charge when a client is slow to make progress. It’s all too easy to assume that a client who isn’t making progress — or not progressing in a way the counselor might want or expect — isn’t benefiting from counseling, Richter-Abitol notes.

Instead, she advises practitioners to take a step back and consider the client’s full context, including the barriers and challenges that are making it difficult for them to engage with a counselor.

“Their fear or discomfort can come off as resistance or presenting a vibe that ‘I don’t want to be here.’ … They just don’t know how to feel about this space yet, and you need to give them time to figure that out,” Richter-Abitol says. “Don’t make the assumption that someone who is uncomfortable isn’t gaining anything from the experience. It might not be that they don’t want to be there but they just don’t know how to be there yet.”

Have honest conversations 

If patience is the first thing that clients who are hesitant or slow to engage in counseling need from a practitioner, transparency is the second. For Craig, this comes in the form of direct questions to the client to gauge their comfort level and an honest invitation to let her know when things aren’t working.

If a client appears uncomfortable or is hesitant to engage in counseling, Craig will address it directly, saying, “Here is what I’m picking up on. Tell me if I’m right or wrong.” She emphasizes to clients that she cares for their well-being and genuinely wants to hear how they’re feeling — and that they have a choice and a say in the counseling process.

Sometimes what counselors view as resistant behavior in clients can be caused by the use of methods or techniques that aren’t a good fit for that individual, Craig says, or it can be that the practitioner themselves is not the right fit. Because clients may not bring up problems to a counselor on their own, she makes a point to broach the topic with honesty, explaining that no therapist is going to be the best match for everyone who walks through their door.

“If someone is taking the huge step to start counseling, I want them to benefit from it as much as possible. I’m honest and tell them that they’ll never make progress if we are not a good fit,” says Craig. “People are not ready for different reasons, and that’s why I like to have such open conversations. … I might not be able to give them everything they need, but I certainly want to talk about it and I want to try.”

She not only checks in regularly with clients throughout therapy but also makes time for a deeper conversation about what is and isn’t going well once a year (on their anniversary as her client). 

During these check-ins, she prompts clients with questions such as:

  • How do you feel about our work together?
  • Do you respond well to me taking the lead in counseling, or do you prefer to take the lead?
  • What has been helpful during our work together?
  • What do you need more of? And less of?
  • What did you expect from therapy and how has this not met your expectations?
  • What’s working and what’s not?

Not only do these conversations provide Craig with valuable feedback, but they also help set an example for the client to advocate for their own needs outside of counseling, she notes. Learning to be able to communicate their needs and expectations is a big — and important — milestone for many clients.

Craig recommends clinicians ask clients directly about how things are going in counseling rather than fall into an easy pattern of making assumptions about individuals who are avoidant or hesitant to engage. Honest feedback from a client is a good thing, Craig stresses, and not something that a counselor should take personally.

Overcoming cultural barriers

Counselors also need to take a proactive approach when clients are hesitant because of challenges and barriers related to their cultural background, says Camila Pulgar, a licensed clinical mental health counselor associate who is a research faculty member at Atrium Health Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.

Building trust and forging connection with clients who are from marginalized cultures require a counselor not only to be comfortable broaching the subject of culture (and cultural differences) in client sessions in an ethical and compassionate way, Pulgar says, but also to be fully aware of and sensitive to the many barriers that keep them from accessing counseling or being fully comfortable in the setting. 

A native of Chile, Pulgar specializes in the mental health needs of Latinx clients, including suicide prevention. She does clinical work once a week in her faculty position at the medical center, and she is the only bilingual (Spanish/English) provider on her team. Being the only bilingual counselor is not unusual for Pulgar; in fact, this has been the case for most of her professional career, she says. The mental health care system in this country is simply not built to support the needs of clients whose first language is not English.

Language is only one of many barriers that can deter clients from minority cultures from seeking or becoming fully engaged in counseling, Pulgar points out. Individuals may face logistical challenges such as trouble accessing transportation to appointments, finding child care or affording the cost of sessions. They may also be fearful or have adverse feelings about counseling because of stigma, past harm or skepticism about therapy within their culture or family group.

“If people make it to my office, they’re usually hesitant to share their mental health journey with their family members because of stigma. I often hear ‘I don’t want anyone else to know I’m here’,” says Pulgar, who also sees a small caseload of clients at her private practice in Winston-Salem, North Carolina. “When we talk about their supports and who they can reach out to in times of crisis, they often don’t list anyone [in their family] because they don’t want their family to know they’re struggling.”

Shivonne Odom, a certified perinatal mental health provider whose private practice is the only practice in the Washington, D.C., area that specializes in perinatal mental health care and is owned by an African American therapist, says this is also common among her clients, the majority of whom are African American.

She’s had clients whose families reacted very negatively when they found out the client was attending therapy, and other clients have chosen not to disclose the fact that they were seeking counseling to their families and, in some cases, even their spouse.

Hesitancy is very common among Odom’s clients; she recently had a client tell her that she needed to take an hour-long walk to calm her nerves before logging in for her first counseling session.

There is an extra layer of stigma for minority clients who are seeking perinatal mental health care because pregnancy and childbirth are often assumed to be a joyful and happy time — not one of despair. All of these challenges add up and severely affect clients’ help-seeking behaviors, says Odom, a licensed professional counselor in Washington, D.C., and a licensed clinical professional counselor in Maryland.

Pulgar notes that conversations around challenges in minority mental health care often place the blame on the stigma that many cultures have regarding counseling. In reality, minority populations face many barriers when seeking treatment, and that should be an equally, if not more, important part of the discussion.

This issue is compounded by the fact that most of the evidence-based treatment methods that students are taught in graduate counseling programs were created by and tested within members of the majority population. So, it makes sense that many of counselor’s go-to methods may not be a good fit for some minority clients, says Pulgar, an ACA member.

Clients can also become discouraged if they are referred to counseling by a medical provider and none of the counselors on the referral list look like the client, Odom adds. Because of this, she goes out of her way to accept many different types of insurances and often consults and works with multidisciplinary professionals in related fields, such as lactation consultants, to advocate for her clients and ensure that other providers know of her services.

Counselors should also be aware that these clients are often unfamiliar with the process of counseling. A first step toward forging a therapeutic connection can be to explain what therapy is (and isn’t) and why it’s helpful, along with the concepts of privileged information and confidentiality, Odom says.

Pulgar and Odom emphasize that one way to reduce these clients’ stress and barriers to treatment is for counselors to become knowledgeable of culturally connected resources in their area, such as nonprofit organizations and support groups and services.

Free support groups can be very helpful to validate a client’s feelings and experience in a way that individual counseling can’t, Odom says. And if there isn’t a group that matches your clients’ culture and identity (e.g., single mothers by choice), she suggests that counselors consider seeking training to start and lead one.

It’s equally as important for counselors to forge a connection with the marginalized community in their area as it is to build a strong therapeutic relationship with individual clients, Pulgar says. She suggests that practitioners start by becoming involved with organizations that serve the local marginalized community and participate in events such as health fairs.

“Get out of the four walls of the office,” Pulgar stresses. “Marginalized communities are so collective, and community is an important part of life.”

Small changes, big impact 

Counselors have an opportunity to build trust with a client with every interaction. And sometimes, seemingly “small” things that are outside of the core work of counseling can make a big difference to a client. Here are just a few small steps clinicians can take that will make a big impact on clients. 

Explain the process of counseling and why it’s helpful. Don’t assume that clients know what therapy is or what it entails, Tursi advises. “If they’ve never been to counseling previously, the idea of connecting with feelings might be very foreign to them,” he says. “They might start counseling thinking that the counselor can just make these [difficult] feelings go away. When instead, counseling [works to] change their relationship with their feelings — and a practitioner may need to explain that.”

Remember that a breakthrough does not mean clients are completely comfortable in counseling. A counselor whose client makes a significant gain toward trusting their practitioner in one session may feel that they’ve built their relationship enough to move on and address other issues. However, the only way to truly build trust is to have patience and show a client, over time, that you are trustworthy, Craig says. This is especially true for clients whose trust has been broken by others in their life, including health care providers. “Remember that even if they open up about their fears, it doesn’t mean they’ll be less fearful at the next session,” she adds. “It’s about patience and giving them that chance to warm up.”

Welcome clients before they even sit down. Forging trust with hesitant clients takes “more than what you are doing in the [counseling] room, it’s the whole experience,” Richter-Abitol says. “And we want to make people feel as welcomed as possible. … I know what it takes to walk through that door, and how hard it can be.”

She has taken client comfort into consideration in every aspect of her practice, from choosing cozy décor for the waiting room to a casual staff dress code. She built her website to be particularly user-friendly and extend a welcoming vibe before clients even set foot in the door. For example, she provides a detailed biography of all members of the clinical team, including photos of the practitioners, adjectives that describe them (e.g., bubbly, enthusiastic, loyal, creative, motivated) and a description of what a client can expect when working with them. 

“We try and dial down the clinical and dial up the parts of our personality” on the website to make potential clients feel comfortable, Richter-Abitol explains. “With the anxiety population, fear of the unknown is a big issue, so seeing the office and the pictures [online] helps fills in that space [and] helps people form connections before even coming in.”

Pronounce their name correctly. And if counselors are not sure how to pronounce the client’s name, they should ask and remember it, Pulgar says. This is a seemingly small thing that can be overlooked by practitioners, she notes, but it lets the client know that a counselor values their identity.

Don’t assume they’re resistant. Clients who are opposed to treatment and those who are hesitant or slow to engage in counseling can exhibit some of the same behaviors, such as canceling appointments frequently, answering a counselor’s questions with one-word answers or avoiding talking about heavier topics. However, counselors have an opportunity to build trust and explore the reasons why a client appears reluctant, rather than labeling them as resistant.

“We have been taught [in counselor trainings and graduate programs] that it’s a normal way to view clients. It’s really discouraging to know that [the word ‘resistant’] is even part of the dialogue,” Craig says. “Just because your perception as a clinician is that a person is not trying doesn’t mean that they’re not trying. They might not be doing the homework you assign, but they’re showing up every week. And that may be all that they can do right now. That is trying for them. Be sensitive to what they need to make progress.”

Do no harm and seek training. An important aspect of building trust with hesitant clients is ensuring that a practitioner is providing ethical, appropriate and competent care to keep from exacerbating their hesitancy or repeating any bad experiences they might have had previously in therapy. This includes seeking training, consultation or supervision when a counselor has a client who comes from a culture or is dealing with a challenge that the counselor is not familiar with.

In the case of perinatal clients, clinicians who are not trained in the needs and nuances of work with this population risk providing inaccurate — or even harmful — care, Odom says. Some of the symptoms that can be common in perinatal clients, such as intrusive thoughts about harming their baby, can easily be misinterpreted, she explains.

[Hear more on this in an ACA podcast episode featuring Odom: “Counselor Advocacy with Maternal Mental Healthcare.”]

“We [counselors] have an ethical duty to only practice in areas in which we are trained, and if we’re not, we have an ethical obligation to reach out to providers who are and consult with them,” Odom says. “Don’t be afraid to take a training on perinatal [mental health]. I have seen way too many clinicians treating these clients [inappropriately] and it leads to clients having to unjustly interface with systems that will do harm.”

Leave the door open for them to return. Clients who are hesitant about counseling are more likely to drop off a practitioner’s caseload. Counselors should take measures to focus on retention with this client population, but they should also understand that when the client stops counseling, it doesn’t mean that it wasn’t beneficial. Sometimes people simply have so much going on that life “gets in the way” and they can’t come to regular sessions, Pulgar points out.

Practitioners should emphasize to these clients that they’re always welcome to return to counseling whenever they’re ready. Instead of placing blame and asking the client not to return after missing multiple sessions, a counselor can instead say, “I understand this may not be the best time to start counseling in your life, but please do reach out when it is. I am here for you, please keep my number,” Pulgar says.

“The truth is, not everyone is ready for counseling when it comes time for the appointment, even if they made the phone call [to schedule]. They may not be ready to engage yet in the process of what counseling demands,” Pulgar says. “Stay calm and don’t overthink ‘What am I doing wrong?’ or ‘What more can I do?’ Take a couple of deep breaths and think about ways that the door stays open. … If clients get a good sense of counseling just with that interaction with you, maybe in a year or five years, they will come back. That interaction, although brief, can give them a positive feeling about counseling.”

 

*****

Reasons why 

Many different factors and barriers deter people from seeking counseling or feeling comfortable in sessions. This is by no means an exhaustive list, but some common client fears and concerns include:

  • The client (or someone they know) has had a bad, hurtful or unhelpful experience previously with a mental health or medical practitioner.
  • They come from a culture where counseling is not widely accepted or a culture that has been historically maligned or harmed by mental health professions.
  • They are struggling with an issue that involves feelings of shame. 
  • They are afraid to confront the issue they are struggling with; this can include hesitancy to relive trauma as they process it or fear of showing vulnerability or imperfection.
  • They fear being given a diagnosis and/or being misdiagnosed.
  • They worry the counselors will judge them.
  • They fear meeting and opening up to a person they don’t know. 
  • They experience overwhelming negative or catastrophizing thoughts (e.g., “Counseling is not going to work”).
  • They face logistical challenges (lack of insurance or inability to pay, trouble finding child care or transportation, etc.).
  • They worry that others (family, peers, etc.) will find out they are attending counseling.
  • They do not have a choice in attending counseling (e.g., a person who is mandated to complete therapy, often as the outcome of a court case).
  • They are hesitant or unable to connect with a practitioner who doesn’t come from the same background or experience as them (e.g., a Latinx or LGBTQ counselor, one who has served in the military, one who understands miscarriage and infertility).

This information came from interviews with the following counselors: Megan Craig, Shivonne Odom, Camila Pulgar, Bri-Ann Richter-Abitol and Michael Tursi.

 

*****

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

****

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