Tag Archives: therapeutic alliance

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.

 

****

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.

****

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.

****

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.

****

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.

 

****

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.

 

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

****

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.

Counselor considerations for disclosing LGBTQ+ identity

By Benjamin Hearn June 2, 2020

The question of what is appropriate to disclose about ourselves to clients is one that all counselors face, whether it be about an upcoming vacation, an emotional reaction to a client or how our own past struggles may parallel those of a client. Beyond these more common self-disclosures, we also may choose to disclose aspects of our identity that are not inherently visible, such as our sexual orientation, gender identity or even religious beliefs.

These invisible aspects of the self differ from others such as race in that there may be incongruence between how these identities are perceived by the client and experienced by the counselor. At times, disclosure of such identities may be beneficial for clients, but we must proceed both with caution and intentionality prior to taking that step. Although I will be discussing LGBTQ+ identity disclosure for the remainder of this article, it is my hope that all counselors will benefit from engaging in the process of deciding when and what is ethical to disclose to our clients.

I first became aware of the utility of disclosing my sexual orientation in practicum, during which time I needed to obtain group hours. The only active group at my site was a women’s anxiety group facilitated by my supervisor, who was also a woman. My supervisor was intent on my gaining group experience and asked the women whether they would be comfortable having a male co-facilitate sessions. Most of the group was hesitant until one of the members spoke up and said, “That’s fine, but only if he’s gay.” Her statement was met with concurrence by the rest of the group, and I was allowed to co-facilitate after sharing that I was indeed gay. My supervisor thought this was a strange contingency, but I was not surprised. I have a long history of seeing people interact differently with me once they learn I am gay.

My initial experiences self-disclosing LGBTQ+ identities demonstrated that it could be used to enhance client trust and perhaps provided greater autonomy to clients by allowing them to find a counselor with whom they “fit.” However, after reflecting, obtaining supervision and exploring the literature on self-disclosure, the concept of appropriately disclosing LGBTQ+ identities became much murkier for me. Compounding the issue was the fact that the literature also described risks to the concealment of an LGBTQ+ identity.

Overall, the consensus from these sources was that disclosure is a choice rather than a rule and needs to be addressed on a case-by-case basis. Factors that influence the choice span a wide range and may include characteristics of the client, the counselor and treatment settings. The remainder of this article explores these issues within the context of the counseling profession’s values and ethical principles, professional literature, and theories that my colleague Kelli Hess and I developed and presented at an American Counseling Association Conference.

Professional values and ethical principles

Whenever considering whether a course of action is ethical, counselors should turn first to the 2014 ACA Code of Ethics and the Practitioner’s Guide to Ethical Decision Making, a white paper developed by Holly Forester-Miller and Thomas Davis in collaboration with ACA. While neither of these documents provides concrete answers to the question “Is it ethical to disclose my LGBTQ+ identity to my clients?” they do offer a good starting point to assess the question. So, let’s begin by outlining applicable ethics standards and professional values and principles so that they can be kept in mind and later applied.

The preamble to the ACA Code of Ethics states that the promotion of social justice is one of the core professional values of the counseling profession. In the glossary of terms for the ACA Code of Ethics, social justice is defined as “the promotion of equity for all people and groups for the purpose of ending oppression and injustice affecting clients [and] counselors …”

The preamble also outlines a number of important principles that inform our topic, including:

  • Beneficence: “Working for the good of the individual and society by promoting mental health and well-being.”
  • Veracity: “Dealing truthfully with individuals with whom counselors come into professional contact.”
  • Autonomy: “Fostering the right to control the direction of one’s life.”

It is worth noting that the ethical decision-making model developed by Forester-Miller and Davis elaborates on these definitions and describes these principles in action in ways that may not be intuitive. For example, helping a client understand how their actions and values are likely to be received in the context of society promotes client autonomy.

The ACA Code of Ethics also provides several standards that are relevant to our discussion:

  • A.4.b. Personal Values: “Counselors are aware of — and avoid imposing — their own values, attitudes, beliefs and behaviors. Counselors respect the diversity of clients, trainees and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.”
  • I.1.b. Ethical Decision Making: “When counselors are faced with an ethical dilemma, they use and document, as appropriate, an ethical decision-making model that may include, but is not limited to, consultation; consideration of relevant ethical standards, principles, and laws; generation of potential courses of action; deliberation of risks and benefits; and selection of an objective decision based on the circumstances and welfare of all involved.”
  • I.2.c. Consultation: “When uncertain about whether a particular situation or course of action may be in violation of the ACA Code of Ethics, counselors consult with other counselors who are knowledgeable about ethics and the ACA Code of Ethics, with colleagues, or with appropriate authorities, such as the ACA Ethics and Professional Standards Department.”

Types of disclosure

Now that we have an understanding of the relevant professional values, principles and ethical standards, we can begin considering how they inform self-disclosure. We typically think of self-disclosure in terms of information that we share verbally with our clients during session. This can be broken up into “intra-” and “extra-” therapy disclosures, with the former being disclosures about the counselor’s own thoughts or feelings in session and the latter being disclosures about the counselor’s life outside of session.

Self-disclosure also takes place through nonverbal means, such as our body language, office layout and dress. The information that we disclose nonverbally is either intentionally or unintentionally shared and can also suggest or confirm an LGBTQ+ identity.

Nonverbal suggestions and confirmations

To understand how nonverbal information may suggest an LGBTQ+ identity, we must first acknowledge that human beings use stereotyping to make sense of and navigate the world. Sexual orientation and gender identity are often spontaneously assumed about an individual based on the nonverbal information they present. Some nonverbal information, such as the counselor’s mannerisms and voice inflection, are not intentionally disclosed but still may inform a client’s assumption of the counselor’s LGBTQ+ identity. A counselor may also intentionally display information, such as choice in dress or a pride flag in their office, that suggests to clients that the counselor is LGBTQ+.

Counselors may also nonverbally share information that confirms their LGBTQ+ identity to clients. This type of disclosure can take several forms and may also be either intentional or unintentional. Intentional nonverbal disclosure of this type occurs through things such as disclosing an LGBTQ+ identity on a professional biography or displaying a picture of a same-gender partner in the office. Unintentional confirmation may take place if the counselor is seen in public with a same-gender partner or if a client discovers the information through social media platforms that are not professionally oriented.

Verbal disclosure with and without prompting

In addition to nonverbal means of disclosure, we can begin to consider how and when counselors may choose to broach the topic verbally in session. In some instances, the client may ask or express something that prompts the counselor to disclose, while at other times, the counselor may disclose without prompting.

Perhaps the two most common instances that could be considered “prompts” are when a client expresses an incorrect assumption about the counselor’s sexual orientation or gender identity or when a client asks about either of these directly. Counselors may be more prone to being questioned directly or to have incorrect assumptions expressed based on the degree to which they “fall into” common LGBTQ+ stereotypes. For instance, I believe that I present few nonverbal suggestions that I am gay, and I wear a wedding ring at work. As a result, clients often ask questions about my “wife.” Another prompt to consider is the unintentional confirmation of an LGBTQ+ identity, such as the counselor being seen in public with a same-gender partner.

When it comes to responding to these questions or assertions, a counselor can always redirect the topic back to the client by asking why this information is important to them or how it would affect their treatment. The counselor may choose to disclose an LGBTQ+ identify when asked directly by a client or when correcting a client’s expressed assumption, provided that a counselor perceives minimal risk to the client and is comfortable with disclosing when prompted.

In these situations, unethical responses would be those that conflict with the principle of veracity. They would include lying about one’s LGBTQ+ identity or providing a response that affirms a client’s incorrect assumption. Such responses might damage the therapeutic relationship in the future should the client discover through other means such as social media or public encounters that the counselor identifies as LGBTQ+.

Counselors who wish for a middle ground between redirection and coming out may choose to use gender-neutral words to answer appropriate questions about themselves or their relationships. For example, “My partner and I have been married three years.”

Counselors may also wish to disclose their LGBTQ+ identity without prompting from the client for a variety of reasons, including:

1) To promote perceived similarity or relatability between counselor and client: Similarity between counselor and client identities, particularly with aspects of identity such as race, has been found to be helpful in developing rapport and with client retainment and engagement. While disclosing similarities may build rapport, counselors should be cautious of using disclosure as a shortcut for rapport or as a stand-in for mastery of LGBTQ+ competencies and expertise.

2) To increase client autonomy or comfort: Disclosure of LGBTQ+ identity may also serve to promote client autonomy. Many clients “shop” for their counselor, and early disclosure, such as on a professional biography, may aid clients in making their selection. In addition, as I described earlier regarding my experience with a women’s group, disclosure of LGBTQ+ identity may serve to promote client comfort. While the situation I described was prompted, counselors may also find that disclosure promotes comfort when clients are reluctant to broach certain issues that may be related to the counselor’s gender identity.

3) To assist in resolution of a client’s internal values struggles.

4) To model a healthy LGBTQ+ identity.

To understand how disclosure might assist a client’s internal values struggles, we’ll return to the professional value of autonomy. Forester-Miller and Davis suggest that disclosure might serve to help clients understand how their actions and values are likely to be received in the context of society. An illustration of this could be a client who is experiencing distress at work due to difficulties with a new LGBTQ+ employee and is unaware that their counselor has an LGBTQ+ identity. The counselor may choose to disclose their LGBTQ+ identity in such an instance should the client not be at risk for self-harm or in crisis and should the therapeutic relationship be strong enough to withstand the disclosure. A counselor taking this approach should consider how they will maintain their focus on the client and manage any significant ruptures to the relationship.

Disclosure of the counselor’s own LGBTQ+ identity may also work to model a healthy identity to clients who have less-developed identities. Models of LGBTQ+ identity development suggest that comfort in disclosing LGBTQ+ identity is indicative of a healthy identity. Given this, counselors may use self-disclosure as a means to explore the reasons behind clients’ own discomfort with disclosure, such as internalized homophobia.

Additionally, instances in which cisgender, heterosexual counselors feel at ease to disclose may also work to model a healthy LGBTQ+ identity and may be viewed as an act promoting social justice. To illustrate this point, consider a community counseling clinic in which some cisgender, heterosexual clinicians display family pictures. An LGBTQ+ counselor who chooses to display similar pictures that illustrate nontraditional family structures promotes equality and raises awareness about such families.

Such seemingly small acts are important to help LGBTQ+ counselors feel comfortable in their work settings because these counselors may also experience fear of client, peer or supervisor judgment and thereby be less effective in their roles. Peer or supervisor judgment may seem unlikely, but I have met many LGBTQ+ counselors who have felt ostracized within their agencies, been told to lie to clients about their sexual orientation or gender identity, or even been fired for their disclosure to clients. Concerns such as these may be indicative of issues related to multiculturalism and diversity within the agency or wider culture but also may be related to the counselor’s unresolved issues regarding internalized homophobia. In such instances, LGBTQ+ counselors may seek their own counseling services.

To illustrate these concepts, consider this vignette: Thomas is a counselor working at a group practice in a moderate-sized city with an established client, Jared. Jared has been voicing increased complaints about his work, particularly concerning a new co-worker who is openly gay and inappropriately discusses his sexual relationships in the workplace. Jared exasperatedly states, “I just can’t stand gay people. They’re all like this. Why can’t they just keep that stuff to themselves?”

As a counselor who displays few nonverbal suggestions about his own sexual orientation, Thomas assumes that Jared believes he is heterosexual. Thomas believes disclosing that he is gay might help Jared, but he first considers the strength of his therapeutic alliance with Jared and what other services would be available to Jared were disclosure to cause irreparable damage.

Thomas decides that Jared would likely be able to process this information in a healthy way and chooses to disclose his sexual orientation in the next session when Jared once again complains about people who are gay. Jared is surprised by Thomas’ disclosure. Jared discusses stereotypes he has about gay people and why he didn’t suspect that Thomas was gay. This process allows Thomas to model a healthy LGBTQ+ identity to Jared while also dismantling unhelpful stereotypes. Jared is now able to see his co-worker’s behavior originating from poor interpersonal boundaries rather than from his sexual orientation.

Choosing not to disclose

Although it appears there may be benefits for clients, counselors and the larger LGBTQ+ population when counselors choose verbally to disclose their LGBTQ+ status, there are also times when counselors should refrain from doing so. In arriving at this decision, counselors should carefully consider:

  • Whether their disclosure is relevant to the client’s issue
  • The purpose of and motivation for disclosure
  • The client’s immediate needs
  • The strength of the therapeutic relationship

In many, if not most, cases, the counselor’s LGBTQ+ identity is irrelevant to the client’s presenting issue, and prompts for disclosing may not arise. Should the counselor still feel an urge to disclose, the counselor should consider their purpose and motivation in disclosing to ensure that disclosure is not used to meet personal needs such as client approval.

Counselors may also refrain from disclosure in instances in which the client has poor interpersonal boundaries, the client is in crisis, or there is a real risk that the therapeutic relationship may not withstand disclosure. Building on this last point, counselors should also consider what additional resources are available to the client should the client refuse to work with an LGBTQ+ counselor. This is particularly important in underserved areas or in agencies that assign counselors to clients or that have long waiting lists.

Here is a vignette to illustrate an instance in which a counselor may choose not to disclose: Janine is a heterosexual trans woman who consistently “passes” in social settings. She is providing mental health counseling services in a rural school-based setting to high school students and receives a referral for a new client, Jamil. Jamil is a junior who has recently been withdrawing from his friends. He has also been experiencing increased conflict with his family after beginning to wear his older sisters’ clothing to dinner and disclosing to them that he often wishes he were a girl.

Jamil presents in the initial session with his mother, who expresses prejudice and disdain toward the LGBTQ+ community. She states, “I was shocked. I’ve seen them in the news, and I won’t have my son being one of them.”

Janine keeps her composure throughout the intake and processes her thoughts and feelings later in supervision. She expresses that the mother’s comments did upset her and caused her to be distracted because of her own family history. She believes that Jamil would benefit from knowing someone else in the LGBTQ+ community. Janine considers this possibility with her supervisor but decides disclosure of her identity as a trans woman to Jamil at this point is too risky. She reasons that Jamil’s mother might pull Jamil from services with Janine, and there are no other readily available providers in the surrounding rural setting.

Janine collaborates with her supervisor to develop ways to bracket her discomfort with respect to the mother’s comments and Janine’s desire to build rapport with Jamil through disclosure. During the treatment planning session, Janine works with the family to develop rapport. She uses her training and education, rather than her personal experience, to explain the myriad difficulties faced by gender-nonconforming individuals and the importance of family support. Janine, Jamil and Jamil’s mother develop a plan aimed at increasing family cohesion by using small, incremental steps that will allow Jamil greater ability to express his gender identity.

Wrapping up

Counselors who identify as LGBTQ+ are faced with the unique challenge of determining whether to disclose this identity to clients and how. Myriad factors influence this decision, making it not unlike many other decisions related to self-disclosure. Counselors can begin considering the issue using an ethical decision-making model and taking into account the professional principles of beneficence, autonomy and veracity alongside relevant ethical standards.

Counselors may find themselves in a position of disclosing more or less often based on their own nonverbal attributes and behaviors, which clients may consider as suggestions that the counselor is LGBTQ+. Clients may use these attributes or behaviors in creating a prompt for the counselor to disclose their LGBTQ+ identity, or counselors may broach the topic themselves when appropriate. 

Counselors should consider verbal disclosure on a case-by-case basis, taking into account knowledge of the client’s presenting issue and needs, the strength of the therapeutic relationship, and other available resources. Counselors should refrain from disclosing when disclosure would pose an immediate risk to clients. LGBTQ+ counselors may look to their heterosexual or cisgender peers for more immediate norms on self-disclosure.

****

Benjamin Hearn is a first-year doctoral student at the University of Cincinnati, where he is developing approaches for the counseling profession to use psychedelic-assisted therapies for mental health and substance use disorders. He is also interested in the integration of spirituality to counseling and is an active member of the Association for Spiritual, Ethical and Religious Values in Counseling. He has practiced in a variety of settings, including school-based mental health, private practice and wilderness therapy. Contact him at hearnbg@mail.uc.edu.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

****

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.

Engaging avoidant teens

By David Flack May 4, 2020

Ben** is a 16-year-old high school sophomore. He completed a mental health assessment about four months ago, following a referral from his school due to behavioral concerns, poor attendance and “possible issues with marijuana and other substances.” He previously attended school-based mental health counseling in seventh grade and has been meeting periodically with a school counselor for about a year.

(** Ben is a former client who gave permission to use his story. His name and some identifying details have been changed to protect confidentiality.)

At the time of assessment, Ben was diagnosed with major depressive disorder, moderate. He also completed screening questionnaires for trauma, anxiety and various other issues. All scores came back well below clinical levels. Despite the school’s concerns regarding substances, a formal drug assessment didn’t occur.

Todd and Julie, Ben’s parents, have been divorced since Ben was 3. Ben lived with his mother until about a year ago. Todd now has full custody but frequently travels for work. Both parents have been fairly disengaged in the counseling process. In fact, Doris, Ben’s fraternal grandmother, was the only family member to attend the assessment.

At the assessment, Doris appeared overly enmeshed with both Ben and Todd. She also reported that Julie “has bipolar but won’t take any meds” and “drinks too much, at least if you ask me.” Doris also stated that Ben “probably was abused” by Julie’s ex-boyfriend but refused to provide further details. “I don’t think I should have said anything.”

Following the assessment, Ben entered services reluctantly, meeting with his original counselor for almost two months. At that time, he was referred to me because the original counselor decided, “I can’t be effective with such a resistant kid.” The counselor said Ben’s attendance was poor and that he displayed an unwillingness to engage when present, did not complete treatment homework, and “showed up high at least a few times.”

During our first meeting, Ben reported, “All that other therapist did was keep saying how her office was a safe space to talk about feelings and crap like that. You know, the bullshit therapists always say. The bullshit I bet you’ll say too.”

Numerous studies show that an effective therapeutic alliance is essential for engagement, retention and positive treatment outcomes. However, many teenage clients simply aren’t interested in counseling, let alone creating connection or building rapport with some strange adult. This is especially true when it comes to avoidantly attached teens such as Ben.

Building effective therapeutic alliances with these youth can seem daunting to even the most seasoned counselor. In this article, we’ll explore practical, field-tested strategies for cultivating rapport with avoidantly attached teens. First, though, let’s briefly review some core attachment ideas.

We aren’t sea turtles

When a mother sea turtle is ready to lay eggs, she heads to a beach and digs a hole in the sand with her rear fins. She lays her eggs in this rudimentary nest, covers them, and quickly returns to the ocean. At this point, the mother sea turtle has completed all her parenting tasks and has nothing more to do with the eggs. Male sea turtles have nothing at all to do with their offspring.

When the eggs hatch, the newborn sea turtles awkwardly scamper to the ocean, using fins meant for swimming, not avoiding predators on land. If they survive this mad dash, they’re fully ready to live on their own. No caregiver ever provides nurturing, teaches them life skills or protects them in any other way.

Humans aren’t sea turtles. In our early years, we need caregivers just to survive. If these caregivers are attentive, protective and nurturing, human babies quickly learn that the world is a safe place, their needs will be met and people are glad they’re here. These children will be securely attached. However, if their primary caregiver isn’t dependable, then this healthy attachment process can be disrupted, resulting in an insecure attachment and possibly lifelong challenges with relationships, self-esteem and personality development.

There are three styles of insecure attachment: avoidant, anxious and disorganized. Avoidant attachment is the most common style of insecure attachment, with studies indicating that up to 1 in 4 Americans fall into this category. Undoubtedly, this percentage is higher in clinical settings.

Young children who develop an avoidant attachment style predictably have caregivers who are emotionally unavailable and ignore the child’s needs. These caregivers may reject the child when hurt or sick, typically encourage premature independence, and sometimes are overtly neglectful. As a result, the child learns, “I’m on my own.”

Attachment styles are continuums, so avoidantly attached teens don’t all act the same. That said, these youth often appear defiant, defensive or dismissive. They’re likely to present as highly independent, oppositional and unwilling to change. They’re also likely to be suspicious of any empathetic gesture.

A little more about empathy

Simply put, empathy is the ability to understand the feelings of another person. As counselors, we’re taught that empathy is an essential component of all effective therapeutic relationships. I certainly don’t disagree with this. However, it seems to me that empathetic gestures are far from one-size-fits-all.

With reluctant clients of all ages, many counselors demonstrate empathy by saying things such as, “Seeking support is a courageous step” or “My office is a safe space to explore your feelings.” It’s like turning the volume up on some secret empathy knob. With anxiously attached clients, this could be quite effective. For avoidantly attached teens though, this is often overwhelming. Life has taught these youth to be cautious of such statements. So, when they hear such statements, they retreat.

I’m certainly not suggesting that we turn our empathy off as counselors. However, in the early stages of building therapeutic alliances with avoidantly attached teens, we need to turn the volume down. With this in mind, don’t congratulate avoidantly attached teens for starting counseling, especially if doing so is simply their least bad choice, and don’t declare your office a safe space. They know better.

I believe this more nuanced perspective of empathy is an essential foundation for engaging in the attachment-informed strategies that follow.

Starting out right

With avoidantly attached teens, first impressions are essential for starting out right. Here are four tips to help ensure that first meetings are therapeutically productive:

Emphasize rapport building. First meetings often involve stacks of paperwork, required screening tools and initial treatment planning. I encourage you to put that stuff aside and spend time getting to know the teen sitting across from you. You’ll have to finish all those forms eventually, but if this new client never returns, tidy paperwork and a well-crafted diagnosis won’t matter much. Besides, you’ll get better answers from teens such as Ben once you’ve developed some rapport.

Get parents out of the room. Unlike Todd and Julie, parents or caregivers almost always attend first meetings. When they do, I meet with everyone to cover the basics, such as presenting concerns, my background, and confidentiality issues. I then ask parents what they think I should know. After I get their perspective, I have them leave. That way, most of the first meeting can be focused on learning what the teen wants from services and cultivating rapport.

Focus on what they’re willing to do. Therapists love to focus on internal motivators and lofty treatment goals, but this isn’t useful with avoidantly attached teens, who want one thing — to leave and never come back. You’ll get further by helping them identify external motivators, such as fulfilling probation requirements or keeping parents happy. Helping avoidantly attached teens move toward these concrete goals proves that you’ve actually listened to what they’ve said, makes you an ally, and keeps them coming back.

Don’t hard sell therapy. When confronted with resistant clients, it’s easy to overstate the advantages of engagement. After all, if we didn’t believe in therapy, we wouldn’t be therapists, right? However, our enthusiasm may be exactly what an avoidantly attached teen needs to justify a quick retreat. Instead, objectively present your treatment recommendations, then explore the pros and cons of engaging. In my experience, most avoidantly attached teens agree to services when they don’t feel coerced.

With the first meeting successfully concluded, our next task is to cultivate an effective therapeutic alliance. Edward Bordin (1979) wrote that the therapeutic alliance is composed of
1) a positive bond between the therapist and client, 2) a collaborative approach to the tasks of counseling and 3) mutual agreement regarding treatment goals. When we strive to fully integrate these elements and genuinely embrace a teen’s motivators, we stop being an adversary and become an ally. For avoidantly attached teens, we also become a much-needed secure base — maybe their only one.

Building a strong therapeutic alliance with avoidantly attached teens requires us to focus on being trustworthy and creating connectedness.

Trustworthiness

Avoidantly attached teens have learned to continuously question the honesty of others. As a result, it is essential for us to be absolutely impeccable in our trustworthiness as counselors. It isn’t enough simply to be trustworthy though; we must demonstrate it — and not just once or twice but during every single interaction.

Brené Brown (2015) likened trust to a jar of marbles. Every time that we demonstrate our trustworthiness, we put a metaphorical marble in the jar. As the jar fills, trust grows. When it comes to building therapeutic alliance with avoidantly attached teens, there are five especially important marbles:

Authenticity. In the context of therapeutic alliance, authenticity means being our true, genuine selves during interactions with clients. In other words, we set aside therapeutic personas and canned responses. Instead, we show up as who we really are. This should be our goal with all clients but especially so with avoidantly attached teens, who are often quite sensitive to insincere behaviors or actions — a skill they learned to help them navigate difficult relationships with the adults in their lives.

Consistency. Being consistent means acting in ways that are predictable and reliable, something avoidantly attached teens probably haven’t experienced much. When we are consistent in our interactions with these teens, we are not only demonstrating trustworthiness but also modeling a new way of being in relationships. A few ways to demonstrate consistency include always starting and ending sessions on time, scheduling appointments at the same time every week, and following through on any promises we make.

Nonjudgment. Avoidantly attached teens have often learned to notice seemingly minor cues, such as a slight change in facial expression. This is a useful skill to have in situations in which care is unpredictable. With that in mind, it is important for us to avoid comments, gestures or facial expressions that could be interpreted as judgmental. This seems obvious but can be harder than it sounds, especially when a client is frustrating, evasive or baiting us — you know, like teens do sometimes.

Usefulness. Another way to demonstrate trustworthiness is to provide something useful at every session. This doesn’t mean achieving a major clinical breakthrough every week. That wouldn’t be realistic. However, there should be a tangible takeaway of some sort each time that we meet with an avoidantly attached teen. Possibilities include a helpful skill, a solved problem, an opportunity to vent or a meaningful insight — as long as it adds value to the youth’s life.

Transparency. This means being completely open about the therapy process, including our intentions as a helper and what clients should expect from services. Truly transparent therapists spend time exploring the pros and cons of counseling, reasons for discussing certain topics, and the theoretical underpinnings of proposed treatment approaches. In other words, transparent therapists strive to eliminate the mystery from the process. Like a good magic trick, knowing how it works should make it more engaging.

Connectedness

According to Edward Hallowell (1993), connectedness is “a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone.” I often describe this deep connectedness as feeling felt. In order for any of us to truly feel felt, we must believe that we are understood, respected and welcomed. We must feel as though we’re interacting with another person who has purposefully chosen to join us in this exact place and moment.

Avoidantly attached teens haven’t had this lived experience of connectedness. When working with these teens, we should always strive to model connectedness in ways that honor their implicit suspicion of empathy, while simultaneously helping them move toward more secure attachment styles.

Allan Schore (2019) refers to these as “right brain to right brain” connections. We can intentionally create such connections by using approaches that focus on emotion, creativity and attunement. It seems to me that teen therapy typically focuses on problem-solving, decision-making, psychoeducation and similar left-brain approaches, ignoring the importance of helping clients become more comfortable using their whole brain.

Here are five simple yet effective strategies for intentionally fostering right-brain connections:

Validate and normalize. Viewed in the context of his lived experiences, Ben’s distrust, oppositional behavior and even substance use were functional. In other words, Ben found value in these behaviors. In fact, he once said, “I guess what I really want is to push people away, and I’m good at it. Really good!” We can validate intentions without endorsing problematic behaviors. With avoidantly attached teens, this is often an essential step to building therapeutic alliances.

Use first-person plural language. The words we use matter. Here’s one example: Instead of using the pronouns “you” and “your,” shift to “we” and “our.” This shift results in a subtle, yet tangible, change in our interactions with avoidantly attached teens. It also helps reinforce that we’re together in the process and that the teen’s experiences are understandable. I’m not sure that clients overtly notice this word usage, but I definitely believe there is value in making the shift.

Use more reflections, ask fewer questions. Most therapists ask way too many questions. To an avoidantly attached teen, questions can seem intrusive, annoying and disingenuous. It may seem counterintuitive, but fewer questions from you will actually result in more talking by the client. Instead of all those questions, use reflections. While you’re at it, avoid cautiously worded reflections. Instead, commit to what you’re saying, with statements of fact such as, “That was tough for you.” Such statements demonstrate connection, not interrogation.

Talk less, do more. From a developmental perspective, full-on talk therapy isn’t the best fit for teens, especially for avoidantly attached ones who don’t want to engage in the first place. I suggest incorporating some no-talk approaches for building rapport and addressing therapeutic goals. The card games Exploding Kittens and Fluxx are excellent choices for building rapport. They are teen-friendly, easy to learn and filled with opportunities for making metaphors. Favorite therapeutically focused activities include collages, creative journaling and walk/talk sessions.

Be fully present. Being present means having your focus, attention, thoughts and feelings all fixed on the here and now — in this case, the current session with the current client. From my perspective, this requires more than a basic attentiveness. It requires being fully engaged, human to human, with no judgment or agenda. This level of presence can feel risky at times, for counselors and for avoidantly attached teens. However, the connectedness it brings makes the risk well worth taking.

Relationships are reciprocal

Imagine your response if a client reported being in a relationship in which the other person refuses to share personal information and frequently makes statements such as “I’m curious why you want to know that,” even when the question is fairly innocuous. Perhaps you’d amend this client’s treatment plan to include working on healthy relationships or building appropriate boundaries. I sure would. Yet, this is what we do all the time as counselors, based perhaps on an assumption that self-disclosure is inherently bad.

It seems to me that we shouldn’t expect teens, especially ones who are avoidantly attached, to be open with us if we aren’t open with them. I’m certainly not suggesting that we share every detail of our lives with teen clients, but I do believe we should be willing to disclose relevant information, answer questions asked out of true curiosity, and be as honest with clients as we expect them to be with us. By doing so, we model effective interpersonal skills, demonstrate healthy ways to connect with others, and solidify the therapeutic alliance.

When teen clients ask questions of a personal nature, some therapists view this as a form of resistance, as a way to avoid the topic at hand or as behavior that interferes with treatment. I disagree, at least sometimes. Perhaps the teen is making an initial attempt to cultivate a relationship with us. Perhaps these questions are a sign that we’re becoming a secure base for the teen. Perhaps we’re witnessing a little nugget of change. Why would we shut that down?

When we deflect all questions of a personal nature, maybe we aren’t reinforcing appropriate therapeutic boundaries or challenging client avoidance. Maybe we’re rejecting a tentative attempt at connection. Maybe we’re demonstrating that we aren’t a secure base. Maybe we’re reinforcing the client’s avoidant attachment style.

For the first several weeks, sessions with Ben were slow going. He often showed up late, sometimes refused to talk and frequently stated he didn’t need or want help. One day, I taught him Fluxx. He commented that the game was about unpredictability. “I hate that,” he said.

The next session, Ben brought his own game, Unstable Unicorns. “It’s a complicated game,” he said, “but I’m a complicated person, and you seem to understand me.”

I let that register, picked up my cards, and lost three games in a row. At the end of the session, for the first time ever, Ben said, “See you next week.”

John Bowlby (1969) described attachment as a “lasting connectedness between human beings” and stated that the earliest bonds formed by children with their primary caregivers have significant, lifelong impacts. When meeting with avoidantly attached teens, it’s essential that we remember the ghosts in the room with us. It’s essential that we intentionally earn marbles. It’s essential that we slowly, but steadily, create connectedness. When we do, we invite teens such as Ben to move toward a more securely attached way of being.

 

****

David Flack is a licensed mental health counselor and substance use disorders professional located in Seattle. For 20 years, he has met with teens and emerging adults to address depression, trauma, co-occurring disorders and more. In addition to his clinical work, he regularly provides continuing education programs regionally and nationally. Contact him at david@davidflack.com.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

****

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.

Technique without soul is dead

By Peter Allen December 10, 2019

As a licensed professional counselor, I am interested in what is helpful or effective for my clients. As a client in therapy, I am equally interested in what helps me to reduce my own suffering and develop better skills for navigating the larger world in which I live. Therefore, I consider myself a student in both respects. The clinician in me studies to achieve greater skill and experience, whereas the client side of me is ever sensitive to what is helpful in everyday life. I have had many experiences as both clinician and client that inform my approach, depending on which chair I happen to be sitting in on any given day.

There is one particular experience I had in therapy that has taken me years to integrate and use toward positive ends. At the time, I had been seeing a therapist for a few weeks. I was there to work through some old resentments and anger that were bogging me down and interfering with what was an otherwise good life. A trusted colleague and friend had referred me to this particular clinician, an older man with years in the field and a positive reputation.

After a few sessions, I remember thinking that the therapist was a little aloof for my tastes and perhaps a bit too professorial. He was kind but in a detached way. I had the sense that he did not think about me or my problems after he left the office for the day. Reflecting on my experience with him, I realize it was not what he did that sticks in my memory so much as how he taught me what not to do.

I had been attempting to work through some of my aforementioned anger issues with his help but had become somewhat stuck. He gestured toward a large, cube-shaped pillow on the ground in his office, measuring roughly 3 feet on each side. I hadn’t paid this object much attention until that moment, which is strange because a large cubed pillow in any office strikes me as noticeable in hindsight. The therapist asked me to repeatedly strike the pillow while verbalizing the very things that were upsetting me. I looked at him incredulously, and I remember specifically thinking, “This is stupid.”

I voiced my reservations, telling him openly that I did not think hitting a pillow and venting my anger in this way would be of much help. He smiled at me, trying to be reassuring, and encouraged me to try the exercise despite my misgivings. And so, I did.

Not surprisingly, I felt stupid. I was a grown man standing in a quiet therapy office hitting a large, cube-shaped pillow and trying to muster real anger in hopes that it would overtake my embarrassment. It did not. It caused me instead to feel like a petulant child who was not getting his way. Later, I would in fact feel the anger that was elusive in that moment, but my anger would be directed at the therapist rather than at the other people in my life.

What went wrong?

We processed this event immediately afterward in a somewhat perfunctory way, owing to my new resentment toward the therapist. I told him that I felt stupid, and he listened without comment. He was less interested in how the exercise reflected on him and more interested in my experience of it. The session ended on an anticlimactic note. I left his office and decided not to return. I should note that I could have given him more decisive verbal feedback about my experience, or inquired further about his intentions or technique. I did neither of those things, so in a way, perhaps I cheated him out of an opportunity to learn and grow. I take some comfort in the thought that his training and development were not my responsibility.

Upon reflection, I came to see that this therapist had disregarded valuable information and feedback I had given him in session. He used an intervention with me that he had likely used countless times before with other clients, and perhaps with some success. After all, he had gone to the trouble of purchasing that strange cube-shaped pillow. He executed a technique despite my obvious resistance because he thought he knew better than I did about what might be helpful. My experience was that I felt unimportant, unheard and embarrassed.

After reflecting on this somewhat minor event, I finally came to understand some of the dynamics that had played out in that room. The therapist was applying a technique without any soul — or, in other words, without first establishing an emotional bond or connection with me. Because he had not forged such a connection with me, the intervention was an abject failure. He assumed that the technique alone was powerful enough to overcome my reservations or, as I’ve said, that he knew better and I just needed to trust him. In my attempt to be the good client, I placed my trust in him, and he showed me that he had not earned it yet.

A basic critique I have of this method is that it does not translate to my life in the world. Hitting objects when one is angry has no application in the real world. We cannot repeatedly hit the table if we become angry in the middle of a corporate board meeting. This method is not encouraging the development of further skills; rather, it is reinforcing a negative human behavioral habit.

Although it took me many years to understand what I had experienced in that therapy session, I eventually arrived at an obvious answer: I went there assuming the therapist was, in fact, an expert, but the person who instructed me to hit the pillow was simply a flawed human being using a flawed methodology. He, like me, is in the process of learning and growing, and, as such, he is still making mistakes. I accept this, and I accept him as being in process.

Cause for reflection

Being on the receiving end of this intervention gave me license to truly examine its effectiveness, or lack thereof, in my own life. This small experience also led me to reflect on how often I — and perhaps, we, as clinicians — may be deploying techniques in a mechanical and disconnected fashion, whether we learned these methods in school, from a trusted mentor, or from a celebrity therapist. I have come to believe that when we do this, we are elevating and accenting the academic concept at the expense of an interpersonal connection.

What benefits our clients is subject to debate, of course, and reasonable people can disagree about this. We learn a variety of evidence-based practices, techniques and theories in the hope that we can help reduce our clients’ pain and suffering. I have colleagues I trust and respect enormously who approach therapy from a more scientific standpoint. They have a toolkit of interventions they use for a variety of presenting problems. Presenting problem A gets intervention B and so on and so forth. I also know brilliant clinicians who use a primarily interpersonal approach, in which the central and ongoing interventions are kindness, consistency, nonjudgment and acceptance.

I would be willing to gamble and say that the majority of therapists artfully blend the scientific with the interpersonal. What is scientific in counseling is by definition methodical, detached and concerned with evidence. What is interpersonal is by definition emotional, involved and subjective. There need not be tension between these two concepts; skillful therapists braid them together.

Carl Rogers, the founder of client-centered therapy (also known as person-centered therapy), came to the conclusion that the interpersonal approach actually produces scientific, measurable results. I will not dive too deeply into discussions of duality and what the superior approach might be (in part because I don’t know), but it is incumbent on the professional counseling community to ascertain anew each day what is effective versus what is ineffective.

My conclusion was that my therapist at that time was relying on pure scientific technique, which lacked warmth. Therefore, what I experienced was his detachment from me and his failure to respond to the verbal and nonverbal feedback I was conveying to him in that moment. My bias, of course, is the golden thread in this entire experience: I lean mostly Rogerian as a counselor, and my therapist had failed to honor one of Rogers’ most important insights — namely, that I am the expert on myself. My therapist put himself in the role of expert, which was a natural result of his unique life experiences, training, upbringing, biases and blind spots.

Undoubtedly, this therapist’s approach has been helpful and effective for many people over the decades that he has been in practice. With the enormous variety of human beings on this planet, an enormous variety of styles and approaches in counseling is merited.

I have concluded from this experience that technique without soul is dead. The cold application of scientific knowledge in the therapy office lacks humanity. However, using only warmth and empathy without technique can be amorphous and ungrounded. I occasionally find myself wanting to revert to technique alone for its definitive attraction — namely, that it is an intellectual and finite concept and therefore seems easier to grasp. Conversely, when I rely too heavily on an interpersonal connection, even as a Rogerian, I find this to be limiting in a different way.

For me in my process of development now, the interpersonal connection is what builds trust, and that is what allows techniques to flourish and gain traction. When techniques are successful and helpful, and when clients experience real change from them, the interpersonal connection thrives. In this way, a skillful pairing of these approaches serves to reinforce the strength of both of them.

I have tremendous empathy for my previous therapist, despite my obvious critiques of him. It was easy for me to see, both then and now, that he meant well. I also have the benefit of being able to evaluate his approach, whereas my own approach is not subject to his scrutiny. I have an inherent advantage in this sense because nothing I have done is under the microscope. That being said, readers of this article may find fault with my analysis, and I welcome a robust debate. I am grateful to him in a noncynical way for showing me what type of therapist I do not want to be: detached, professorial, expert. I strive to become more and more who I want to be as a counselor: someone who is involved, humble, and allied with my clients. In short, I strive to become the professional whom I needed that day in his office.

 

****

Peter Allen is a licensed professional counselor at East Cascade Counseling Services in Bend, Oregon. Contact him at peterallenlpc@gmail.com.

 

Letters to the editor: ct@counseling.org

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

 

****

 

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.