Tag Archives: therapeutic alliance

Restoring relationships with survivors of human trafficking

By Lindsey Phillips August 4, 2021

Jenna Hershberger, a licensed associate professional counselor, was working on a crisis response team for a regional human service center in North Dakota when she received a call from a young woman reporting physical abuse. The woman was forthcoming about her medical complaints but not the state of her mental and emotional health. Hershberger could tell there was more to the woman’s story, so she asked to meet her in real life to discuss things further. The woman agreed.

During their in-person meeting, Hershberger, a therapist at the Village Family Service Center in Fargo, North Dakota, noted signs of potential sex trafficking. “Her presentation was really concerning. She was very tearful,” Hershberger recalls. The woman also kept mentioning how her “friends” had forced her to do things while she was under the influence of substances. The more the woman shared, the more convinced Hershberger grew that the people being referenced were human traffickers, not friends. When Hershberger asked where the woman was staying, she revealed that she was currently homeless.

After talking for a while, the woman finally acknowledged that she had been forced into sex trafficking and wanted to get out. She was scared and didn’t know what to do. Fortunately, Hershberger did. She found the woman a safe shelter for the night and helped her locate mental and physical health services.

“I’m in North Dakota … [where] prevalence rates [of human trafficking] are lower, yet it’s still happening,” says Hershberger, a member of the American Counseling Association. “The tragedy where I am and in Midwestern, rural areas is that people just seem to say, ‘Well, this doesn’t happen here.’”

Jared Rose, a licensed professional clinical counselor and supervisor with a private practice, Moose Counseling and Consulting LLC, in Toledo, Ohio, has also encountered a “that doesn’t happen in my community” mentality when it comes to human trafficking. He began working in anti-trafficking about 15 years ago when someone involved in an anti-trafficking organization in Toledo approached him because of his work with the LGBTQ+ community and with people infected with, affected by or at risk for contracting HIV, both of which often intersect with trafficking. When conducting trainings in rural Ohio counties, Rose has heard law enforcement say, “That’s not happening here.” This statement makes Rose cringe because he knows firsthand from his work with individuals who have been trafficked that it is happening.

Human trafficking, in fact, is more common than we think. The International Labour Organization reported that approximately 40.3 million people were in modern slavery globally in 2016. Sometimes people incorrectly assume that human trafficking is a problem only in developing countries, but the National Human Trafficking Hotline identified 63,380 survivors of human trafficking in the United States from 2007 to 2019.

Rose, an ACA member who wrote an ACA fact sheet on human trafficking awareness for school counselors in 2019, finds that too many counselor clinicians also remain unaware of the definition and signs of trafficking. “You could have the epitome case sitting in front of you,” Rose says. “And if you don’t even know what trafficking is, you’re going to miss it.”

Recognizing the Signs

The U.S. Department of Homeland Security defines human trafficking as the use of force, fraud or coercion to obtain some type of labor or commercial sex act. Rose, an assistant professor of counseling at Bowling Green State University, advises counselors to stay alert to signs of force, fraud or coercion with clients. “Take note of who they are with and where the power and control lie,” he says. For example, is someone else benefiting — often financially — from the client’s actions? Does someone else seem to be in charge or making all the client’s decisions for them?

Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, also looks for visual signs such as bruising, scarring or branding. Individuals who are being or have been trafficked are often branded with “ownership” tattoos with the name of their trafficker or with symbols such as a star or cowboy hat. Because sex acts place a lot of strain on the body, survivors often discuss medical complaints such as dental issues, migraines or urinary tract infections, she adds.

Clients who have been trafficked “may appear overly compliant and submissive, or they might appear really abrasive and abrupt,” Hershberger points out. Counselors must recognize “that those strategies were adaptive at one time but they’re not right now.”

As it relates to falling victim to trafficking, Rose notes that the No. 1 risk factor for children is being unhoused. He prefers the term unhoused to runaway, he explains, because children are often abandoned or “thrown out” by their families. “Within a matter of two to three days of being out of the home, kids are approached [by traffickers], and one-third of those [unhoused] kids are going to get trafficked,” he says. “So, that piece of being unhoused — couch surfing, staying at a shelter, living on the street or whatever the case may be — puts them at significantly higher risk.” Children who are already vulnerable may easily fall prey to an adult who shows them attention or what they initially perceive as support, he adds.

Other risk factors include lower socioeconomic status, past trauma (sexual, physical, emotional, verbal or spiritual), being differently abled, substance use, and belonging to a racial or sexual minority group, Hershberger says. Given the complex trauma that these individuals experience, they often present with comorbid disorders such as substance use, bipolar and severe depression, she notes.

Counselors may overlook or miss signs of trafficking when they take the client’s circumstances or presenting issues at face value, notes Paige Dunlap, an associate professor of counseling at North Carolina Agricultural and Technical State University. For example, if a client is homeless or doesn’t have any identification, counselors may start to talk about the emotions, behaviors and social systems surrounding the client’s chronic homelessness and help them come up with a plan to find a more stable environment. But in doing this, clinicians may miss the larger picture, stresses Dunlap, a licensed clinical mental health counselor with a private practice in Greensboro, North Carolina. Perhaps the client was forced into sex trafficking after being taken from their home or fleeing an unsafe environment.

“There’s a lot of different risk factors. There’s a lot of different things to look for. There’s a number of populations that we are particularly concerned about, but at end of day, it all boils down to vulnerability,” Rose says. For that reason, he stresses that counselors need to be cognizant of that vulnerability piece in connection with their clients.

Sometimes counselor practitioners worry that they won’t be able to recognize the signs that someone has been trafficked, Rose says, but he reassures them they know how to read interpersonal reactions. They know when someone is looking to another person for answers. They notice when people’s stories do not match up.

Counselors also need to consider what a trafficking survivor might look like in their particular clinical setting, Hershberger says. For example, if a counselor is doing crisis work, they might have someone who is in denial about being trafficked or confront a situation that appears to be domestic violence.

The office setting may determine the likelihood of a practitioner encountering an individual who is currently being trafficked or who has gotten out. Counselors who work in public health settings or hospitals are more likely to see individuals who are currently being victimized when these individuals come in for a medical issue such as testing for a sexually transmitted disease or injury from abuse, Rose notes. Counselors working in private practice or at a community agency will typically see these clients after they have been extricated, he says.

Establishing trust and safety

People who have been trafficked may find it difficult to trust others. Before thinking about clinical treatment plans, counselors need to establish a sense of safety and a healthy therapeutic rapport with these clients, Hershberger stresses. These individuals have experienced “complex trauma in the sense that it’s repeated for long duration and often comes from people who should be caregivers,” she explains, “so it makes it really hard for survivors of trafficking to trust us. We need to be really authentic because survivors will pick up on it if [we’re] not.”

Hershberger, president of the North Dakota Association for Counselor Education and Supervision, advises clinicians to maintain an open-door policy with survivors of human trafficking, especially when they are working on engagement with the client. People who are dealing with significant trauma may be more prone to canceling sessions, so adhering to a policy of termination after two missed sessions will not help build engagement and rapport with these clients, she cautions.

Counselors’ innate desire to help clients heal can sometimes be an impediment to build-ing this relationship. Rose sees counselors who want to dive right into the trauma work before first building strong therapeutic and strategic foundations, which can take a long time. “The minute we try to push too much — even if our best intentions are there — is when someone can have [a negative] reaction” and feel that the counselor is forcing them to do something they don’t want or are not yet ready to do, he says.

Rose has also witnessed the inverse: clients who get frustrated when counselors don’t jump straight into the trauma work. When this happens, he explains to clients that although they may feel ready, their whole system may not be. To further illustrate the point, he compares trauma work to a physical wound: “If I start poking around at a wound and you don’t trust me yet or your entire system isn’t ready to allow that yet, you’ll immediately pull back and you’re not going to want me to go near it,” he tells clients. “And the same [thing] is happening cognitively and emotionally with trauma. If we start poking around and you’re not ready, then it’s going to fall apart on us.”

The need for clinical trauma care

Rose asserts that counselors are in a prime position to provide clinical psychotherapy and trauma-focused work. Rose is an executive member of the Lucas County Human Trafficking Coalition, and he was awarded the Social Justice Leader Award from the Human Trafficking and Social Justice Institute in 2017.

Mental health services geared toward survivors of trafficking are great at managing clients’ symptoms through art or expressive therapy or group work, but Rose finds this is often where their treatment ends. “It has to be more. It has to be evidence-based trauma work,” he stresses. “We can’t just treat symptoms. We have to treat the whole person, and we have to treat the trauma.”

“Folx that have been labor trafficked have all sorts of layers of trauma damage. … Sex traffic victims have all of the symptoms of domestic violence, emotional abuse, physical abuse, sexual abuse — all rolled into one very unpleasant package,” he continues. “And expressive therapy is not going to treat that trauma; it’s going to treat the symptoms. If we really want to help folx, we have to go deeper, and that’s where counselors really need to come into play.”

Rose, a certified therapist in eye movement desensitization and reprocessing (EMDR), recommends that counselors use an evidence-based trauma treatment that follows a triphasic approach that a) establishes a foundation, b) reprocesses and works through the trauma and c) plans for the future. Rose often uses EMDR when he’s working with this population because he finds it helpful to treat the root cause of the trauma. He also recommends trauma-focused cognitive behavior therapy, especially when working with children and adolescents.

Take the relational approach

Hershberger points out that traffickers differ from other sexual offenders (who are often described as socially awkward and desire a sense of belonging) in that they are often socially intelligent, charismatic and good at forming relationships. They gain the trust of vulnerable individuals by initially fulfilling their need for love, connection and belonging, she explains. For example, the trafficker could be the first person in the individual’s life to recognize and celebrate their birthday or give them special attention, such as taking them to get a manicure.

These acts can cause some survivors to form bonds with and defend their traffickers — a condition often referred to as Stockholm syndrome. Hershberger and Dunlap point out that something similar sometimes happens with individuals who experience domestic violence. “Survivors will often defend their trafficker because they didn’t have that sense of belonging or that family growing up. So, this is the first time they’re experiencing that — along with horrible kinds of trauma — but it’s hard for them to differentiate that,” Hershberger explains.

According to Hershberger, these trauma bonds illustrate survivors’ desire for human connection. Traffickers thwart this connection by exploiting this desire for their own gain.

“Human sex trafficking is the ultimate anti-relationship,” argues Hershberger, who recently presented on this topic at ACA’s Virtual Conference Experience. Survivors of sex trafficking have been forced “to exist in a world absent of authentic, growth-fostering relationships,” she explains. Thus, she recommends that counselors use a relational-cultural approach with this client population to foster an authentic growth-fostering connection.

To explain this approach, Hershberger presents Marie, a fictional client: When she was 14 years old, Marie lived in an abusive home where her mother’s boyfriend molested her. So, Marie was excited when Jake, a 24-year-old man, approached her and promised a better life as his “girlfriend.” He bought her nice things and told her she was “amazing in bed.” One day, he told Marie some money hadn’t come through at work and asked if she would help him by having sex with a few guys. When she resisted, he beat her until she complied. He forced her into sex trafficking, and she was having sex with as many as 10-15 men a night. (See Hershberger’s 2020 article, “A relational-cultural theory approach to work with survivors of sex trafficking,” published in the Journal of Creativity in Mental Health, for a more detailed discussion of this case study.)

Following a relational-cultural framework, Marie’s counselor first establishes a sense of safety and trust, and they are authentic, empathetic and consistent in their interpersonal interactions, Hershberger says. So, if the counselor makes a mistake by showing up late for session, they own that mistake, apologize and ask Marie how they can make up for it.

Marie may have internalized negative beliefs or self-blame such as “I’m only good for my body and others’ use” or “I’m not worthy of being loved.” The counselor can help Marie first identify and name these beliefs, and then they can work together to challenge these negative beliefs. The therapeutic relationship further challenges Marie’s distorted thinking about herself and relationships, Hershberger notes, and models what a healthy relationship entails.

To challenge Marie’s belief, the counselor could use self-disclosure and tell Marie, “I experience you as a creative, confident individual who is worthy of being loved.” Hershberger recommends that counselors use the client’s own words when reflecting positive attributes to help the client identify and own their strengths.

As Hershberger points out, traffickers try to keep victims in a constant state of uncertainty about their environment, safety or identity. So, the counselor’s role is to identify moments or thoughts that are unclear, such as Marie’s negative perception of her self-worth, and help her add clarity to them.

Hershberger names bibliotherapy and narrative therapy as useful approaches for empowering survivors of trafficking and helping them find their own voice. For example, the counselor could ask Marie what name her trafficker gave her and the name she wants to use moving forward. Then, Marie could journal about this new identity and the qualities associated with it.

The counselor could also add in creative techniques such as collage or relational imagery. For example, Hershberger once had a client who identified with the image of a wounded deer because they too had been hurt and abandoned. The wounding paralleled their own trauma around the physical abuse they had experienced while being trafficked. Later, Hershberger used this image to help the client think about what they wanted their future identity to be and to create a collage of their strengths.

The therapeutic relationship becomes a healthy relationship — one that is safe, dependable and empowering and that counters the disconnection and uncertainty survivors experienced when they were trafficked, Hershberger says.

Preparing to work with this population

The best way to understand what is going on with human trafficking in a specific area is to get involved and volunteer in the community, Rose says. One place to start is joining or attending meetings of local, regional or state trafficking coalitions and task forces. “You can learn more about what agencies are providing services for this population,” he says. “They need to know where mental health providers are, and you need to know where additional services are for survivors.”

Rose advises counselors to approach these partnerships with an attitude of wanting to learn and help. Communities don’t respond well to people who think they know what is best or have all the right answers, he says. Instead, inform these organizations of the crucial skills they may be missing. Counselors have “the clinical piece that a lot of these places need and strive for,” Rose notes. “There’s a lot of social workers, nurses and different helping professionals, but clinical mental health treatment may not be what they have.”

In addition to attending monthly meetings of North Dakota’s trafficking task force, Hershberger prepared to work with this population by reading case examples and familiarizing herself with these tough stories. She also reached out to other clinicians in the field to hear about their experiences. As she points out, “It’s one thing to hear terminology, but it’s another thing to hear somebody’s story.”

Rose and Dunlap recommend that counselors limit their caseloads (if they have that option) when working with this population. “You can’t hear the thing of nightmares for three, four or eight hours a day and expect to be OK by 6 or 7 o’clock at night,” Rose says. Both he and Dunlap, an ACA member who researches and works with youth with disabilities, survivors of human trafficking and criminal populations, have had to learn how to balance their clinical schedules better. They intentionally leave time between these difficult sessions so they can reflect, reenergize and regroup before seeing their next client.

Counselors must also remember that not every client-counselor relationship is the right fit, Rose says. For example, someone may refer a female survivor of sex trafficking to him because of his expertise in EMDR, but if she has been abused by men her entire life, she may not want to work with Rose regardless of his qualifications and reputation as a counselor.

“These clients have had people treat them really poorly their entire lives,” he points out. “Part of that therapeutic relationship is recognizing maybe I’m not the best counselor for every person I want to help, and that’s OK. Just giving [clients] that freedom and autonomy will help them along in their journey. They don’t have to work with me to fix the problem.”

Rose reminds counselors there are other ways to help serve this population without working directly with clients. Counselors can get involved in local agencies that work on human trafficking, provide education and trainings, or work on prevention, he says.

Hershberger understands how difficult it can be when counselors must refer a client. Because she was part of a crisis response team when she met the woman who was a survivor of human trafficking, she wasn’t able to continue working with her. The woman was referred to another clinician who worked for the human service center. “That was hard,” she recalls. “I couldn’t stay with her, and having that continuity of care would have been nice.”

Hershberger did have a chance to meet with the woman a few months later. With the help of her new counselors, she was making progress toward creating healthier relationships.

fizkes/Shutterstock.com

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Working with perpetrators of human trafficking

Paige Dunlap, a licensed clinical mental health counselor in Greensboro, North Carolina, once worked with an agency in Detroit that assisted individuals who no longer wanted to be engaged in gang activity. In sharing their stories, some of the group members disclosed that they had been directly or indirectly involved in trafficking other individuals. After recovering from the initial shock of hearing that, Dunlap started to think and educate herself about ways counselors could help perpetrators of trafficking.

“We as counselors don’t really talk about this hidden population” of perpetrators, she says. “We don’t know too much about them.”

Often people’s biases can cloud their judgment about these individuals. The more Jenna Hershberger, a licensed associate professional counselor in Fargo, North Dakota, researched and worked with cases of sex trafficking, the more she discovered the dichotomous thinking attached to it: People consider traffickers to be “bad” and survivors to be “good.” But it’s more complicated than that, she says.

“In the literature, we see that traffickers and survivors experience the same kinds of childhood traumas, such as sexual, emotional, physical and spiritual abuse,” she explains. But for individuals who become traffickers, “there is a distortion that happens in the way that they respond to the trauma.” Hershberger, a doctoral candidate in the counselor education and supervision program at North Dakota State University, acknowledges this is an area of research that mental health professionals do not fully understand yet. But initial clinical findings, as well as Hershberger’s own professional experience, indicate that traffickers often seem to have empathy deficits and endorse trafficking myths such as “people like this way of life.”

Dunlap, an associate professor of counseling at North Carolina Agricultural and Technical State University, says that traffickers and victims of trafficking often get enmeshed in that world for similar reasons. “There is a need for belonging in all of these individuals,” she says. Both groups often lack support systems, have limited work opportunities and are tempted by the promise of a “better” life, she explains.

Once individuals get involved in trafficking, it becomes difficult for them to leave, Dunlap points out. “It becomes almost an institutionalization for them too. … They don’t know how to function outside of that.”

“Getting those individuals into your office to do this hard work is really going to be tough,” she admits. “If you’re a counselor and you do happen to have these clients, the last thing they need is for your own biases to be stopping them from getting help, because they’re doing good just to be there.”

Hershberger hopes counselors continue to research ways to better help both the survivors and perpetrators of human trafficking. In doing so, she encourages counselors to consider a larger question: How as a society are we creating spaces in which people don’t know what a healthy relationship looks like so that they’re seeking out this subculture for a sense of belonging?

 

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

Counseling outside the box

By Bethany Bray February 25, 2021

Clients bring an unending range of presenting issues, personalities, life histories and challenges into counseling. Fortunately, counselors also have an infinite supply of tools for forging therapeutic bonds, meeting clients’ needs and helping clients tell their stories.

Counselors need only flex their creative muscles to find approaches that can bolster trust with clients and speak to each person’s unique life experiences and worldview. Exploring a client’s interest in skydiving as a metaphor for self-awareness and trust? Discussing a favorite dish or recipe as a prompt to get a client talking about family-of-origin issues? Assigning a client to play video games online with peers as a first step toward addressing social anxiety? The sky’s the limit.

Counseling Today contacted several counselors who are using interesting, fresh or different approaches to help their clients and students. We hope that you will be inspired by their ideas and possibly use them as a jumping-off point to think outside the box in your own work.

Sparking connection with photos

As the adage goes, a picture is worth a thousand words.

American Counseling Association members Brandee Appling and Malti Tuttle believe the truth of this saying holds up even in counseling settings, especially in the age of smartphones, when photography is ubiquitous. Why not leverage that by asking clients to bring photos and images into sessions, they reasoned. Prompts such as “bring in an image that represents you feeling happy” or “bring in an image that represents your family” can be eye-opening for clients and clinicians alike, Appling and Tuttle say.

The duo, former school counselors who met while working as co-coordinators of the school counseling program at Auburn University, have found that “phototherapy” can encourage dialogue and boost empathy and connection in counseling. This can be especially true in group settings, with child and adolescent clients, and with individuals who struggle with speech or whose primary language is not the same as the counselor’s.

Photos and images introduce “another mode of communication” in counseling, says Tuttle, a licensed professional counselor (LPC) who is an assistant professor and school counseling program coordinator at Auburn.

“Photographs can bring insights into someone’s life that we might miss when talking — things that the client can’t verbally express or doesn’t think to,” adds Appling, an LPC and approved clinical supervisor who is now an assistant professor in the Department of Counseling and Human Development Services at the University of Georgia. “It helps to break down walls [in session] and makes it easier for the client to talk about something that’s concrete rather than [topics] that are in the air, so to speak.”

When Tuttle and Appling have used this approach in school settings, students have often been able to display photos on their cellphones. If students don’t have access to a cellphone, they may be able to check out digital cameras from the school, or the exercise can be widened to include printed images such as postcards or magazine clippings, the counselors say.

The counselor’s role is to prompt conversation by asking questions about the client’s image and then allowing the client to reflect and speak. The counselor should never try to interpret the image or impose their feelings about it, Appling stresses.

“This is not to be used to diagnose [clients]. This is not meant to be a stand-alone tool but part of a range of counseling tools,” Appling notes. “It’s one thing that we would use, but it’s not the only thing we would use. It should be part of the therapeutic process, one tool to use in an interrelated system.”

In group settings, an assignment to bring in an image that “represents you” can help participants get to know one another, build connection and create a sense of belonging, Tuttle says. Asking group members to explain why they chose their image can prompt meaning-making, empathy and recognition of others’ viewpoints and perspectives. It can also provide the group leader a glimpse into each group member’s personality and emotions.

The exercise “builds a sense of universality and connection with one another, [prompting] conversations that might not happen organically,” Tuttle adds.

She suggests spurring dialogue in sessions (whether individual or group) by asking open-ended questions such as:

  • Why did you choose to bring this particular photo?
  • What meaning does it hold for you?
  • What would you title this photo, and why?

Appling has used this approach with a group she ran for students who were going through family transitions (e.g., divorce, a death in the family, living in foster care). When asked to share an image that represented the changes they were going through, one student brought in a photo they had taken of a unique seashell.

The seashell “was a representation, for them, of where they had been,” Appling recalls. “It looked very different than any other seashell that I had ever seen, and I initially didn’t recognize the image as a seashell. We talked about how water had changed it and eroded it. The seashell represented [the student] but also the growth and change they were experiencing.”

This intervention can also be flipped, with the counselor bringing in a photo for clients and students to discuss. When presenting on this intervention at conferences and trainings, Appling and Tuttle use an image of an aging set of concrete steps with vegetation growing through the cracks. They ask participants:

  • What do you think this image means?
  • What emotions does it elicit?
  • What does this photo remind you of in your own life?

Despite being shown the same image, participants typically share a wide range of thoughts, reactions and associations regarding the picture, Tuttle and Appling say. Some people see resiliency and growth in the vegetation, whereas others see decay and despair in the cracked steps.

“It’s really interesting to be able to see the perspective of each participant,” Appling says. “It’s a lesson that we all see things very, very differently and that it depends on the things we have been through, our different lenses. It’s a lesson that we all bring different experiences and viewpoints.”

 

Walking (and running) the walk

Counselors can use a seemingly unlimited number of running-related metaphors to encourage clients: It’s a marathon, not a sprint. Keep putting one foot in front of the other. Focus on the mile, not the marathon. You have to learn to walk before you can run.

But for Natae Feenstra, an LPC with a private practice in Smyrna, Tennessee, this approach goes beyond the metaphorical. An experienced runner who has completed multiple marathons, she sometimes conducts outdoor counseling sessions with clients as they run and talk, side by side. As a counselor who specializes in “running therapy,” Feenstra offers running sessions for clients who are comfortable with and interested in donning their sneakers and hitting the trail with her.

“For the client, it’s first and foremost a counseling session,” says Feenstra, who is working on a dissertation on running as a therapeutic treatment for trauma as part of a doctorate in counselor education and supervision through the University of the Cumberlands in Kentucky. “A goal to get to a certain number of miles is never part of a client’s treatment plan. The goal is improvement of mental health, and running is a tool for that.”

Counselors have long known the benefits that movement and exercise can have on mental health, including stimulating the release of endorphins, dopamine and other brain chemicals. Engaging in movement and exercise also offers opportunities for processing thoughts and mindfully focusing on one’s breath and stride.

“Natural bilateral stimulation — that’s all that running is. Rhythmic movement of large muscle groups, and we know that can bring amazing benefits to our brain,” explains Feenstra, a former school counselor who recently transitioned into private practice. Running therapy also offers the built-in ecotherapy component of enjoying sunlight, fresh air and views of nature as she and the client run and talk, she adds.

Feenstra’s approach is individualized. If a prospective client requests running sessions, Feenstra agrees only after having at least one consultation to get to know the client and their presenting concerns and determining whether the approach would be a good fit. She also offers walking and walk/run sessions, as well as traditional, stationary counseling sessions.

During the COVID-19 pandemic, Feenstra is conducting all of her traditional counseling sessions via telebehavioral health. She continues to offer in-person running therapy for clients who are comfortable doing that, while following health guidelines concerning physical distancing as much as possible.

Above all, she suggests running only if the client is comfortable with it. She points out that clients don’t need to be experienced runners to engage in this approach. She modifies each session to the client’s ability and comfort level. “It’s never about the pace or distance of the run. It’s about the movement, going alongside the therapeutic conversation,” says Feenstra, a member of ACA.

Feenstra has seen significant improvement in clients presenting with anxiety and depression who engage in running. Her clients have also self-reported boosts to their self-esteem, self-efficacy and overall wellness.

In addition to the mental health benefits that running provides on it own, these mobile sessions can help strengthen the counselor-client bond and support clients who might otherwise struggle to open up in a more traditional therapy setting, says Feenstra, who is also a certified running coach with the Road Runners Club of America. “Some people are intimidated by eye contact or other aspects of face-to-face sessions, or being in an office with a power differential. For some people, [running during counseling] can help them speak more freely,” Feenstra says.

This was recently the case for an adult male client on Feenstra’s caseload who presented with severe depression and anxiety. During the COVID-19 pandemic, his condition had worsened to the point that he was no longer leaving home.

When Feenstra and the client began meeting, counseling sessions were the only time the man ventured out. They eventually transitioned to mobile sessions, beginning with a walk/run mix to fit the man’s comfort level. Within a few sessions, his anxiety and depression had lessened so that he was leaving his house more frequently and beginning to reengage in hobbies and activities that he had enjoyed previously.

“The platform of running therapy was what prompted him to leave the comfort zone of his house. A telehealth platform would not have made him leave his house, and he was not interested in pursuing [therapy in] an office environment,” Feenstra says. “In this case, the running therapy was what helped him pursue counseling services. I think it was the running piece that was intriguing [to him], and it was so helpful to get him outside to conquer his anxiety.”

Running therapy “is not a miracle treatment, of course, but there are cases where it can make a difference, just like any therapy,” she adds. Running therapy, pioneered by American psychiatrist Thaddeus Kostrubala, has been around since the 1970s, she notes.

For running sessions, Feenstra meets the client in a park, on a trail or in another public place that she is familiar with or has checked out ahead of time. She begins by warming up with the client and chatting as they stretch. After completing a run or walk, they finish by cooling down and reflecting on the session together.

Feenstra acknowledges the potential lack of confidentiality when holding counseling sessions in a public place. She addresses this with her clients ahead of time, both with detailed language in her informed consent forms and verbally, explaining that they can pause their conversation whenever another person is within earshot.

“I let the client dictate,” she says. “I let them know that [they] can choose to lower their voice, stop talking or continue talking if they are comfortable.”

While many counselors may not be runners themselves, they could have clients who enjoy running. Practitioners don’t have to offer running therapy to leverage running’s benefits for their clients, Feenstra points out. She sometimes incorporates running by assigning clients to run outside of session (again, only if they are interested and able) and then uses that to prompt counseling work in their next session together. Running provides an opportunity to relieve stress, tap into the subconscious and process thoughts away from the distractions of life, Feenstra explains.

Clients may find it helpful to keep a journal to record their thoughts, questions and discoveries made while running. This can be used as a self-development tool or as something the client brings into sessions, Feenstra notes.

“Since the run time is often prime time for thinking, clients and counselors can discuss [in sessions afterward] how the run went and what their thought process was like on the run,” Feenstra says. “Also, since running has an innate mindfulness component, this [aspect] can be used as a counseling tool. The counselor might give the client a thought to ponder or a mindfulness activity to meditate on during their run time.”

 

Movies and moral development

One of Justina Wong’s clients had served a long military career as a sniper with a special forces unit. His experiences in service, including multiple deployments overseas, had left him with posttraumatic stress disorder and a relative inability to show or express his emotions. When he did, it often manifested as anger. His relationship with his wife and family was becoming increasingly strained, and one of his children was beginning to fear him.

In counseling, what clicked for this client was Wong’s suggestion that he watch two movies that, on the surface, were geared toward children: Charlotte’s Web and Inside Out. Wong’s client was able to see himself — and many of the emotions he was having trouble identifying and expressing — in the moral arc these movie characters experienced.

“The response that he had was very powerful,” says Wong, who completed an internship at a nonprofit that serves military veterans and their families as part of her master’s in counseling program at the Chicago School of Professional Psychology. As they processed the movies together in session, “We talked about healthy coping skills and unhealthy coping skills. He began to open up more about what he saw and experienced in the military. He had a very hard time differentiating [between] feeling angry and feeling sad, which is common among this population. Feeling angry is accepted, but feeling sad is seen as [a] weakness or being undependable.”

Cinematherapy, or using movie storylines, characters and themes as a therapeutic tool, can be particularly helpful with child or adolescent clients and those who struggle with depression, trauma, loss or social anxiety, Wong says. It’s also useful for individuals who might not respond well to more traditional counseling interventions and those who have trouble opening up to a counselor, she adds.

Clients can observe and learn from movie characters’ struggles, growth and perseverance in the face of challenges throughout their story arcs, explains Wong, a member of ACA. Clients “can feel like they’re not alone because someone else [a movie character] is going through a similar thing. They can see a character’s unhealthy behavior, coping skills and what they did or didn’t do to manage. It can help clients communicate and voice their emotions and understand what their values are.”

A counselor can either assign a client to watch a particular movie (that the practitioner has vetted) outside of session, or the counselor and client can watch film clips together in session. Either way, the important part of the intervention involves the therapeutic discussion afterward, Wong says.

Wong, a recent graduate of the Chicago School, prompts dialogue with open-ended questions. For Inside Out, these include:

  • Which emotions do you consider to be positive, and which do you consider to be negative?
  • Tell me about a time when you suppressed a particular emotion and, as in the movie, your “island” started falling apart.
  • What islands do you have in your life?
  • What role do joy, sadness, anger, fear and disgust have in your life?
  • Describe a time you felt embarrassment, shame or guilt regarding something from your childhood.

Wong stresses that cinematherapy must be individualized when used in counseling. Practitioners should carefully consider whether the approach is a good fit for each specific client and appropriate for their presenting concerns and therapeutic goals. She uses only movies that she is very familiar with and has prescreened. Her list includes About Time (2013), Mulan (1998 animated version), Yes Man (2008), The Lion King (1994 animated version), Eternal Sunshine of the Spotless Mind (2004), Toy Story 3 (2010) and others.

“You really want to do your due diligence and make sure you’re using this intervention to the benefit of the client,” says Wong, a certified trauma professional. “If you don’t, it [watching movies] just becomes a recreational activity.”

The therapy goals of Wong’s veteran client included mending his relationship with his family and being able to have conversations without becoming triggered and angry. As a grown man and hardened military veteran, he initially bristled at the idea of watching children’s movies. But when he began to understand how they could help him strengthen his family relationships, he agreed. He watched Inside Out with his entire family and discussed Wong’s therapeutic questions afterward with his wife.

When Wong suggested he watch Charlotte’s Web, she warned him about the movie’s sad ending because he had never seen it before. Even so, Wong recalls, he was very upset in the following counseling session. As they began discussing the movie, the client realized that he identified with Wilbur’s feelings of isolation and loneliness. The pig’s friendship with the spider, Charlotte, reflected the camaraderie he felt and the bonds he had formed with the soldiers in his unit, some of whom had not made it home alive.

“He put two and two together and understood that when Charlotte dies, she couldn’t return home with Wilbur, and he [the pig] was angry, sad and in despair. [The client] had served in special forces and had lost many friends and was trying to bury and push away his troubles. … After processing it [in therapy], he understood why I chose that movie for him to watch,” Wong says. “The lightbulb turned on for him when Charlotte and Wilbur have a conversation in the movie and she tells the pig that she can’t return home with him.”

Wong talked these issues through with the client, supporting him as he processed, during which he began to show emotion and cry — a major breakthrough for someone who had appeared emotionless and “very by the book” at intake, according to Wong.

The movie discussion spurred the client to open up to Wong. He disclosed that during one of his deployments, several soldiers he was in charge of had died as they worked to secure and occupy an area. The area was eventually retaken by insurgents, and the client wrestled with feeling that his comrades had “died for no reason,” Wong says. He struggled with moral conflict and felt frustrated and betrayed by his commanding officers and the government. “It was powerful progress. He was able to talk about that, which he had never [done] before,” she says.

When used intentionally, cinematherapy can be a powerful tool, Wong notes. She was inspired to explore the approach after hearing Samuel T. Gladding, a past president of ACA and a professor of counseling at Wake Forest University, present on a range of creative interventions, including cinematherapy, at the International Association of Marriage and Family Counselors conference in January 2020. “It’s up to the counselor to be as creative — or not — as they want to be,” Wong says. “I never thought of myself as a creative counselor, but when I heard Dr. Gladding’s presentation … I guess I’m more creative than I thought I was.”

 

Once upon a time

As a doctoral candidate at North Dakota State University, Robert O. Lester recently taught a class on group counseling to first-year, master’s-level counseling students. Most students, Lester notes, came into the class with an innate understanding of empathy, but as the class neared its end, he looked to delve deeper, teaching empathy in an applied manner.

He turned to fairy tales. Lester asked students to write a tale that illustrated some of the challenges they had encountered and the personal growth they had experienced over the span of the class. The assignment had just two requirements: Begin the story with “Once upon a time …” and don’t make fun of any tale shared in class.

The exercise succeeded in opening students’ eyes to a greater understanding of empathy while spurring the growth of their professional identities. It also equipped them with a creative intervention that can be used with clients in counseling sessions. Going through the “imaginative labor” of observing one’s self in unfamiliar places or scenes expands our concept of what is possible, Lester explains.

“Many students began with ‘I don’t have a story to tell,’” says Lester, a school-based counselor and ACA member. “You don’t need to have gone through some great suffering; you just need to be up close to your own desire and belief. It’s the distance of suffering that empathy can’t cross. It was an assignment to bridge the distance between ourselves and others by keeping the desire and suspending the disbelief. It’s about a willingness to let other worlds be possible. This is the initial move of empathy.”

Weaving one’s experiences into a fairy tale can be a helpful exercise for counseling students and clients alike because the stories are compact and give the writer the satisfaction of identifying a coherent story arc and conclusion, even if it’s not a happy one, Lester says.

Writing fairy tales “is expressive, playful and may surprise you. It can loosen the tongue for serious talk. Letting people become a little more enchanted and surprised with themselves would have a lot of possibilities [in counseling]. Then, it would be on the counselor to facilitate a good discussion afterward,” says Lester, who is now living in California and working as a counselor at an alternative-education high school while he completes his doctoral dissertation. “One of my favorite things about this [intervention] is when we surprise ourselves. … It can certainly break some of the narrative ruts we can get into.”

In counseling sessions, prompting clients to express themselves through fairy tales could be a good fit for “any situation where you want someone to begin trying on differences,” Lester says. “Organizing our experiences into an imaginative story — a story where there’s room for enchantment, and the marriage of emotion and imagination — [can be beneficial] for clients who operate with a lot of constraint in their life, either self-imposed or imposed by culture or external forces, especially if they’re having trouble imagining themselves otherwise.”

Fairy tales offer students and clients a chance to cast themselves in new roles, organize their experiences into a sequence, and reflect on the challenges they’ve overcome and how they’ve grown from start to finish, Lester explains. In turn, they gain an appreciation for their belief of what they’re up against and their desire for how they go on.

This benefit was magnified when Lester invited his counseling students to share and discuss their fairy tales in class. This enabled them to see how different each of their journeys were.

“At the deepest level, I was hoping the fairy tale project would be a hermeneutical project [and] part of their professional identity development — marrying your own worldview into the profession [and] taking the feelings of others seriously and compassionately, especially those who don’t experience the world as we do,” Lester says. “They are just beginning in counseling and have to learn to honor others’ worldviews. This fairy tale [assignment] was a compact way to help them begin by rendering their own experiences as unusual and in need of close reading.”

One of Lester’s students wrote an impactful fairytale about a protagonist named Mia. She lived in an idyllic village where everyone knew one another and worked according to their talents — except for Mia, who spent much of her time alone, reading. Although she liked her fellow townspeople, Mia felt something was missing in her own life, Lester says. She harbored an intense curiosity and sense of imagination that many of her neighbors did not share.

Her story took a turn when some creatures from the outlying forest visited her and asked for her help. An ancient well where they lived, deep in the forest, had dried up. The well was the source of the creatures’ magical powers.

Kindhearted Mia knew she had to help and journeyed into the forest, where she found the well in shambles. Her heart broke for the forest creatures, and at a loss for what to do, Mia began to cry. As her tears flowed, they filled and restored the well. Mia’s compassion had saved the day. Not only had she revived the creatures’ source of magic on her quest, she had also discovered her own sense of purpose.

In class discussions afterward, the student who wrote Mia’s tale talked about feeling alienated in the small town where she grew up. Everyone in town seemed to know how they fit into the fabric of the community, but this student was never able to find her niche, Lester says.

Her fairy tale was a beautiful description of this concept. “She [Mia] is looking for a world where her tears have a place and can do something on behalf of others,” Lester explains. This paralleled the student’s own struggle to find her way and cultivate her professional identity.

“We all go through growing up and forming identity, but her fairy tale elevated the experience,” Lester says. “Suddenly, Mia’s tears could do work and were life sustaining. I find that incredibly moving — that language of having permission to cry, because you don’t know what wells your tears might replenish. To me, that’s a whole other order of coming to apply empathy. [Learning empathy] begins with ourselves and becoming empathic with some of the pain and beauty of growing up. … There’s something poetic in that everydayness.”

 

Culinary therapy

Each of the elements in chef Samin Nosrat’s 2017 cookbook, Salt, Fat, Acid, Heat, can be used as therapeutic metaphors in counseling work with clients, suggests Michael Kocet, a professor and chair of the Counselor Education Department at the Chicago School of Professional Psychology.

If a dish doesn’t have enough salt, it can be bland, but if the cook oversalts the dish, it becomes inedible. “One little [extra] pinch of salt can ruin a dish,” Kocet says. “Talk that through with the client: In life, what do you have that’s not enough or too much? What in your life is that extra pinch of salt? Is it unleashing an opinion on a family member? How can we control that?”

Similarly, acid is very powerful and must be wielded correctly, as in ceviche, in which citrus juice is used to cook the dish without heat. Continuing the metaphor, a counselor can ask a client about the “acid” they have in their life. “Maybe their sarcastic humor is biting. Talk about when that can be useful and when it can be hurtful,” advises Kocet, a licensed mental health counselor and approved clinical supervisor who provides pro bono counseling at the Center on Halsted, an LGBTQ community center in Chicago.

Food, eating and cooking are so intertwined in most people’s life histories, perspectives and preferences that they can become beneficial tools when leveraged in counseling, says Kocet, who taught a course on “culinary therapy” when he was a professor at Bridgewater State University in Massachusetts. Although he no longer teaches that class, he continues to weave culinary elements into his work with clients and students in Chicago and has provided workshops and trainings on the topic.

In addition to tapping into a bountiful supply of culinary-related therapeutic metaphors and conversation starters, counselors can consider giving clients the assignment (when appropriate) of cooking a dish at home and debriefing in session afterward. The dish doesn’t need to be anything complicated, Kocet emphasizes. It could be a peanut butter and jelly sandwich or a simple salad, he adds. Cooking or preparing food mindfully, no matter the recipe, can prompt reflection. Tracking experiences in a cooking journal may also benefit clients who respond well to this approach.

“Food is often a binding element,” Kocet explains. “If I have a client who is struggling in a relationship, I might have them cook a recipe that represents their relationship and talk about that [in session afterward]. Or if a client and their partner are from two different cultures, I might have them cook a meal that incorporates elements from their two cultures. … One aspect to [help] forge cultural connection with clients is to discuss food: what they grew up eating and what was ‘celebration’ food. That’s one way to get to know the client a little more. Clients are often really proud of food and cultural traditions, and it’s one way to connect and break down barriers in a counseling setting.”

Assignments for a client to cook with a partner or family member can prompt bonding and offer a fun and creative way to work on healthy behaviors introduced in counseling, Kocet adds. Also, cooking “failures” don’t have to be failures when talked about and learned from in counseling. Perhaps a client forgot an ingredient or strayed from the recipe. How does that parallel the choices made and lessons learned in their life outside of the kitchen?

Even time spent cleaning up and washing dishes after cooking can serve as a mindfulness exercise, Kocet points out. Practitioners could suggest that clients take time to reflect on how they felt stepping outside of their comfort zone to try a new recipe as they clean up the kitchen and feel the dishwater on their hands.

Kocet has developed a culinary version of the genogram mapping tool that he uses with clients to delve into family issues. He keeps a small collection of cooking spices and a sleeve of mini paper cups in his counseling bag. As he begins the exercise, he lines all of the spice containers up on the table and asks the client to select a spice that represents them and other members of their family circle. The client pours a little bit of each person’s spice into a separate cup. Eventually, a constellation of spice-filled cups is displayed in front of them.

Kocet prompts the client to talk through why they chose that particular spice for each person. Cinnamon or red pepper flakes might signify either a warm personality or a hot temper, Kocet points out. The exercise encourages clients to talk through issues related to their own identity and helps the counselor better understand how the person views their family network, Kocet explains. Similarly, questions that invite discussion of traditions and memories surrounding food can encourage clients to reflect and open up, while giving practitioners additional context on clients’ families of origin and related emotions.

Kocet, an ACA member and a past president of the Society for Sexual, Affectional, Intersex and Gender Expansive Identities (SAIGE), a division of ACA, specializes in grief counseling. “If a client is missing someone they lost, such as a grandmother, it can bring comfort to cook a dish that she used to make,” he says. “Cooking uses all the senses — we can connect with loved ones through the tastes and smells [involved] in the act of cooking.”

As with any counseling intervention, practitioners must be mindful of the ethical ramifications of incorporating cooking and culinary elements into therapy and consider whether it is appropriate for each individual client, Kocet stresses. Clinicians should practice caution in using the approach with clients who struggle with disordered eating, and cooking assignments should not be given to clients who have a history of suicidal ideation or self-harm because knives and other equipment could be involved, he says.

Kocet plans to continue exploring the use of culinary elements in counseling and is in the early stages of a research study on therapeutic cooking as a coping tool for the isolation, anxiety and depression people have experienced during the COVID-19 pandemic.

 

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Staying within scope of practice

Practitioners considering the use of nontraditional approaches in client sessions must always keep the profession’s ethical guidelines in mind. Professional counselors’ licensure guidelines and scope of practice vary from state to state. Practitioners must ensure that any approach, whether a widely used talk intervention or one of many complementary methods such as aromatherapy, reiki, yoga, acupuncture and others, fall within their state’s scope of practice regulations before using them with clients or students.

In addition, counselors must consider the potential risks to client welfare, whether the approach is evidence-based (which is called for by the 2014 ACA Code of Ethics), and their own level of competency in using the method.

 

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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.

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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.

Voice of Experience: Violations of trust

By Gregory K. Moffatt January 19, 2021

Trust is the foundation on which relationships of any kind are built. Think about how much we depend on trust in our everyday lives. We trust that our teachers are telling us the truth. We trust that a check from someone won’t bounce. Even the cash we exchange requires trust in the value of the currency in our hands. We trust that the products we buy will function properly and feel betrayed when they don’t.

And with every secret we share in confidence with another person — no matter how big or small the secret — we trust that it will be protected.

Trust comes easily for children in almost all relationships. Whether it’s with parents, siblings, teachers, coaches or sometimes even with counselors, children generally are quick to trust. “My teacher said …” “Coach told me …” “My dad told me …”

Sexual perpetrators take advantage of the ease with which children trust by “courting” — pushing boundaries a little at a time so their victims don’t ask too many questions. Con artists do the same thing to adults, preying on our natural human instinct to believe in one another. But once trust is violated, it will never come naturally again. A violation of trust compromises not only that relationship, but all relationships.

So, to protect ourselves, we must learn, by necessity, that not all people are equally worthy of trust.

In the field of ethnography, the term incorrigible propositions refers to beliefs that are so fundamental to our existence that we don’t even question them. The most serious violations of trust involve incorrigible propositions. When these beliefs are called into question, it shakes all of our beliefs. In a way, we say, “If I can’t trust in this, then what can I trust?”

For example, most people are familiar with statistics on divorce, but upon getting married, almost no one assumes that they will experience divorce themselves. They trust their spouses. But when the belief that they will always stay together is shattered — by infidelity, for example — their entire world is shaken. The incorrigible proposition that people are trustworthy comes into question. Distrust can generalize to all spouses, everyone of a given gender, or to people in general.

Marriage and family therapists see this kind of shaken trust almost every day. The abused children who come through my office have had their trust violated as well, and I have to work hard to prove myself worthy of their trust. This is often a monumental task. Their childlike gullibility is long gone by the time they come through my office doorway.

I have written before in this column that confidentiality is the foundation on which most of our ethics are built as counselors. This is so important because it relies on a client’s trust that we won’t betray secrets.

Sometimes, however, trust must be betrayed. We must act, for example, if clients are a threat to themselves or to others. Mandated reporters have no choice but to violate confidentiality when they suspect abuse or neglect. Even the sharing of therapeutic information with parents or guardians can potentially compromise our clients’ trust in us. These violations of trust cannot always be avoided.

But perhaps most damaging is when counselors — those of us entrusted with the scariest and most embarrassing secrets carried by clients — violate that trust in an unethical manner.

Unethical violations of trust can come in many forms. Unfortunately, carelessly using a client’s name while talking to a colleague or failing to adequately disguise a client’s identity in consultation with a supervisor are not uncommon occurrences.

Most serious is the violation of trust that takes place when a therapist engages in blatant boundary violations with a client. Inappropriate touching, inappropriate social relationships and other egregious boundary violations with clients always destroy trust in the long run.

Those of you who have been in the counseling profession very long have likely seen your share of clients who have had bad experiences with previous therapists. Therefore, you have almost certainly experienced the painstaking job of trying to prove that you are trustworthy (and that the profession as a whole is worthy of trust) to someone whose personal experience has taught them otherwise.

Even more painful to me is the knowledge of all of the clients who will never risk going to a counselor again. These clients will not seek help because of a violation of the trust-based relationship that is at the heart of our profession. Whether these violations were careless or intentional, the effects are the same. These are the people we have lost.

An ethical “oopsie” that violates trust might never be known to anyone else. But then again, it might. Even the slightest breach might damage a client’s trust to the point that they will never seek counseling again. And that, my dear colleagues, is unforgivable.

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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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.

Primum cura te ipsum: First, heal thyself

By Samuel Kohlenberg August 17, 2020

During this bizarre and painful epoch beset by pandemic, racial trauma and social injustice, there is a growing emphasis on clinician well-being and self-care, and rightfully so.

Countless articles and blogs have been written about self-care for counselor clinicians, and here is one more. Why write another one? Because as a counselor educator and supervisor, I want to sell you on a goal other than being OK enough to work. Because avoiding burnout is not enough. We need to set the bar higher to competently render care. Make no mistake, this is an ethical issue.

Like many, perhaps, I have always found Latin venerating in a way that underscores the importance of a phrase or idea. Whether carved into cornerstones or encircling university seals, the tradition has gravitas. One idea I find worthy of such reverence, as it pertains to psychotherapy and behavioral health, is that clinicians need to “do their own work.” Therapists need to heal.

Whether it is through traditional talk therapy or other means, therapists need to attend to their own trauma, developmental journeys and growth. While the oft-cited phrase attributed to Hippocrates, “primum non nocere” (first, do no harm), is a vitally important doctrine in mental health, I am suggesting that there is an overlooked and more sequentially vital step in terms of primacy required to avoid doing harm: that therapists confront and deal with their own issues.

Although therapists are often told that they need to take care of themselves and “do their own work,” I do not believe there is enough understanding regarding why this is so crucially important. Yes, it benefits the therapists, it may mitigate burnout, and it may increase professionals’ longevity in the field. But from my perspective, not enough emphasis has been placed on the idea that people who are not OK do not make competent therapists.

This is not to say that people who have endured trauma or have previously met criteria for a behavioral health diagnosis should not pursue jobs as therapists. Far from it. Many of the best therapists I know are as good as they are in large part because of the difficult roads they have had to walk.

There are many ways to describe how therapists doing their own work might affect them professionally, but I am going to focus on three ideas:

1) Your nervous system is an instrument for attachment work and relationship, and it is shaped by how much work you have done.

2) Doing your work helps you project less and become more aware of your projections.

3) Having done the work means being able to genuinely relate to what your patients are going through instead of just understanding. (Note: Although I say “patient,” please feel free to substitute “client.” The reason I prefer patient is that I feel it better emphasizes the connection between the physical and psychological realms, and given the field’s current understanding of the interconnection between the two, I intentionally use language that fits in both lexicons.)

The nervous system

In a typical stress response, a perceived threat can activate the amygdala, leading to the release of epinephrine and coordinating a sympathetic response to the stressor. Typically, this sort of sympathetic activation means that you are no longer using the circuits associated with optimal social engagement (consider, is it harder to tell how other people feel when you are angry?).

The social engagement system is characterized by the feeling of social connection, the ability to read social cues, eye contact, voice modulation and comfort. All of these things shut down when we go into sympathetic activation as part of a stress response.

Imagine a therapist who has yet to “do their own work” sitting in their office listening to their patient describe a traumatic event. Even if an activated therapist gives no obvious facial expression or gesture, how do you think the person sitting across from them will be affected by the therapist’s nervous system switching gears from social engagement to fight-or-flight?

Imagine for a moment a scared child running to a parent or caregiver and being met with warm eyes, a soft smile and a soothing voice. Now imagine the same child being met with scared eyes, decreased facial muscle tone and a flat voice. In which situation is the child going to be more OK?

Similar dynamics play out in therapy. This means that therapists’ ability to stay in their social engagement system affects patients’ likelihood of being OK while doing things such as trauma work. Part of a therapist’s work is using their nervous system to help resource a patient’s nervous system. For some, it will take significant and ongoing work to be able to do this well. 

Awareness

Awareness and projection share a simple relationship: The more aware you are of your projections, the less likely you are to inadvertently allow those projections to affect your relationships with others.

Regardless of theoretical underpinning, modality or clinical philosophy, virtually all types of psychotherapeutic work regard the relationship between therapist and patient as instrumental. Thus, if the therapeutic relationship itself is one of the primary means by which therapists ply their trade, and a lack of awareness can lead to one’s projections interfering with relationships with others, there is an argument to be made that therapists are on ethically dubious ground if they practice without having cultivated enough awareness and done enough work to overcome this potential pitfall.

You are missing your patient if all you can see is your projection. You are not going to realize that it is a projection if you have yet to cultivate enough awareness. 

Relating

There is a difference between understanding what someone is going through and being able to truly relate to it. While psychotherapists are undoubtedly an empathetic bunch, helping someone engage in the process of developmental therapeutic growth beyond where you yourself have grown is no easy task.

Imagine for a moment a 40-year-old in the midst of an existential crisis. Now imagine an empathetic and well-meaning 14-year-old attempting to help that 40-year-old. Unfortunately, a developmental stage is not always as clear as chronological age, and this can lead to blind spots for clinicians that may negatively affect quality of care. Being able to genuinely relate to what your patients are going through is important, and the 14-year-old is going to have a heck of a time helping the 40-year-old.

Keep doing your work

The thing that all of the above ideas boil down to is relationship. It is your job to ensure a helpful clinical relationship, and the relationship itself is the greatest clinical tool that you have. Ensuring that this primary tool is going to be functional, let alone optimal, can require time, effort and a willingness to endure the discomfort necessary for growth.

Of course, more basic day-to-day self-care is still important for fighting burnout and for resourcing one’s self, especially when you are tasked with taking care of others and especially during times in which nobody seems to be OK. The invitation, the challenge, the mandate, is to not stop at “resourced.”

Aim higher. Embrace catalysts for growth and development. Get comfortable with discomfort when it means a potential breakthrough. Do it for you. Do it for them. Do it like it’s your job.

 

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Samuel Kohlenberg is a clinical psychophysiologist, licensed professional counselor and behavioral health educator specializing in the treatment of stress. He is a master of education in the health professions fellow at Johns Hopkins University and a postdoctoral fellow at Saybrook University and works in private practice in Denver. Contact him through his Facebook page or through his website at denverstressclinic.com.

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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.

Encountering and addressing racism as a multiracial counselor

By Michelle Fielder and Lisa Compton August 11, 2020

It was a simple question, “How are you doing?” that started us on a path of discovery. I (Lisa) wanted to check in with Michelle, my teaching assistant, after racial tensions consumed the news. George Floyd had just been killed, and the media were focused on his death, the shooting death of Ahmaud Arbery, and the outcry for justice for the African American community.

Michelle was initially numb, unsure of how to articulate the different thoughts and feelings the recent events had triggered for her. I could tell she needed a break from our usual academic work, so I assigned a reflective activity to give her space for introspection.

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The events brought to my (Michelle’s) mind a comment that actor Will Smith had previously made on a late-night television show: “Racism is not getting worse; it’s getting filmed.”

As my ideas began to crystallize, Lisa and I began to share our perspectives on the sobering current events. The result was a rich dialogue between us — raw, authentic and refreshingly open.

What follows is an excerpt from our discussion. We hope that it will stimulate other discussions and encourage counselors to not fear engaging in dialogue about race. We believe that such open communication will help us to better understand one another and the reality of systemic issues, to identify our blind spots and areas for growth, to improve our care for clients and to move our profession forward.

Racism at first glance

Lisa: Michelle, you told me how triggering the recent acts of racism in America and subsequent protests have been for you. Could you share some of your background?

Michelle: I was born to an African American father and a Japanese mother around the civil unrest and well-publicized riots of 1968. The United States was embroiled in an unpopular war in Vietnam, and racial tensions at home were an additional black eye on our status as a world leader. It is sobering to consider that the institutionalized racism which led to the widespread violence and destruction of many cities, including Washington, Chicago and Baltimore, has not been eliminated over my lifetime.

My first understanding of racism occurred when I was in the first grade. My mother would meet me after school each day to walk the mile or so back to our house. One day, a white pickup truck pulled alongside us, and two Caucasian men started yelling racial epithets and throwing beer bottles at us. My mother grabbed me and ran into a nearby park where they could not follow in their vehicle.

My mother reported the incident to the police, but it was not investigated, and the matter was dropped. It was not until several years later that I understood what transpired that day and the reality that the very notion of my existence was abhorrent to someone simply based on how I looked.

The path to becoming a counselor

Lisa: That must have been a terrifying experience for you. What impact did your childhood have on your career path as a professional counselor?

Michelle: I became driven to prove my value and worth to society through academic and athletic achievement. When it came time to apply to college, I wanted to mark the “other” box because, back then, “multiracial” was not an option.

My mother surprisingly challenged my decision: “Michelle, whether you like it or not, the world is going to look at the color of your skin and decide that you’re African American. Why not show them you are also kind, driven, intelligent and talented? It doesn’t have to be either-or.”

My mother’s advice empowered me to look beyond my neighborhood and the typical path of my peers, which was community college or service and retail jobs. I applied to the United States Naval Academy and was accepted into the 10th class that allowed women. As a midshipman, it was not lost on me that there were few black or brown faces, and I was often reminded that there were 20 other applicants for everyone who was accepted, so I had to make my presence count.

I found my follow-on experience in the Marine Corps to be a great example of inclusion, as we all worked together toward a common mission. There were not black, white, brown or yellow Marines — we were all “green.” As an intelligence officer, I became adept at understanding the human nature of our enemies and advising appropriate responses to conflict. This intuitiveness and desire to bring healing to suffering led me straight to my next career as a professional counselor.

Experiencing racism with clients

Lisa: Have you experienced racism in your interactions with clients and, if so, how have you managed it?

Michelle: Depending on how I wear my hair, it has apparently been difficult for others to determine my race. Over my lifetime, I have been mistaken for Filipino, Puerto Rican, Thai/Burmese, South Korean and Samoan.

As a licensed professional counselor, I have had clients decline to meet with me because I was not pale enough for their liking or not dark enough “to understand their experience.” Several clients have made racially disparaging comments about African Americans or Asian groups in my presence because they were unaware of my multiracial background. One Caucasian client made the flip comment, “She [a Hispanic friend] is so stupid. What did she expect dating a Black guy? They’re all dogs and can’t keep a job!”

Those comments were spoken so casually that it is not hard to imagine that worse was being said in other settings. It is a sad reminder that racial prejudice and stereotyping are still at the forefront of some people’s minds. Sad because such views prevent the speaker from seeing the potential good aspects of another race and benefiting from their culture. Sad because such divisiveness prevents unity that could make us stronger as neighbors, co-workers or fellow journeyers on this path through life. My identity is not the “little mongrel” girl who had to hide in a park, nor are those individuals being described the sum of those demeaning or devaluing statements. We can and need to do better.

Early in my career, I had a Caucasian client tell me he hated “Black people.” I was quite surprised, and it must have shown on my face because he immediately added, “But you’re all right. You’re not like the other ones I’ve met.”

As you can imagine, I was angry at his audacity and saddened by his views, but I knew based on where he was in treatment that it was not the time to get into a heated debate about his racial beliefs. However, I realized that his sharing of those ideas with me indicated that he felt safe to do so in my presence and that I had been entrusted with a variable that I had not known about him previously. While I was offended by his remark, I remember thinking, “Stay focused on the client. This is not about me; it’s about the client.”

I am going to be judged, fairly and unfairly, but I choose to live in a manner to be a credit to my race rather than a detractor. I also recognize that every instance of racism is a learning opportunity — for me to better understand how the other person came to their beliefs and for clients to perhaps expand their views to see past a person’s appearance to their character. We are all a product of our genetics, nurturing, environment and experience. A client’s life may have taught them to hate, but if we, as counselors, do not believe in the potential for people to change and grow, we are in the wrong profession.

Racism can come in many forms. It can be overt or covert, generational or situational, and institutional or individual. As counselors, we need to be prepared for however it manifests and to recognize that some people are not even aware of how hurtful their beliefs are until they are uttered out loud and someone checks them on it. When working with clients, I have come to recognize that racism is often based on fear, and the more information the client is willing to learn about the object of their fear, the less impact it has. Working with a client’s racist remarks takes the same unconditional positive regard that you would give any client, and it is an opportunity to model healthy self-concept and emotional regulation.

So, take the client I mentioned previously who stated that he hated Black people. For this interview, I will call him “John.” When John made that statement, I did not react to his remarks, but I was able to work with him later in therapy surrounding some of his distorted schemas when he was ready. The following are some practical suggestions for working with clients who show signs of racism:

1) It’s not about you. (Do not personalize clients’ racist remarks).

Me: “It sounds like there are anger and pain behind that statement. Tell me about the Black people you’ve previously met.”

John: “Well, they make me sick. They’re lazy. They lie around doing drugs and collecting a welfare check while I bust my butt working all the time.”

2) Gently challenge any overgeneralizations.

Me: “Who are ‘they’? Are you talking about specific people you know?”

John: “No, you know what I mean. Just Black people.”

Me: “I know some Black people, but they don’t do drugs and they have jobs.”

John: “I know they’re not all like that. Like I said, you’re all right because I know you work for a living.”

Me: “So you don’t hate all Black people, just the Black people who are uneducated or unemployed?”

John: “Yeah, I guess.”

3) Help clients clarify their feelings.

Me: “Some might take your response as jealousy rather than hatred. You work hard, but they get by without working. Would you consider jealousy to be a better word?”

John: “No! I’m not jealous of those Black people. Shoot, I’m way better than them. I’m financially secure with a good job and a house. There’s nothing to be jealous of.”

Me: “You do work hard and have a lot going for you. So, why are you comparing yourself to them?”

John: “I’m not! They’re a drain on society. They could be doing as well as I am if they would just apply themselves.”

Me: “So, help me understand. If there is no comparison in your eyes, why do you even care?”

John: “Because my taxpayer dollars are going to finance their lifestyle.”

Me: “Actually, your and my tax dollars are going to finance a lot of things, like the military, Social Security and the national debt. Do you hate them too?”

John: “No, that’s just stupid. Of course I don’t hate the military. They’re necessary for our nation’s defense. It’s just our precious resources should only be used on important things that benefit all of society.”

Me: “If hate is too strong, or not the right word, what is a better way to describe how you feel?”

John: “I guess you could say I’m frustrated.”

4) Help clients clarify their beliefs.

Me: “OK, you are frustrated with some uneducated or unemployed Black people.”

John: “Yeah, because they’re on welfare.”

Me: “I also know a lot of people on welfare — White, Black, Hispanic, etc. Are you frustrated with them as well?”

John [staring at me]: “I know what you’re doing. No, I’m not frustrated with all of them. You are just twisting things around.”

5) Follow up with psychoeducation.

Me: “I’m just trying to understand what you believe and why you believe it. Words matter, and I hope you can see there is a big difference between ‘I hate Black people’ and ‘I’m frustrated with what I believe is the misuse of taxpayer money.’

Some people are where they are due to a lack of nurturing, growing up in an unsafe environment or even traumatic experiences. But when you are hindered by those things, which are outside of your control, and the color of your skin habitually prevents others from seeing you as a person or recognizing your worth, it is hard to have hope of living any other way.

We all have biases — because of our genetics, nurturing, environment and experiences — that can incite our emotions and distort our thinking. Racism occurs when we start believing those distortions about an entire group of people without considering individual differences. It may be easy to blame an entire group of people in a situation, but it is much more helpful to honestly examine why we feel the way we do and, when in our power, to do something about it.

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Having an open conversation about race with a client is possible, but counselors must consider the client’s readiness and make sure the discussion is integral to the context of the client’s presenting issue. The counseling office is not a bully pulpit, nor is it a place for counselors to get their own emotional needs met. However, when a client is ready and open to discuss the subject, counselors should be ready to “go there” while maintaining empathy and without allowing countertransference to interfere with their effectiveness.

Experiencing racism within the profession

Lisa: Thank you for sharing your experiences and such practical suggestions for working with clients. I think we are often caught off guard by comments made during sessions, and it is very helpful to think ahead of time about what to do in those situations. In addition to interactions with clients, have you experienced racism within our professional field?

Michelle: Sure. I once had a colleague tell me that she was no longer going to take Medicaid clients because they were “all Black, unemployed and unmarried with a gang of kids.” Another colleague commented that the Black clients brought their kids in for testing for attention-deficit/hyperactivity disorder “just so they can get a check.” These were seasoned professionals who had been seeing clients for many years.

Lisa: How disappointing to hear such comments from your peers. As a Caucasian, I have noticed that many of my White colleagues feel content in knowing that they do not personally hold prejudiced feelings against others. However, I realize that a lack of personal hate does not do enough to confront systemic racism. What can we do as a profession to make progress and move forward in this area?

Michelle: The first thing is to stop apologizing. I cannot speak for all people of color, but we are not looking for apologies. Now, let me caveat that: I always advise my clients to “own what’s yours.” If you personally contributed in any way to the oppression of a person of color, then apologize to that person. Otherwise, a blanket apology often indicates that someone does not understand the nature of institutional racism.

Secondly, ask, listen, learn and act. We will never solve the problem if we do not understand the nature of the problem. Ask people of color about their experiences. You may be surprised how many instances of racism — such as inappropriate comments or jokes in the workplace — individuals have had to push aside or ignore. Question formal processes at work that have been in place for a long time because “that’s the way we’ve always done things” attitudes can indicate tacit approval of an oppressive infrastructure (e.g., not taking Medicaid clients because it does not pay as well as commercial insurance).

Listen to the conversations being held when people of color are not in the room. They may be an indication of an undercurrent of racism (e.g., gossip or complaining regarding people of color) that needs to be exposed.

Learn by reading books, listening to podcasts or subscribing to YouTube channels by people of color.

Act by speaking up when you hear racist comments or when you see acts of discrimination. Be willing to get involved with faith organizations, social justice movements and causes of people of color (e.g., speaking at a city council meeting about trauma-informed care for African American neighborhoods or joining a peaceful march). Lastly, help affect the future of the counseling profession. Become a supervisor and share the wisdom you learn about institutional racism and the need to work with people of color to fix the system.

Thirdly, for supervisors, it is important to recognize that our supervisees are coming from different backgrounds and are at different levels of multicultural competence. I hold an initial interview with my supervisees to get a sense of their goals, strengths and weaknesses. Included in this interview is a question about their ethnicity, nurturing, environment and experience as it pertains to working with race and other marginalized groups. The answer is usually, “I had a multicultural awareness class as part of my master’s degree.” I take that to mean that they do not know what they do not know, so the onus is then on the supervisor to prepare counselors-in-training in this area of competency.

I take a developmental approach with supervision and challenge supervisees to take multicultural considerations into account as they approach each client and their diagnosis. Our discussions also include case studies tailored to increase their ability to recognize their own biases and blind spots.

These past weeks, with all of the media coverage of the racial unrest, have offered a rich environment for my supervisees to learn about institutional racism and to ask questions about social justice for their clients. It is not just a multicultural issue but also an ethical one. So, I try to ensure that my supervisees are not only comfortable working with people of diverse backgrounds but also willing to admit their own areas of cultural ignorance and work toward increasing their knowledge.

Connecting multicultural competency and trauma-informed care

Lisa: Is there any other area where we can look for change?

Michelle: All professional counseling organizations have submitted statements of support to the current nonviolent protests and offered ways to help support the victims of racial trauma. This is a great start to addressing the issue. However, if we want to make a difference, we need to reevaluate the profession’s approach to multicultural and trauma-informed education because they go hand in hand.

Most counseling programs have one mandatory multicultural class and may offer some trauma electives. However, multicultural competency should be infused throughout the program, and trauma-informed care should be a required part of every curriculum. Recognizing that the design of the master’s programs is toward clinical competency as determined by face-to-face hours, how well do practicum and internships expose and evaluate multicultural and trauma care competencies? Your new book, Preparing for Trauma Work in Clinical Mental Health, addresses concepts such as historical trauma, disenfranchised grief, advocacy and ethnic identity strength and would really fill this curriculum void.

For provisional and licensed counselors, in the same way that ethics continuing education is required every year, multicultural and trauma refresher training should be required on an annual basis to ensure that counselors are maintaining the best practices. To obtain licensure, counselors should demonstrate competency in working with diverse clients and various trauma backgrounds. In addition, all professional counselors should take an active role in advocacy work on behalf of their clients and in their communities.

Just as the color of my skin is going to be subconsciously noted by the people I meet, similar experiences are happening to our clients of color, most of whom have lived with some form of oppression during their lifetime. Counselors need to be prepared to approach multicultural considerations in trauma-informed care to understand how to appropriately establish strong therapeutic alliances with clients and enhance safety and stabilization. This is a herald’s call for counselors to change the way we approach the effects of institutionalized racism if we truly want to be agents of change.

 

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Michelle Fielder is a licensed professional counselor and approved clinical supervisor in private practice. She is also a doctoral candidate in the counselor education and supervision program at Regent University. Contact her at michfi3@mail.regent.edu.

Lisa Compton is a certified trauma treatment specialist and full-time faculty at Regent University. Contact her at lisacom@regent.edu.

 

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