Tag Archives: stress & anxiety

More than simply shy

By Bethany Bray July 29, 2019

Social anxiety is different from — and much more than — simply being shy or introverted or having poor social skills. Even so, people who live with social anxiety often find the disorder trivialized or minimized by others, including some mental health professionals, according to Robin Miller, a licensed professional counselor (LPC) and a member of the American Counseling Association.

“Shyness doesn’t necessarily have a negative impact on someone’s life. That’s an important thing to remember from a clinical point of view,” explains Miller, who specializes in working with adults with anxiety disorders at an outpatient practice just outside of Milwaukee. “Many of my clients get a pat on the head from people and [comments such as], ‘You’re just shy. You have nothing to worry about.’ But you wouldn’t get that for [symptoms of] posttraumatic stress disorder or other mental health issues. You wouldn’t say there’s nothing to worry about.”

Most of all, clients with social anxiety need support and reassurance as they try to discontinue old patterns and behaviors that they have adopted to cope with the paralyzing fear that often accompanies the disorder, says Brad Imhoff, an LPC who was diagnosed with social anxiety disorder in 2012 as he was working on his doctorate.

One characteristic of social anxiety is a constant feeling of apprehension regarding social situations. It is difficult to express just how oppressive and pervasive that feeling can be, says Imhoff, an assistant professor of counseling at Liberty University who lives in central Ohio and teaches in the university’s online program. “You carry this feeling of ‘I just can’t do this’ all the time,” he says. “As human beings, we’re social. And apprehension in every one of [those social situations] can be overwhelming.”

Imhoff, a member of ACA, says he recognizes the irony of his career choice: a person with social anxiety who speaks regularly to rooms full of people, both as a counselor educator and as a frequent presenter at conferences, including giving a session on social anxiety at the ACA 2019 Conference & Expo in New Orleans.

Imhoff has learned to navigate the challenges of social anxiety since his diagnosis, but he acknowledges still feeling anxious before speaking engagements. “The question is, how do I manage it and not let it get in the way of life?” he says. “I will have to manage this, to some extent, for my entire life and not let it get to the extremes it has in the past.”

Navigating life through avoidance

Social anxiety is one of a number of related issues — including specific phobia, panic disorder, separation anxiety disorder, generalized anxiety disorder and others — that fall under the anxiety heading in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Called social phobia in decades past, social anxiety disorder is characterized by persistent fear over social or performance-related situations, according to the National Institute of Mental Health, which cites diagnostic interview data to estimate that 12.1% of U.S. adults will experience social anxiety disorder during their lifetime. Among adolescents ages 13-18, the lifetime prevalence is 9.1%. For all ages, social anxiety disorder is more prevalent in females than in males.

Researchers have not singled out a specific cause for social anxiety disorder, pointing instead to a combination of biological and environmental factors as contributors. Genetics appears to play a large role in many cases, as can negative childhood experiences such as family conflict or being bullied, teased or rejected by peers. It is also believed that individuals who have an overactive amygdala may experience more anxiety in social situations.

According to the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, “Social anxiety disorder can affect people of any age. However, the disorder typically emerges during adolescence in teens with a history of social inhibition or shyness. The onset is usually accompanied by a stressful or humiliating experience, and the severity varies by individual. … There is a higher incidence of social anxiety disorder in individuals with first-degree relatives affected by other panic and anxiety disorders. However, there is no one gene that explains this biological trend. General findings indicate that personal experiences, social environment and biology all play a role in the development of the disorder.”

People often experience symptoms of social anxiety disorder to varying degrees across the life span, according to the center. Symptoms may lessen for stretches of time and then worsen during periods of change or stress, such as a job transition or when dealing with feelings of grief and loss.

What sets social anxiety apart from general anxiety is not only the social component but also an intense fear of judgment by others, explains Holly Scott, an LPC whose Dallas private practice is a regional clinic of the National Social Anxiety Center. People with social anxiety often harbor strong and pervasive feelings that others will notice their anxiety and judge them, which triggers avoidance behaviors, she says.

At the same time, there are nuances to the diagnosis, and social anxiety can look different in each client, Scott adds. For example, someone may be fine with public speaking and yet not be able to walk into a room in which they don’t know anyone.

“People think it’s not treatable,” Scott says. “Clients label it as ‘this is just the way I am, and I can’t change the way I am.’ It can be difficult to treat or to find a qualified practitioner, but it is treatable.”

Imhoff says he has read that on average, people go 15 years before seeking treatment for social anxiety. Counseling itself is a social interaction, he notes, and people with social anxiety may avoid treatment out of a fear of the close interaction or of being scrutinized by a practitioner.

Because people with social anxiety typically adopt avoidance as one of their coping mechanisms, and perhaps because of the way that social anxiety tends to get minimized or passed off as simply being introverted or shy, these clients often live life without seeking treatment until they reach a breaking point. As Imhoff points out, people can self-manage their social anxiety for an extended period of time by maintaining the same small circle of friends and following certain behavioral patterns such as always using the self-service checkout line at the grocery store.

Living with social anxiety is their reality, Imhoff explains, and they “forge ahead until something causes [them] to realize it’s more significant.” For Imhoff, that “something” was the impending scrutiny involved in defending his doctoral thesis.

“For social anxiety, it’s possible to navigate life with avoidance and survive for a long time. Then something comes up — a life change, such as entering the workforce — that causes them to need help,” he says. “A lot of these safety behaviors aren’t being done consciously. They are things we’ve done throughout our lives to find safety.”

Assessment and core beliefs

Avoidance behaviors are one of the biggest red flags that a client might be dealing with social anxiety, Miller says. These behaviors can extend to staying in situations in which the person is unhappy yet comfortable, such as a bad romantic relationship, a toxic friendship or a job that the person doesn’t enjoy or isn’t advancing in.

Other indicators include rumination and overthinking social experiences. This can include asking oneself over and over again, “What did that person think of me?” Miller explains, whether it’s an interaction with a neighbor while walking the dog or a yearly performance evaluation with one’s supervisor.

Counselors should be aware that social anxiety often co-occurs with other mental health issues such as depression and substance abuse (which often becomes a coping mechanism) that may need to be treated first or in tandem with the disorder, Miller adds. In addition, other issues such as grief may be complicating a client’s social anxiety. “They’re not always struggling with one thing. Make sure you’re working on what they’re struggling with the most,” Miller says.

Scott suggests asking clients at intake about how they deal with social situations and how often they go to gatherings or parties. Are they uncomfortable introducing themselves to new people, making a phone call or using the restroom in public places? If Scott hears symptoms that might indicate the presence of social anxiety, she uses a questionnaire (she recommends the Liebowitz Social Anxiety Scale, available at nationalsocialanxietycenter.com) to pinpoint the client’s fear level and to identify goals to focus on in therapy.

It can also be helpful to identify a client’s core beliefs and values and how those are affecting the person’s choices and behaviors, Imhoff says. People with social anxiety often carry a core belief that they’re inadequate or inferior, which spurs a fear of being judged, he explains. These clients frequently place weight and focus on situations that seemingly confirm their core belief and discount those that might disprove it. They might ruminate over a conversation with a colleague that didn’t go well, for example, without giving any consideration to all of the past conversations that did go well, Imhoff notes.

“They move through life paying very close attention to and taking to heart scenarios that confirm their core belief,” he says. “It’s important to help the client take off the blinders. Talk through ways they are competent, and get to the root of their concerns. Be aware of the multitude of their experiences and not just those they struggle with.”

To identify core beliefs, counselors can listen for themes in the way that clients talk about themselves, other people and the world. These themes can suggest deeply held beliefs to challenge or to explore further in therapy. Having clients work on thought journals can also be helpful in finding patterns, Imhoff says. He also suggests using a prediction log, in which clients name upcoming social scenarios that make them anxious and describe what they assume will happen. After the scenario occurs, clients can look back at their predictions with the counselor to talk through how accurate these foresights were.

After core beliefs and values have been identified, the counselor can work with clients to reframe their perspective around new core beliefs. For example, clients who place value on providing for their family could focus on that value to help them overcome their anxiety and discomfort over applying for a new job.

“Look for evidence that supports their new core belief,” Imhoff says. “If their belief is ‘I am capable,’ have them write down even the most minor piece of evidence [in a journal]. It makes it concrete and documented so they can refer back to it and talk it through with a counselor.”

From there, the counselor can work with clients on challenging cognitive distortions and black-and-white thinking, Imhoff suggests. Acceptance and commitment therapy (ACT) can be helpful, as can guiding clients to adopt a growth-focused orientation. With that mindset, every social interaction becomes an opportunity to learn rather than a pass-fail situation, Imhoff explains.

Clients with social anxiety may also feel that they’re failing because they can’t assume an extroverted, life-of-the-party façade. Counselors can help these clients learn that there is a continuum of social skills, Imhoff says. For example, perhaps they got through a work meeting and contributed their thoughts despite having a shaky voice and sweaty palms. “Work on [helping them realize] that it’s not black and white, it’s not all success or failure. There’s an in between for almost all scenarios,” he says. “Help them to recognize that in all social interaction, there is ebb and flow. It’s not a pass-fail exercise but an opportunity to connect with someone and learn moving forward.”

Additionally, ACT techniques can help clients learn to accept their anxiety rather than trying to get rid of it or avoiding triggering situations. Imhoff uses the imagery of “keeping anxiety in the passenger seat because I know it’s coming along but not letting it take control of the wheel.” Clients can learn to say, “There you are anxiety; I knew you were coming,” even as they move on with life and navigate situations they previously would have avoided.

Scott regularly uses cognitive restructuring and cognitive behavior therapy (CBT) with her clients who have social anxiety. She also uses a mindfulness technique called curiosity training that helps clients label their anxious thoughts as “background noise.” With this technique, users try to adopt an approach of curiosity about and interest in what is being said by others rather than assuming that others are judging them.

“In any situation,” Scott says, “whether they’re having a conversation, public speaking or sitting somewhere having lunch, they’ve usually got a constant dialogue going in their head. [It’s] self-criticism about how people must be thinking of them: ‘They don’t like my clothes’ or ‘I just stuttered while speaking.’ Curiosity training helps keep your mind on the present and learn how to pull your mind back when it starts wandering.”

Elizabeth Shuler, an LPC who has been working as an international school counselor in Amman, Jordan, for four years, recommends mindfulness techniques. She has often used Kristin Neff’s self-compassion practices in addition to dialectical behavior therapy, meditation and yoga for clients with social anxiety, both when she was in private practice in Colorado and Wyoming and currently in her work with adolescents and adults at her school.

“When we dig into their fears, most clients with social anxiety are really afraid that other people will agree with their own negative judgments of themselves. They’re worried that they will be proved right,” says Shuler, an ACA member. “I had a client who walked through the office the same way every day to avoid the people he was afraid of interacting with and had panic attacks when his route had to change or people he was avoiding crossed his path. These types of behaviors are meant to stave off panic but end up reinforcing it. My role as a counselor is to help clients see how these behaviors are actually making their panic worse and help them to slowly replace them with more helpful behaviors.”

Exposure

Exposure techniques are often central to treating social anxiety because they gradually reintroduce clients to anxiety-provoking situations in a healthy way.

Miller is trained in exposure and response prevention and finds it a powerful tool for working with clients with social anxiety. The behavioral technique requires clients to put in a lot of work themselves outside of sessions. The counselor collaborates with the client to develop a hierarchy of exposure based on the client’s needs and treatment goals and supports the client throughout the process.

As Miller explains, exposure assignments start small and build over time as clients become comfortable with each homework task. She describes this as a “Goldilocks situation” — not too much challenge and not too little, but just the right amount, tailored to each individual client. Miller says she emphasizes to clients that the treatment is in their hands — they have to do their part to experience a successful outcome.

“A lot of people have anticipatory anxiety, but once they do it [complete the exposure assignment], they’re OK,” Miller says. “A lot of people get over that hill of worry. They do it for a week or two and realize they can do it. Trust between a client and clinician is huge because we’re asking them to do really scary things.”

Miller often gives clients who are early in treatment the assignment of calling multiple businesses to ask what their hours are. Clients might have to overcome feeling a little foolish because that information is readily available on the internet, she notes. However, the goal is for clients to complete the task without falling back on habits they formed to avoid social situations, such as relying on technology in lieu of having personal interactions. Clients repeat the task over and over until they no longer feel anxious about picking up the phone and making a call, she explains.

Once they’ve mastered that task, clients might move on to going inside a store and asking a question in person. Or they might switch to walking their dog in their neighborhood during a busy time of day and saying hello to at least one other person during each walk.

As clients complete each task and return to their next counseling session, they process these interactions with Miller, discussing how the interactions felt to them and what went right or wrong. “Sometimes the client will come in and say, ‘I’m so bored with this.’ I say, ‘Great! That means it’s time to move on to something bigger,’” Miller says. “You need repetition with assignments. You need to do [tasks] over and over for your brain to get used to it. … The more you do it, [the more] it overwrites [old] patterns and anxious feelings.”

As a practitioner who specializes in treating social anxiety, Scott has a laundry list of exposure assignments that she uses with clients, ranging from making eye contact during a shopping trip to asking for directions from a stranger to calling into a radio talk show to singing karaoke. As clients progress, it can be helpful to assign them tasks that are certain to create some level of discomfort or awkwardness, such as going into Starbucks and ordering a hamburger, she says. This can be especially hard for clients who have a strong fear of being judged by others, but dealing with the responses they receive desensitizes these clients over time as they repeat the tasks.

Miller acknowledges that counselors may need to provide their clients with some ongoing motivation during exposure work. If clients come to session without completing their assigned tasks, she suggests asking leading questions to find out if they are avoiding the work or genuinely struggling to make it a priority among their other challenges.

“Who wants to go home and do anxiety-provoking things?” Miller says. “[We] have to find a way to motivate them. We want them to feel empowered to go out and do [an assignment]. Remind them that they’re in pain because something is not changing. … You can’t snap your fingers and make this go away. It’s going to be hard work and take time.”

It can be useful to circle back and remind clients of their core beliefs and the goals they want to achieve. For example, consider clients who say they ultimately want to start a family but whose social anxiety prevents them from entering the dating scene and potentially meeting a partner.

“They may not see how calling a drugstore [as an exposure assignment] is getting them to be able to date. But remind them that they’re building a foundation to be able to do that,” Miller says. “It may not have an immediate payoff, but the easier these things become for you, everything builds.”

Miller often uses the metaphor of training for a marathon to keep clients motivated. You don’t run 26.2 miles right away, she tells them. You start with one or two miles and then keep adding more distance, mile by mile.

Social skills

In addition to exposure work and cognitive restructuring, the counselors interviewed for this article recommend social skills training for clients with social anxiety. Avoidance behaviors may have kept these clients from learning and practicing social skills that are commonplace among their peers who do not deal with social anxiety.

“If you’ve been avoidant for years, you miss out on learning from all of the social interaction that others have had,” Miller says. “Sometimes they’ve built a life to minimize their pain, their anxiety.”

Goal setting and planning ahead, with support from a counselor, can help these clients navigate situations that are foreign to them and that naturally provoke anxiety. Miller suggests troubleshooting with clients. For instance, if their office holiday party is coming up, a counselor can talk through expected behaviors with clients and work on small talk and other exercises to help them get through the evening.

Setting realistic goals can also be comforting, Miller adds. “[They] don’t have to go in and work the room, [but] if they haven’t had a lot of social experience, they may not realize what’s expected,” Miller says. Instead, clients might set a goal of talking to three people whom they already know. Maybe at next year’s party, they can increase that goal from three people to five people.

Miller also reminds clients that a certain measure of social anxiety is simply part of being human. Even she, a therapist who makes a living talking to people, acknowledges sometimes being uncomfortable in social situations.

Kevin Hull is a licensed mental health counselor with a private practice in Lakeland, Florida, who specializes in counseling children, adolescents and young adults on the autism spectrum. Social skills training, along with group therapy, plays a large role in the work Hull does with clients around social anxiety, which he says often goes hand in hand with autism.

In individual counseling sessions, Hull uses puppets with clients to role-play social situations and work through what is expected. For example, Hull might instruct clients to verbalize a food order to his puppet without the usual help from mom or dad or ask his puppet for help finding a certain building on a school campus. Afterward, they process the experience together and talk about the emotions clients felt as their puppet had to interact and ask questions.

Humor can also be a great tool for overcoming the fear associated with social anxiety, says Hull, a member of ACA. He often shows clips of TV shows or movies (via YouTube) in client sessions as a lighthearted way of starting conversations about what is and isn’t appropriate when it comes to social skills. Particularly popular with clients are scenes with The Big Bang Theory’s Sheldon Cooper wrapping himself in bubble wrap to stay safe or wearing a second set of “bus pants” over his work outfit when taking public transportation. Another favorite is the title character in How the Grinch Stole Christmas, who initially can’t stand being around the Whos but ends up transforming over the course of the story.

“Using humor is a great thing to counter the fear,” Hull says. “When you can laugh at something, that gets people opening up and listening.”

Group work

Group therapy — a format in which clients are expected to interact with others and contribute to a discussion — would seem to be a nightmare for individuals who are socially anxious. But that’s not necessarily the case, according to Hull.

Although it can take clients some time to warm up to the idea, group therapy can play a powerful role in imparting the skills needed to navigate social anxiety, says Hull, an assistant professor and faculty adviser in Liberty University’s online master’s counseling program. In addition to helping participants sharpen their social skills, group counseling can instill perspective — something with which Hull’s clients who are autistic sometimes need extra help.

“With autism, clients have a hard time putting themselves in others’ shoes, so group is a great way for them to hear from the mouths of peers [and] hear them talk about what they’re going through,” Hull says. “Maybe someone [in group] had to ride a different bus than usual. It was terrifying at first, but they were OK and actually ended up talking to the person they sat next to.”

The group format, in which participants take turns offering comments, can model and teach the back-and-forth “tennis match” that is the basis of healthy conversation, Hull adds. It can also help clients learn to tolerate and listen when someone is talking about a subject that doesn’t interest them — a circumstance that previously would have triggered their fight-or-flight response and caused them to exit the situation.

Hull often has group participants speak for five minutes each on something they are passionate about. Afterward, he urges all of the group members to ask questions or make a comment about what was said.

“This is really hard with autism. If they don’t like something, it’s utterly meaningless to them,” Hull says. “This has them put themselves in others’ shoes and imagine how it’s like [something that they] like. This can transfer to social situations outside of group, such as a dinner party where other people are talking about whatever. Can you listen and learn something? It’s teaching their brain to overcome fear and learn a new normal. Everyone is scary when you first meet them, but you can do it. If you can do it in group, it’s the same as at school or a new job.”

Hull also uses video games in sessions as a way for participants to learn about group dynamics, leader/contributor roles and overcoming frustration (see sidebar, below).

It is important to prepare individuals with social anxiety for the group setting as much as possible ahead of time. Hull often shows clients the group room at his office (or emails them photos of it) and explains the format and what sessions will entail before they join group counseling.

“I walk back to the [group] room with the client and their caregiver before a group session so they can see it,” Hull says. “I explain, ‘Everyone who is coming here feels what you feel, and they’re all struggling with this.’”

When new clients join a group, he never makes them introduce themselves or speak right off the bat. He also allows them to bring anything that might boost their courage, such as a favorite stuffed animal or even a parent in the cases of younger clients. With social anxiety, it is important to allow clients to warm up and contribute at their own pace, he says.

“I can see group members five or six sessions in and they haven’t talked yet. I never stop trying to get them to engage or open up, even if all they can do is a head nod or fist bump,” Hull says. “[I emphasize that] I’m just happy they can be in the room.”

Hull acknowledges that group counseling isn’t a fit for every client who struggles with social anxiety. Social anxiety falls on a spectrum, and for some clients, the disorder is so severe that a group setting would be too much, he says. It is important to continue individual sessions with these clients, with group counseling becoming a possible long-term goal for some of them, he says.

When it comes to group counseling and social anxiety, it is crucial to take things step by step and to celebrate little victories, Hull emphasizes. With clients on the autism spectrum “the victories are fewer and far between,” he acknowledges, “but when they happen … you feel like you’ve won the Super Bowl.”

The long haul

Hull says that counselors should view social anxiety as a process rather than something to “fix.” Neuroscience tells us that the brain responds better to slow and steady change rather than forced or rushed adaptation. This is especially true for clients who struggle with social anxiety in addition to neurodevelopmental issues, past trauma or other mental health diagnoses, Hull notes.

Something else that counselors should avoid is projecting their assumptions onto clients with social anxiety. Just because the counselor went to prom as a teenager doesn’t mean that should automatically become a goal for every teenage client or, for that matter, even be considered the rite of passage that it once was, Hull says.

Counselors should really get to know their client’s world first before doing anything else, Hull says. “Avoid putting your agenda or perceptions on a client. We often see the potential in our clients, and it’s hard not to say, ‘Just do it!’ It can be discouraging and slow going at times, [but] be patient.”

 

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Technology and social anxiety: A double-edged sword

We live in a world where a person can text a happy birthday message to a friend, order a week’s worth of groceries for delivery and apply for a loan with the click of a button — all without having to speak to another human.

So, when it comes to social anxiety, technology can be a double-edged sword. Clients can certainly use it as an easy escape route to avoid social situations. At the same time, mental health practitioners can use it as a teaching tool with clients and as a bridge to overcoming long-held behavioral patterns.

“As great as it can be, technology can be part of avoidance,” says Robin Miller, a licensed professional counselor (LPC) who specializes in treating adults with anxiety. “Learn how to have conversations [about technology]. Make sure a client isn’t too reliant on it and unable to do things in a more social, direct way.”

Miller suggests that professional clinical counselors ask clients about their technology use at intake along with other questions about avoidance behaviors. Counselors can prompt clients to provide examples of situations where they feel most anxious and then listen for overreliance on technology, such as texting to ask someone out on a date or habitually using the self-service checkout line when shopping.

Social media can also exacerbate the assumption of judgment that often accompanies social anxiety, Miller adds. Clients who see photos and posts about friends’ and peers’ vacations, children or happy life events may come to believe that their lives pale in comparison.

Elizabeth Shuler, an LPC and an international school counselor, agrees. She says social media has created a new layer of social anxiety “centered around likes, comments and followers” in many of the adolescents with whom she works.

“I see students every day who are upset — to the point of panic attacks — that they’ve lost followers or that no one is liking their Instagram pictures. Instead of being afraid of being seen as stupid, these kids are afraid of not getting likes. It is a whole new world of judgment that has been unleashed on our teens, and it is taking a toll,” Shuler says. “However, many people who find face-to-face interaction intimidating can benefit from starting with digital interactions. Using texting, video and other digital means of conversation can help people with social anxiety learn social skills and give them a chance to practice new skills in a safer, lower stakes environment.”

Kevin Hull, a licensed mental health counselor in private practice, finds technology — specifically, video games — a natural tool for working with his young clients, many of whom are on the autism spectrum. In group counseling, Hull uses multiplayer games such as Minecraft to introduce clients to interacting and working together in a way that provokes less anxiety than face-to-face conversation might. Group members take turns being a “foreman” and leader in Minecraft sessions. The group learns to communicate and work together while dealing with frustrations and the nuances of the leader/contributor roles. “If technology wasn’t there, these kids would be even more regressed,” Hull says.

Conversations about technology use can also be an important part of social skills training in counseling, Hull adds. For example, young clients might claim that they are “dating” someone when they are actually just texting or playing video games together over the internet.

Hull often talks with clients about how texting is a good place to start communication but that it should not become their be-all, end-all. He’ll say to the client, “It’s great you’ve made a connection through texting, but what about the next level? Your brain’s process to communicate in text is the same as in speech. It’s just a different route.”

— Bethany Bray

 

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Social anxiety and college

The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety. Read more in our online exclusive, “Heading to college with social anxiety.”

 

 

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Contact the counselors interviewed for this article:

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

Letters to the editor: ct@counseling.org

 

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

Parent-child interaction therapy for ADHD and anxiety disorders

By Donna Mac March 6, 2019

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

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

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

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

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

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

Addressing self-esteem

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

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

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

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

Implementing PCIT with CDI and PRIDE

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

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

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

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

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

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

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

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

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

Other considerations

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

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

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

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

 

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

 

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

 

Letters to the editor: ct@counseling.org

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

 

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

The messy reality of perfectionism

By Lindsey Phillips February 26, 2019

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

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

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

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

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

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

Healthy striving

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

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

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

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

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

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

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

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

Valuing progress, not outcomes

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

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

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

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

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

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

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

Understriving

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

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

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

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

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

The challenges children and parents face

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

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

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

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

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

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

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

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

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

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

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

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

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

Imperfect experiments

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

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

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

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

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

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

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

The shame of ‘falling short’

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

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

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

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

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

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

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

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

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

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

Living with imperfection

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

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

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

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

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

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

 

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

 

Letters to the editor: ct@counseling.org

 

 

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

Finding love in a ‘swipe left’ universe

By Bethany Bray November 28, 2018

When it comes to dating, it’s often said there are plenty of fish in the sea. But when you’re dangling a fishing pole in the seemingly vast ocean of online dating and not getting many nibbles, it can leave you with a seasick feeling. Or perhaps you’ve heard tales of other people connecting with really nice fish, but whenever you cast a line, all you seem to reel in are sharks and slippery eels.

Online dating can be a great way for people to meet those who are outside of their usual social circles and connect with potential partners whom they might never have crossed paths with otherwise. At the same time, getting to “happily ever after” can be an emotionally charged experience fraught with rejection and anxiety-provoking scenarios.

As with conventional dating, online dating carries with it the inherent risks of having bad dates and encountering hurtful behavior. But with online dating, the always-on nature of the technology allows users (perhaps encourages users is even more accurate) to check, recheck and overanalyze whether a potential match has viewed their profile, responded to a message or blocked the match entirely.

Yes, online dating carries the potential for disappointment and anxiety, acknowledges Rachel Dack, a licensed clinical professional counselor with a private practice in Bethesda, Maryland, who specializes in helping clients with dating, relationship and intimacy issues. However, she believes that online dating is a risk worth taking — if approached in a healthy way.

There are “normal highs and lows associated with online dating, and, unfortunately, many of those situations are unavoidable. … It’s helpful for counselors to understand that, oftentimes, online dating takes years [before finding the right relationship]. Helping clients with patience and setting realistic expectations is key,” says Dack, who writes and contributes relationship pointers for eHarmony and DatingAdvice.com. “Often, social media and pop culture can offer an unrealistic picture of it. It’s helpful to reframe a client’s view. It’s really important to normalize the online dating experience, including the good, the bad and the ugly.”

Fifteen percent of U.S. adults have used an online dating website or app, according to data from the Pew Research Center. Since 2013, usage of online dating has nearly tripled among adults ages 18-24 and doubled among those ages 55-64.

As online dating grows more widespread, it is also becoming more socially accepted. Pew reports that nearly half of all Americans know someone who uses online dating or has met a romantic partner online.

Online dating offers users opportunities to enter the dating pool at their own pace, pursuing and accepting as many messages and matches as they choose, notes Dack, a member of the American Counseling Association.

“It can be overwhelming to have as many choices as we have online, but at the same time, it’s an amazing opportunity to meet people,” she says. “Online dating can be a powerful tool for clients who are more shy or introverted and unlikely to approach new people in public. There can be a large sense of comfort found in starting communication [with a potential match] on a phone or computer and setting the pace for what communication looks like. You can get to know someone slowly, over time, instead of trying to approach someone and make decisions right away.”

 

Getting up to speed

The online dating market is a crowded one, with dozens of apps and programs available. Some require payment to join, and some are free. Some match users on the basis of sophisticated algorithms, whereas others allow users to “swipe” through profiles and choose only those that appeal to them. Certain apps are designed to allow only female users to make the first move of contacting another user. And yet others cater to LGBTQ consumers, those looking for matches of a certain religious faith or other demographics.

Although it isn’t necessary for counselors to know the nuances between all of these options, they should have a basic understanding of what online dating is and how it works so they can connect with clients who present with issues related to online dating in therapy sessions, says Mark J. Taliancich, a licensed professional counselor supervisor in New Orleans whose doctoral dissertation was on online dating. He suggests that counselors search for information online to bring themselves up to speed. Although scholarly research on the topic is limited, especially as it pertains to online dating’s connection to mental health, he says an internet search will yield plenty of consumer-focused reviews and news articles that detail the online dating experience and the pros and cons of different platforms. Should clients raise an issue specific to the online dating app they are using, Taliancich suggests having them talk through their experience in session.

Kathleen Smith, a licensed professional counselor in Washington, D.C., agrees. She says counselors should engage these clients by asking why they chose a particular app or platform and which features appealed to them. “It’s not the client’s job to teach you how it works, but also don’t just pretend that you understand,” Smith says. “Just having a basic knowledge can be important. [Online dating] is not just exchanging messages. Know which are the most-used apps and their features.”

Taliancich also stresses that counselors should drop any outdated or stereotypical assumptions they might harbor, such as the misconception that online dating is used only by people who are desperate or awkward and can’t find dates any other way.

“It’s similar to a multicultural issue, or working with a client who has an aspect of their culture that’s not familiar [to the counselor]. It requires doing a little research, a little homework. Realize that there’s a different process to each app,” says Taliancich, the clinical director of counseling solutions for the Catholic Charities Archdiocese of New Orleans. “Don’t go off of assumptions or things you’ve heard. It’s really easy to say ‘online dating is dangerous.’ But when you dig down into it, it’s as dangerous as traditional dating. … Two common criticisms of online dating are that it’s dangerous and people lie [about themselves]. I would argue [those things] can be true of traditional dating just as much.”

 

Diving in

The nature of online dating can exacerbate mental health issues, including struggles with anxiety, self-esteem and setting boundaries. For some clients, it can also dredge up feelings related to past experiences with rejection, abandonment, loss or trauma. For example, a lack of replies to messages could be especially damaging to a client who has issues with self-worth or rejection. Similarly, selecting photos for an online profile can bring up issues for those who struggle with their body image.

“Dating can be a very triggering and uncomfortable experience based on [individuals’] personal mindset about themselves,” Dack says. “A lot of negative feelings [about yourself] can be reinforced through online dating.” At the same time, she adds, “If you’re working to be your best, that’s what you will attract. [Clients’] attitudes about themselves and connecting to others are a major factor in meeting others and the dating process.”

Counselors can help clients work through past issues that spill over into their online dating experiences and prepare them for the challenges that can be a natural part of dating, Dack says. She emphasizes the need to offer both a compassionate and realistic approach.

“With rejection, reinforce that it’s a normal part of the dating experience and probably has nothing to do with them. But [for some clients], their past is going to make them believe that it has everything to do with them,” Dack says. “Hold space for the client to feel their emotions about the past and really grieve and work through it.”

“Online dating is setting you up to get rejected more frequently — remember that,” she adds. “It’s really hard for us to grasp the concept that not everybody is supposed to like us or will like us, and that comes [up] with online dating.”

Smith says she has similar conversations with her clients, the majority of whom are women in their 20s and 30s. She counsels clients that it’s more important to focus on themselves and becoming the person they want to be rather than on what they think a potential match might be looking for.

“The ability to step back and remember yourself versus being anxious about how to make a person not break up with you, that puts the focus on things that are easier and calmer,” says Smith, whose doctoral dissertation was on cellphone use and anxiety. “Help people recognize that dating, especially online dating, is an anxious process. It’s very risky, and you can only control 50 percent of the process. If your anxiety spikes during the process, it doesn’t necessarily mean something is wrong. You’re putting yourself out there and engaging with someone you don’t know who is allowed to reject you. It’s what you do to manage it and respond to it [that matters].”

 

Navigating the ups and downs

Counselors can help clients maintain a healthy perspective and remain true to themselves even as they navigate the sometimes-choppy waters of online dating. The following takeaways can provide some guidance.

Get to the why: One of the most helpful questions counselors can ask clients about online dating is why they chose to sign up in the first place. The answer can provide insights into the person’s goals, intent and motivations, says Taliancich, an adjunct professor in the master’s counseling program at the University of Holy Cross in New Orleans.

“It’s entirely possible to dive into online dating and never have to spend a night alone,” he says. “People can go on four, five or six dates a week, for whatever motivation. But it can be a way to escape something or not deal with another issue. There is a range of motivations, just as with traditional dating.”

At the same time, Taliancich stresses, counselors shouldn’t assume that every client makes a conscious choice to date online versus pursuing more traditional methods. For younger, more tech-savvy clients in particular, online dating may be the more accepted way to meet people. Others may simply feel it is the best option open to them for any number of reasons, such as there being no eligible matches in their immediate social circles.

Set a good pace: “Helping people get the right pace is a conversation I often have [with clients],” Smith says. “Make sure they focus on work and friends and the life they had before they started to date. Clients often focus on whether a relationship will work or not, but breaking it down into manageable steps can be helpful. People tend to be so terrified that they don’t [date] or are so obsessed that they turn dating into a full-time job and get burned out and frustrated. I have conversations with clients about taking breaks when they need to. There’s so much data, you can spend forever looking at it and go on tons of dates. It can be very overwhelming for people when they see so many potential matches and they forget themselves and what they’re looking for.”

Conduct a time check: It’s important to ask clients how much time they’re spending on online dating apps, Taliancich notes, because in many cases, they may not even realize the degree to which it is eating into other aspects of their life, such as schoolwork or connecting with friends. He explains that the apps draw people in with behavioral “rewards” for staying engaged, such as notifying them that a match has viewed their profile or the app has developed a batch of new matches for them to view.

Smith works with clients to monitor and create boundaries for the amount of time they spend focusing on online dating. This can be especially important for clients whose anxiety fluctuates according to the number of responses and attention they receive from matches. She recommends asking clients, “When does [online dating] get in the way? How can you direct yourself away from that when you need to?”

It can also be helpful to remind clients that they can turn their app notifications off entirely or change the settings so they don’t receive messages that are particularly triggering, such as when a match looks at their profile or blocks them, Smith notes.

“How [a client] engages with the apps and technology is such a good marker for their anxiety,” Smith says. “Ask them questions: ‘How often do you look at the app?’ Gauge how much of their time this is taking up. Are they dating reactively or thoughtfully? People might not own up to that at first, but if you ask, it may be surprising how much they are focusing on it.”

Know your client: Clients who have struggled with anxious or obsessive behaviors in the past may find it difficult to resist checking and rechecking a dating app for messages or new matches. A counselor who knows that a client is sensitive to rejection can help prepare that client to manage his or her reaction when the inevitable happens.

“If it’s someone you’ve been working with, you’ll know how likely they are to be compulsive or sucked into that experience,” says Taliancich, who met his wife through online dating. “People who feel invested by chatting with someone, they can take it a lot harder when they don’t get a response or [the match] stops replying. It feels a lot worse for them because the rejection feels a lot stronger — feeling that stab, over and over. Whereas people who don’t feel as invested in that initial part tend to navigate it a little easier because it doesn’t feel as much like a personal affront [to them].”

Similarly, Smith notes, clients who have a history of relying on relationships to regulate their moods may find it easy to fall into bad habits with online dating. “Your mood will ascend and descend based on dates, inevitably, but if your sense of self is coming from dating, it will be worse,” she says. “Have the client ask themselves, ‘If I’m not paying attention, what might happen? What do I need to be aware of, be mindful of? How can I be my best self?’”

Celebrate goals, not boyfriends or girlfriends: Clients may assume that success in online dating equates to finding a steady relationship. The reality, though, is that it simply won’t happen for everyone. Instead, Smith urges her clients to learn from each interaction and to celebrate each goal they reach.

“There’s also successes such as being able to go out on a date when they haven’t in a really long time. Celebrate that. Or have the goal that I’m going to do this [go on a date] and be OK the next day. And that’s great,” Smith says. “Having those clarifying experiences, even if they’re breakups, I would see as a victory. Next time, things will go more smoothly.”

Turn “failure” on its head: Smith recalls one client who began dating a match whom she really liked. However, he wouldn’t respond to her messages consistently, which “was driving her up the wall,” Smith says. Eventually, the client was able to talk calmly to him and explain what she needed, and the pair came to the mutual conclusion that the relationship wasn’t going to work out. Although some might have considered that a failure, Smith helped the client to see it as a success: She had learned for next time what she wanted and needed in a match.

Likewise, counselors can help their clients reframe some of the things they experience in online dating. “Everyone in life has to learn that rejection and disappointment is inevitable. You learn that in different ways, and dating is one way,” Smith explains. “If you can find humor in it, that can help. Set a goal of going on one terrible date or being rejected a couple of times. It can help to laugh at it a little. It makes it not so intimidating. You don’t necessarily have to get better at rejection, but know that it’s not a failure. Knowing that you can only control 50 percent of the process, it’s more about managing yourself than trying to control another person.”

Stay true to yourself: Smith sometimes suggests that clients create a list of “guiding principles” they can focus on during dating and refer back to when they start to feel anxious. The principles can be as simple as “be honest” or “be kind.” Other clients may need to add more specific benchmarks, such as, “Don’t check my dating app more than once each day.”

As Smith explains, the guiding principles can offer reassurance whenever clients have a bad date or other negative experience. “Focusing on what they can control in the dating process can help them calm down and feel less anxious,” she says. “Measure progress not on whether a person liked [you], but ‘Was I the person I wanted to be? Was I myself?’ If you’re doing that, then you’re doing what you’re supposed to be doing.”

Similarly, Dack works with clients, particularly those who struggle with anxiety, to create predate rituals that can help them focus on goals they have set. The rituals — perhaps listening to a favorite music playlist or repeating a positive affirmation — help them prepare and quiet down their predate jitters, she says.

Use role-play: Dack suggests that counselors use role-play exercises in session with clients to prepare them for interacting on dates. She asks clients some of the sensitive questions that might come up (for example, “How long was your longest relationship?”) and gives them feedback on their responses. This can help teach clients what levels of self-disclosure are appropriate when meeting a potential match and how to express themselves in healthy, genuine ways, she says. It can be particularly beneficial for clients who struggle with vulnerability or who view being vulnerable as a weakness.

Dack notes that questions about past relationships — or a lack thereof — can dredge up feelings of shame for those who view themselves as inexperienced. “We want to help them feel vulnerable and authentic while being confident about what they have to offer. With men in particular, there are societal expectations and poor dating advice telling them to portray themselves as super successful, masculine or strong. Sometimes, this can come off as sales-y or disingenuous,” she says. “I encourage my clients to be more open and real.”

“Remind clients that it’s important to be authentic and truthful, but there are layers to sharing,” she continues. “It’s important to share at an appropriate pace. [Find] balance in disclosure. Also, reading your date’s body language and responses is an important skill. My approach is very direct and feedback-oriented so [clients] can practice self-disclosure in a healthy way and learn what comes off as fake or manipulative.”

Be mature rather than anxious: Smith uses the word “mature” with clients to describe behaviors and reactions that are the opposite of anxious. This often comes up in conversations about online dating, she says. For example, when a match doesn’t text after a date or respond to messages right away, the client might be tempted to react in anxious ways: checking and rechecking the app, obsessing over the date’s social media accounts or barraging the person with follow-up messages.

With clients who find themselves overthinking aspects of the dating process, Smith says it can be helpful for a counselor to ask, “How would you know you are doing this as maturely as possible? How would you interact with this differently than you are now? What’s the mature way? What’s the anxious way, and how do you know the difference between the two?”

“Believe it or not,” she says, “there is a mature way to interact with these apps. The word ‘maturity’ helps people figure out a way to not let it take over their life or not make them want to throw their phone across the room. The more maturely you engage with it, the better the chance that you will match with someone who is mature and handling it well.”

Interrupt the negative spiral: Clients may approach online dating with negative assumptions that it won’t work out, especially if they harbor feelings of self-doubt or shame associated with being single, Dack says. Those feelings can be exacerbated when clients experience rejection or when they aren’t getting many responses from potential matches.

“They may be operating on a narrative that they’re not worthy,” Dack explains. “It can be very challenging to hold on to the belief that love will happen for you. That can be a very challenging belief to sit with. Feeling good about yourself and believing you have something to offer is a key part of dating success. But if it’s not going well, it’s hard to feel good about yourself. They may take the ups and downs personally.”

Counselors can equip clients to quell this negative cycle by teaching them how to use positive self-talk, Dack suggests. The intervention can help clients overwrite the negative thoughts and messaging that “can get particularly loud with bad dating experiences,” she says.

Dack works with clients to create positive affirmations that they can refer to whenever they’re feeling low. For instance, she says, counselors can help clients replace thoughts such as “I’m going to end up alone” or “I’m doomed in the love department” with messages such as “I am open and ready for love,” “I am committed to connecting with others,” “I am worthy of the type of relationship I’m looking for” and “I choose to accept and grow from my challenging relationships and breakups.”

In session, counselors can listen to clients’ language and point out cognitive distortions to help steer them away from negative thought patterns. For example, a client might remark “My dating life never goes right, so why bother?”

“They’re in an internal conflict because they really do want to date and find a satisfying relationship. It’s important to change any self-defeating narratives because these beliefs are going to make them feel worse,” Dack says. “Offer a realistic perspective while trying to step out of their self-narrative. If they say, ‘All men are jerks,’ break that down [with the client]. Look for exceptions and positives that can foster hope and clear out mental blocks.”

Helping clients focus on what they are able to control in the experience can also shift thinking away from the negative, Dack adds. For instance, they are not able to control whether a match responds to a message. However, they can pick and choose which dating apps they use,
what they say about themselves in their online dating profile and other aspects
of the process.

Accept some anxiety as natural: Counselors who understand online dating can help clients set realistic expectations about the process and prepare them for the reality that meeting new people and opening themselves to rejection is bound to involve some measure of anxiety, Dack says.

“With anxious clients, it’s important for counselors to understand that dating is basically exposing them to constant anxiety — everything from waiting to hear back from a date to showing up for a date and figuring out the frequency of communication,” Dack says. “It can be mentally exhausting, but it can also be really good. It’s hard, but it’s worth it. The anxiety about it is natural to living a full life. Anxiety is normal in dating, and it doesn’t have to keep you from dating. The more skill and intention that clients bring to their dating life, the better it goes.”

 

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Contact the counselors interviewed for this article:

 

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

Letters to the editor: ct@counseling.org

 

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

Supporting clients through the anxiety and exhaustion of food allergies

By Bethany Bray November 27, 2018

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

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

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

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

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

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

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

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

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

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

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

 

Tempering the uncertainty

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

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

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

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

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

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

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

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

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

 

Finding balance

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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The Food Allergy Counseling Professionals Networking Group

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

 

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

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

 

 

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Related reading

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

 

 

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

 

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