Tag Archives: stigma

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.

“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.

A time to make dreams come true

By Caitlin C. Regan April 21, 2021

So many people dream of fame, fortune, fast cars and fancy homes. For so long now, I have dreamed of freedom — freedom to be my full true self without judgment, shame or ridicule.

So, who am I, do you ask? I am a 33-year-old female mental health counselor (and former teacher) who also has a mental health condition. I have bipolar II, and for as long as I can remember, I have had to hide part of myself because so much of society stigmatizes, judges and condemns those who have mental health conditions.

It is not that I need to wear a sign around my neck reading “Bipolar II right here,” announcing it to every stranger I meet, but do I want to live in a world where, if that was my choosing, I could do so without being judged or shamed into the darkness. I imagine that many discriminated parties understand where I am coming from and might even be saying, “At least you do get to hide it.” But that is just it — I am tired of hiding. I have spent my life living in the shadows and playing a part the world can accept.

Many people in my life are aware of my condition and accept me — for all of me. I am greatly appreciative of all the support I have received, but it is no longer enough. I want, I demand, more! I want to be able to go to work and say I have bipolar II and not have the room go silent in fear or lack of understanding. I do not want a bad day, simply because I am human and have bad days, to turn into whispers of “Is she manic?” or “Is she depressed?”

For my entire working life, I have kept my condition to myself out of fear of persecution, out of fear of my judgment being called into question because of my condition. In all those years, never once have I put a student in jeopardy (as a counselor, I am placed in a school as well) because I am fully self-aware and manage my condition as I would any other medical condition. On days when I am in a depressive episode or manic episode and am not feeling well enough to do my job, I take a sick day, just as anyone with any other medical condition would need to do.

Those with mental health conditions can thrive if they receive proper care and treatment management. In fact, there are many who have thrived throughout the ages despite having less availability to treatment than is available in the 21st century. Beethoven, Michelangelo and Abraham Lincoln (to mention only a few) all reportedly had mental health conditions, and they accomplished amazing, history-altering feats. Why then is there still such stigma surrounding mental health disorders?

Admittedly, things are better today. In the 1800s, people who were even suspected of hysterics (mostly women) were locked away. In the 21st century, we have many people who openly speak about having mental health disorders and various organizations (the National Alliance on Mental Illness, the Depression and Bipolar Support Alliance, county mental health boards, the Substance Abuse and Mental Health Services Administration, etc.) that work tirelessly to support those with mental health conditions and their loved ones. Even what I do, serving as an intervention therapist, was not heard of as recently as the 1990s and early 2000s when I was in school. 

My beginnings

When I began my journey, at 12 years old, no one knew how to help me. I was consistently described as a “freak” in my school, by students and adults alike. My parents tried to help, going to every medical doctor they could think of to discern why I was randomly fainting. It was not until years later that I was told I had conversion disorder (one’s system converts psychological symptoms to physical symptoms) and not until I was 23 that a psychiatrist diagnosed me with bipolar II. And I was 29 before receiving proper treatment that truly turned my life around.

Ironically, it was not a professional who discovered my miracle treatment. It was me, as a counseling graduate student, doing a paper on electroconvulsive therapy (ECT). Now, coming up on my four-year anniversary of receiving ECT, I am at a new place in my treatment.

I am a mental health professional myself now and experiencing lengths of stability not previously known to me. Even when I do have an episode, they are far shorter and less severe than they ever were before. Most important, I love who I am and am damn proud of myself. It is at this juncture that I want more — not for myself, but for the world of mental health. I am using my newfound stability and happiness to ask, “How can I make a difference?”

I recognize how blessed I am to have found a treatment plan and team that have helped me become the best version of myself, but I want the same thing for all who have mental health conditions, and I want it without bias. As well as I am, I still cannot go into work, sit at the lunch table and talk about my week being difficult because of a medication change for my bipolar. Well, I could, but the ramifications would be costly. For those who doubt my claim and say there are laws against that, let’s be honest. Yes, on paper, there are laws against discrimination and bias. But that does not mean that cases of discrimination and bias no longer take place on a daily basis against every “protected” group.

The fact is, in America, if you are not the “norm,” there are many who look to remove your rights as a citizen, as a person, as a human being. This can no longer be the case, and mental health needs to join the movements rising up. Those of us living with mental health conditions need to demand our right not to be judged and not to be deemed anything less than ALL of who we are. It is true that we need help, but no one goes through life without needing help. With proper treatment and active participation in that treatment, there is no reason that we cannot thrive.

Recognition and moving forward

I have rarely said this out loud. Only a chosen few have heard what I am now going to publish willingly. I think it is in part due to my bipolar that I am so creative. There is something that happens that I truly do believe stems from my condition that allows me to think at the speed I think and write while envisioning my final product (this certainly didn’t hurt during pursuit of the three master’s degrees and one bachelor’s I have earned). It also creates an empathy that allows me to place myself in the moment with people and feel with them, for them, as them.

It is true that this empathy, when I was young and did not understand what seemed an overwhelming amount of feelings, caused me a lot of pain. In return, I caused much pain to myself. But through the receipt of empathy from others and the receipt of caring treatment, I have learned how to hone those feelings and use them in my career as a counselor. I have turned my empathy into my very own “superpower” to help others who are in pain. I receive no greater joy than the work I perform as a counselor for adolescents. First as a teacher and now as a counselor to adolescents in a school, I am privileged to get to turn all I have been through into something truly meaningful.

Again though, it is not enough. Change needs to happen in this society, and I want — no, I need — to be a part of it. Not for political reasons but for humane reasons. I am a human being hurting because I do not have the ability to be my full true self. I have come to a place where I am now proud of who I am, but still I feel I cannot go into society and share my true self — and I want to.

No one should feel they have to hide a part of themselves because it does not fit the accepted “norm.” Now is the time to come together and demand change. Not just for the mental health world, but for all who feel they have to live in the shadows. Support change not because of your political party but because it is the right thing to do for all human beings.

 

Related reading: ACA Virtual Conference Experience keynote speaker Bassey Ikpi also shared her journey with bipolar II disorder. Read more in our coverage of her keynote address.

 

****

Caitlin Regan is a 33-year-old living with bipolar II disorder. She was diagnosed in 2012 and has been living successfully in treatment. She receives electroconvulsive therapy and participates in cognitive behavior therapy as her treatment plan. She is a residential therapist in an adolescent addiction treatment facility. Contact her on her mental health support Instragram account: @caitlins_counseling_corner.

****

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.

Bassey Ikpi shares her gradual journey toward a healthy relationship with therapy

By Lindsey Phillips April 19, 2021

Bassey Ikpi, a spoken word poet, writer and mental health advocate, opened the third week of the American Counseling Association’s 2021 Virtual Conference Experience by sharing details from her own mental health journey. She recalled that her first encounter with mental health awareness happened in elementary school. An avid reader, she consumed whatever she could get her hands on, including her mother’s psychology textbooks and subscription to Psychology Today.

In particular, Ikpi remembers how Psychology Today’s May 1986 cover story on Howard Hughes shaped her relationship to mental health. The article discussed Hughes’ struggle with obsessive-compulsive disorder, describing in detail how he locked himself naked in a hotel room, refused to brush his teeth or cut his hair and nails, and wore Kleenex boxes on his feet.

That image would be startling to most anyone, let alone a 9-year-old, but what stood out the most to Ikpi was how no one helped Hughes. “I told myself that if I ever needed help, I’d find a way to get it,” Ikpi related to the audience for her keynote. “I never wanted to get to the point where I was wearing Kleenex boxes on my feet.”

Finding help

Ikpi, author of the bestselling memoir I’m Telling the Truth, But I’m Lying, first had serious bouts of depression during college. She said that she vacillated between being unable to sleep and unable to get out of bed, and she maxed out her credit card.

Even though Ikpi felt OK at the time, she was concerned enough to seek out the counseling services on campus. The counselor sat across from her and just scribbled in her notepad the entire session, Ikpi recalled, which left Ikpi feeling unheard and unseen. “I had walked in nervous but hopeful, and walked out discouraged and determined never to return,” she told the audience. “If this was counseling, I thought, ‘I’m good.’”

A few years later, however, Ikpi found herself in distress again when, during a hypomanic episode, she took a spontaneous trip to New York City and ended up dropping out of college and moving to Brooklyn. She hoped the move would keep her moods at bay, but it didn’t work. Ikpi sought help, but like her first experience, the therapist mainly wrote notes on a legal pad and asked clinical, nonpersonal questions. Once again, Ikpi left feeling that seeking therapy had been a waste of time.

After joining the Tony Award-winning Broadway show Def Poetry Jam, Ikpi found that her previous coping methods no longer worked, and she started to deteriorate quickly. She was losing weight, not sleeping and withdrawing. After having a breakdown backstage, the stage manager told her, “If you don’t get help, Bassey, you’re going to die.”

Ikpi left the tour the next day with a list of doctors, determined to get help. “Because of my past experiences with counseling, I walked in with an agenda. I wanted to be helped, but only as far as I would be able to accept,” she said. Her goal was to get enough help that she could return to her job.

After receiving several misdiagnoses, Ikpi walked into the office of the last doctor on her list. This therapist didn’t have a notepad. She instead had a conversation with Ikpi, and for the first time, Ikpi felt heard.

“That meeting was what began my journey toward a healthy relationship with therapy. It taught me the kind of therapy that works best for me,” she told the audience. This therapist also introduced her to another psychiatrist who gave a name to what Ikpi was experiencing — bipolar II disorder.

Overcoming the shame of mental health

Ikpi admitted that her first instinct was to keep quiet about her diagnosis out of a fear that it would change the way others perceived her. But she noticed that the shame also meant she wasn’t able to fully take care of herself.

Shortly after being diagnosed, Ikpi was watching an episode of the TV series Girlfriends in which one of the characters finds out her biological mother had bipolar disorder. Ikpi remembers thinking, “They’re going to have a conversation about bipolar disorder. That’s going to make it so much easier for me to have this conversation when I need to have it.” But the series dropped the ball, Ikpi said, because when the character asks a friend if she has inherited the disorder, the friend quickly dismisses the possibility, saying that the character is amazing, not “crazy.”

“The juxtaposition between ‘crazy’ and ‘amazing’ was trying to dispel all these things that I knew to be true about myself and my experience and my diagnosis,” Ikpi said.

Frustrated by this experience, she wrote about her diagnosis on her blog. She acknowledged to the keynote audience that this was in part a selfish act because she didn’t want to feel alone anymore and hoped to find someone else living with a bipolar disorder.

That blog post was the beginning of Ikpi finding ways to create “space for other people to name what they were experiencing, get encouragement from people and then do something about it.” Ikpi, founder of the Siwe Project, a nonprofit aimed at promoting mental health awareness in the Black community, started the global movement #NoShameDay to encourage people of African descent to share stories about mental health issues without shame and to seek help if needed.

She credits the success of #NoShameDay with the fact that “people are given permission to deal with this out loud as opposed to quietly where you can talk yourself out of it or … where you can ‘other’ yourself in a way that makes it uncomfortable to live in your own brain.”

Ikpi also told the audience it’s no coincidence that #NoShameDay falls on the second Monday in July, which is Minority Mental Health Awareness Month. While #NoShameDay day exists for everyone, it’s especially for the Black community because they are the ones who are consistently penalized for their mental health, she noted. “Our mental health is criminalized; our mental health is legislated in ways that others aren’t so [this movement] … bring[s] attention to that,” she said. The movement humanizes mental health by making “it about people’s lived experiences and their stories and not a collection of texts or a list of diagnoses.”

Growing through therapy

Ikpi compared living with an untreated mental health diagnosis with “living in a run-down house in a bad neighborhood,” where she learned how to survive and cope with what she was given. Continuing this analogy, she said that medicine allowed her to move to a better neighborhood, and therapy taught her how to traverse this new neighborhood.

“Your instinct … is to fall back on the habits that worked before. Therapy teaches me a new way to navigate when the old ways are no longer working or no longer serving my needs,” she explained.

Ikpi also shared that some people have aligned her diagnosis with her artistic ability, telling her that if she didn’t have bipolar disorder, she wouldn’t be the writer that she is. To which she responds, “I would rather not be a writer. I would give it all up. I don’t write because of bipolar disorder. I write despite it.”

“Having bipolar disorder isn’t who I am; it is what I have,” she told the audience. “It doesn’t define me anymore than being short or wearing glasses. It’s just a part of what … I have to navigate the world with.”

Ikpi concluded by reminding mental health professionals of how important their job is. “It’s a service that I don’t think is rewarded enough,” she stressed. “I would not be here — literally would not exist — if it wasn’t for the people who have made it their job to care about people like me.”

****

This keynote address is part of a month of virtual events, including hundreds of educational sessions and three additional keynotes, that lasts through April 30.

Find out more about the American Counseling Association’s 2021 Virtual Conference Experience at counseling.org/conference/conference-2021

Registration is open until April 30; participants will have access to all conference content until May 31.

****

 

Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@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.

First lady speaks up for mental health

By Bethany Bray March 6, 2015

Imagine if people reacted to a friend or neighbor’s diagnosis of bipolar disorder or depression no differently than if they just learned that person has breast cancer or heart disease.

“Whether an illness affects your heart, your leg or your brain, it’s still an illness. It shouldn’t be

First Lady Michelle Obama speaks at the launch of the Campaign to Change Direction, March 4 in Washington, D.C.

First Lady Michelle Obama speaks at the launch of the Campaign to Change Direction, March 4 in Washington, D.C.

treated differently,” said First Lady Michelle Obama at a mental health summit in Washington, D.C. this week. “There should be absolutely no stigma around mental health. None. Zero.”

Normalizing mental illness in the United States will take a cultural shift, a shift that will hopefully begin as more and more people talk about it and share their stories. This was the message at Wednesday’s launch of the Campaign to Change Direction, a joint project between numerous mental health, business, nonprofit and government agencies that aims to break down the stigma surrounding mental health. First Lady Michelle Obama was the event’s keynote speaker.

The campaign asks people to pledge to learn and spread awareness of the five signs of emotional suffering that may indicate a person needs help: withdrawal, agitation, hopelessness, decline in personal care and change in personality (see sidebar, below).

We want these five signs of suffering to be as well-known as the warning signs for a stroke or heart attack, said Todd Mahr, a regional partner of the campaign in LaCrosse, Wisconsin, a physician and director of pediatric allergy and immunology at Gundersen Health Systems.

“We’re undertaking a marathon, not a sprint,” said Mahr. “With this launch, I have hope.”

The campaign’s ultimate goal is to change the landscape in America so that mental health has the

Bruce Cohen, producer of the 2012 movie "Silver Linings Playbook" speaks at the launch of the Campaign to Change DIrection.

Bruce Cohen, producer of the 2012 movie “Silver Linings Playbook” speaks at the launch of the Campaign to Change DIrection.

same importance and value as physical health. Campaign partners, from Aetna to Easter Seals and Volunteers of America, have pledged to host programs and distribute materials over the next five years to further the campaign’s mission of “changing the national conversation about mental health.”

“It is really time to flip the script on mental health in this country. Getting help is not a sign of weakness. It’s a sign of strength,” said Obama. “(Those who suffer from mental illness) should be able to get the help you need. End of story.”

According to data from the National Institute of Mental Health (NIMH), an estimated 42.5 million Americans – about one in every five adults – experience a diagnosable mental disorder in a given year.

“We want to create a new normal, where asking for help (for mental illness) is not a sign of weakness,” said Angelo McClain, CEO of the National Association for Social Workers. “We want people to be able to raise their hands and say ‘I need help’.”

At Wednesday’s event, the first lady urged people to listen, connect and offer compassion to those with mental illness so they can get the help they need.

“Reach out and have those tough conversations with a friend,” she said.FLOTUS

Obama’s keynote speech concluded a morning of discussion and talks on mental health issues. Video of the event was streamed live on the Internet and is posted at changedirection.org.

“We will save lives in the year ahead,” Obama concluded. “Let’s roll up our sleeves and keep getting stuff done.”

 

****

 

Take five

 

The Campaign to Change Direction’s five signs that may mean someone is in emotional pain and needs help:

  • Personality change: Sudden or gradual changes in the way that someone typically behaves. He or she may behave in ways that don’t seem to fit the person’s values, or the person may just seem different.
  • Agitation: More frequent problems controlling temper, irritability or an inability to calm down. Symptoms may also include insomnia or explosive displays of anger in response to minor problems.
  • Withdrawal: Pulling away from family and friends, not taking part in activities the person used to enjoy. In more severe cases he or she may start missing school or work. These symptoms should not to be confused with the behavior of someone who is more introverted, but a marked change in someone’s typical sociability.
  • Poor self-care: A deterioration of personal hygiene, which may include things like not bathing or wearing unclean clothes. Lack of self-care can also include abuse of alcohol or illicit substances or engaging in other risky behaviors.
  • Hopelessness: An inability to hope or look forward to anything. Symptoms may also include feelings of worthlessness or guilt. May also include statements such as “The world would be better off without me,” which may be a sign of suicidality.

 

****

 

Be the change

 

For more information or to get involved with the Campaign to Change direction, visit changedirection.org

 

****

 

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

 

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

 

 

The stigma of mental illness and the noble savage myth

By Jonathan Schildbach and Jeffrey T. Guterman May 29, 2014

Branding-AvatarDespite the seemingly widespread understanding that mental illness is a disease that can be effectively treated, prejudice toward individuals with mental health issues still pervades our society. People with such conditions are often depicted as undesirable and incapable of maintaining meaningful personal relationships or holding positions of authority. Organizations such as the National Alliance on Mental Illness and the National Institute of Mental Health have led efforts to overcome the stigma of mental illness. In addition, anti-stigma campaigns have been developed to end discrimination surrounding mental illness. The American Counseling Association has also encouraged its membership to play an active role in the fight against mental health stigma. It is clear that the stigma surrounding mental illness is both a social justice issue and a public health issue.

Stigma compounds the already challenging problem of mental illness. Just as oppressive as its symptoms is the effect of the dominant story in our culture about mental illness that tends to marginalize, subjugate and pathologize individuals with such conditions. Actress and activist Glenn Close, who co-created the anti-stigma campaign Bring Change 2 Mind, suggests that the stigma is worse than the mental illness itself. Stigma affects all sectors of society. For example, the U.S. military has developed programs to combat stigma associated with mental illness and improve quality of care for soldiers who are increasingly dealing with posttraumatic stress disorder and other conditions.

An international study by researchers at Indiana University in 2013 found that stereotyping is a main source of stigma surrounding mental illness. Although notable efforts have taken place to create accurate portrayals of mental illness in the entertainment industry and media, many depictions continue to disseminate stereotypes and other information that is just plain wrong. But rejection of negative stigma may also lead to positive stigmatization: attaching stigmas that are intended to grant a kind of protected or special status to clients with mental illness. The problem with stereotyping of any kind — even if there are positive intentions behind such views — is that it categorizes the objects of the stereotyping as people who are somehow “other.”

In this article, we present the concept of the “noble savage” as a metaphor for understanding how the general public and, in particular, counselors may stigmatize people with mental illness. The noble savage is a fictional archetype based on a common social stereotype. The noble savage describes an idealized indigenous person, outsider or “other” who has not been corrupted by modern civilization, therefore symbolizing the innate goodness of humanity. The noble savage concept suggests that indigenous, native people are somehow closer to nature and therefore possess a heightened spirituality compared with “civilized” people who do little more than corrupt or destroy the natural world.

The phrase noble savage first appeared in the 1672 play The Conquest of Granada by John Dryden. In his play, Dryden differentiates between a world of laws, which includes civilized people, and a world of nature before such laws were brought to bear. The former consists of controlled, debased humans separated from God by modern societal constructs; the latter is a free, natural, wild world populated by noble savages — humans in their pure state.

Examples of the noble savage are replete in contemporary films, including Avatar, Dances with Wolves, The Last of the Mohicans and The Last Samurai, tales in which invaders, corrupted by their desire for wealth and conquest, are contrasted with more primitive cultures. Most of these narratives involve a member of the invading culture turning against one’s own kind to champion the cause of the noble savage. For example, Avatar is about tall, striped blue beings living in trees — the noble savage Na’vi — who are rescued by a white male who comes from a technologically advanced planet that is attempting to plunder Na’vi resources.

Films based on actual events have also depicted the noble savage concept. Mississippi Burning casts the struggle of African Americans in terms of how members of the dominant white culture become involved with resolving the other’s situation. Those who are not part of the dominant culture take a back seat in their own struggle to be recognized as equals and treated with dignity.

Viewing clients as noble savages

It is easy for counselors to metaphorically transform clients into noble savages. From this perspective, mental illness provides some measure of immunity from the modern world and the maladies that make those who do not struggle with such conditions somehow more corrupt. It follows that mental illness takes a person out of the normal flow and function of modern life; it comes to be seen as a purifying agent, something that makes people with mental illness “good.” Yet such a view contributes to the belief that those with mental illness are ultimately uncivilized and less than human. Hence, viewing people with mental illness as “noble savages” creates and perpetuates stigma.

The concept of heroism associated with entering into the world of the noble savage is particularly relevant for counselors. Perhaps some counselors see themselves as “champions” for clients, not only because counselors have the means to bring about positive change, but also as a result of assigning clients a special status as people incapable of helping themselves. Effective counseling requires an ability to guide clients to identify their own strengths and problem-solving skills. If a counselor falls into the trap of viewing clients as noble savages, then he or she may see clients as “good” but also ultimately incapable of making their way in the same world that so-called “normal” people occupy. In such cases, the counselor becomes primary, a member of the dominant culture, while the client becomes secondary, a representative of the “other.” The counselor becomes the hero, the client someone to be saved.

It is important for counselors to recognize the precise meanings of their descriptions of clients. Although counselors may use the Diagnostic and Statistical Manual of Mental Disorders, such diagnoses should serve as limited guidelines for treatment, not labels that confine clients to roles as limited persons. Any label connected to mental illness must be approached with clear self-reflection. If counselors place themselves in the role of hero, then clients may not be afforded an opportunity to be empowered during the change process. Therefore, it is critical for counselors to consider if they are viewing clients with mental illness as essentially different from themselves.

Challenging the noble savage myth

Viewing clients with mental illness through the noble savage lens amounts to a fundamental denial of human nature and, in turn, contributes to stigma. Cognitive psychologist Steven Pinker has suggested that humans are not born as blank slates but, rather, have predetermined faculties for various traits, including language, memory and perception. Similar to the blank slate, the noble savage continues to be an influential concept in modern society. It has contributed to the development of ecological movements that distrust all things man-made and synthetic. The noble savage has also occasioned the emergence of the recent utopian view of bullying as a phenomenon to be eliminated rather than a fact of life that has always been and which is inevitably tied to aggressive and competitive tendencies in humans.

Research in various disciplines suggests that mental illness is deeply rooted biologically and can be explained in terms of evolutionary development. Advances in genetics have shown that personality traits are heritable. Neuroscience has identified brain mechanisms associated with aggression. And evolutionary psychology has taught us that the pervasiveness of human violence is related to Darwinian processes. Although there are cross-cultural differences between people, human universals suggest we are more alike than different. It is a misconception then to think of human beings in terms of “us” who are free from mental illness versus “them” who are uniquely plagued by such conditions.

Viewing clients as noble savages in need of rescue and counselors as their saviors ignores the ubiquitous nature of mental illness and the complex ways that mental illness can arise. According to the Centers for Disease Control and Prevention, 25 percent of U.S. adults have a mental illness. Mental illness is a complex phenomenon related to genetic, psychological and social factors. We are all prone to mental illness. For counselors to reduce themselves and their clients to archetypes is to deny that each of us encompasses a wide range of assets and deficits. We do not exist as simplified characterizations of virtue and vice.

What now?

Counselors serve an important function in combating stigma because of their relevant education, training and experience, as well as their direct contact with clients, educators, health care providers and policymakers. A major part of the effort to address stigma involves calling attention to the underlying attitudes that reinforce stigma and then working to change those attitudes. Like the culture at large, counselors often view people with mental illness in terms of established cultural narratives, such as that of the noble savage, which casts individuals in terms of stereotypes. Counselors need to examine their own beliefs and practices to ensure they do not perpetuate such stigmas.

Sometimes counselors buy into stereotypes about mental illness using the same inaccurate language and biases as social institutions, the media and the general public. For example, some counselors may refer to a client as “a borderline” rather than a client who has been diagnosed with borderline personality disorder. Becoming aware of expressions of stigma is an important role for counselors, and learning how to challenge these expressions is a critical skill. Counselors can reinforce their own anti-stigmatizing efforts by helping colleagues, friends and family members identify instances when they use diagnostic terms as insults or pejoratives. In addition, counselors can involve themselves in the efforts of organizations to fight stigma and call attention to inaccurate portrayals of people with mental illness in the media.

Perhaps most important, counselors have unique opportunities to help fight stigma in their clinical relationships with clients. Counselors can promote social justice in the fight against stigma one case at a time. This can be achieved by viewing clients as individuals with their own resources, strengths and skills. Clients must not be confined to roles as noble savages — good, but incapable. Instead they should be viewed as complete human beings who have struggles that we all share as part of the human family.

 

****

 

Jonathan Schildbach is a licensed mental health counselor in Seattle. Follow his blog at respecttheblankie.com, and contact him at jcschildbach@gmail.com.

 

Jeffrey T. Guterman is a licensed mental health counselor in Fort Lauderdale, Florida. Visit his website at JeffreyGuterman.com, and contact him at jguterman@gmail.com.

 

Letters to the editor: ct@counseling.org