Tag Archives: Group Work

Group Work

Fried chicken, watermelon, addiction and Appalachia

By Gerard Grigsby February 8, 2018

Hearing jokes about watermelon and grape Kool-Aid. Hearing someone talk about their “half-colored” nephew’s “nappy” hair. Being called “boy.” This is what I experienced over the year that I led an addictions process group in rural Appalachia.

After working in the area for almost four years, I had grown accustomed to hearing these types of comments, but the straw that broke the camel’s back was a response made in group after one member shared that she was dating outside of her race for the first time.

This particular group member said that she was no longer interested in “full-blooded white men.”

“Yeah, you like him now, but wait until he blacks your eye,” another group member commented.

We were gathered outside on a warm, sunny spring day, but a storm cloud of mixed emotions swept over me as I sat there in disbelief. As the leader of the group and the only person of color among a group of eight, I was at a total loss for words. I had no idea how to address what had been said, and I was too overwhelmed to convey exactly what I thought or felt in that moment.

I knew I felt invisible. I knew I felt voiceless. But without any guidance, I struggled to determine what my response should be or whether it would even be appropriate to share what I was feeling. Ultimately, I chose to remain silent and let the moment pass as if nothing had happened, but the weight of what had transpired lingered with me long after our group meeting had ended.

By the time I arrived home that evening, my initial shock and disbelief had transformed into anger and disappointment. I had been really fond of the group member who made the offensive comment, so it stung to hear him perpetuate such a harmful stereotype about people of color. It didn’t help that he had made this comment after I had worked so hard to be understanding and sensitive to the needs of the group, especially considering that many members perceived that their backgrounds made them targets for judgment and mistreatment by law enforcement, family, friends and even other counselors.

I had also worked very hard not to perpetuate stereotypes about people who are in recovery from addiction, and I had avoided repeating the derogatory language that is often used to describe the people of Appalachia. What made matters worse is that just months prior, there was general consensus among the group that no one liked being called a “junkie” or an “addict,” especially by someone who has never used drugs. Clearly, these members knew what it was like to feel marginalized, so how could they allow someone in the group to make such a racially insensitive comment and not challenge him?

I went to bed that night still upset about what had happened and woke up the next day feeling even angrier. In fact, I thought about that incident for several days. I consulted with my supervisor and processed what it was like for me to have led the group that day. I shared the details of the incident with my colleagues in a separate supervision group. I spent hours brainstorming different ways to confront the group about what had happened. I thought to myself, “Maybe I should compile a list of derogatory terms, share them with the group and ask members what they think about culturally insensitive language. Maybe I should stop being so careful with my words and ask members how they feel when they’re on the receiving end of microaggressions!”

These ideas came from a wounded place in me. I had worked hard to protect my group members, and it hurt having to accept that they had not been as protective of me. Thankfully, ongoing self-examination helped me set aside my own baggage and reminded me that it would be harmful and unethical to prioritize my own needs over those of the group.

Instead, I did some more processing and eventually decided it was less important for me to get retribution and more important for me to leave the members with greater insight than they had before joining the group. I wanted to do something that would be meaningful and impactful for everyone in the group, including myself.

The next week, I sat everyone down and implemented a new group rule: Please be mindful of the diversity represented within the group. Without my having to confront him directly, the group member who had made the offensive comment the week before knew immediately why I had made this request and, to his credit, apologized for what he had said. Although I did not take the opportunity to share with the group exactly how his words had impacted me, the act of advocating for myself and others in the group was healing enough.

In fact, addressing diversity issues that day served as a critical moment for the group and opened the door for continued discussions about race, culture, sexual orientation and other aspects of multiculturalism. Just a few weeks later, for example, a group member made a comment about fried chicken, to which I lightheartedly responded, “Is this another racist joke?” To my relief, the group laughed, and we went on to have a productive conversation about ethnicity, regional diversity and similarities between Appalachian culture and African American culture.

In hindsight, I don’t know if I used the best approach to address diversity issues in my group, but I can look back and appreciate how that first challenging experience (there were others afterward) helped to shape my counseling philosophy and improve my group counseling skills. It taught me when and how to address diversity issues in groups, and it served as a reminder that multicultural issues are always relevant, even in an addictions process group in rural Appalachia.

 

My recommended resources

If you have been in a situation similar to mine, or would simply like more guidance on addressing diversity issues in addiction counseling groups, check out the following books:

  • Group Exercises for Addiction Counseling by Geri Miller (2012)

Miller describes two activities that can be used to address diversity issues in addiction counseling groups. My favorite of the two, “Sharing Culture,” is a dynamic group activity that facilitates engagement, information sharing and processing. I won’t provide any spoilers if you haven’t read the book, but just know that this activity involves yarn and sounds like a lot of fun.

  • Group Work Experts Share Their Favorite Activities for the Prevention and Treatment of Substance Use Disorders, published by the Association for Specialists in Group Work (2015), and edited by Christine Bhat, Yegan Pillay and Priscilla Selvaraj

This book is full of engaging activities for anyone interested in group work, but one activity in particular may be useful for practitioners who want to address diversity issues in group. Submitted by Beverly Goodwin and Lorraine Guth, this activity requires group participants to identify what they know about their own ethnic, racial or cultural group, and then consider how different aspects of their identity impact their recovery.

My own spin on this activity would involve an initial discussion about drug culture — its norms, unspoken rules, daily practices and common beliefs of which people may be unaware. I see this as a helpful way to set the stage for a broader discussion about culture and diversity. I also think it would be a useful way to help group members process the fact that they are indeed giving up certain aspects of a valued cultural system when they decide to start their recovery. This context can help enrich subsequent discussions about culture, assimilation and acculturation as members discuss the process of letting go of drug culture and embracing aspects of other cultural systems that may be less harmful.

 

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A version of this article was originally published in the December e-letter of the Association for Specialists in Group Work, a division of the American Counseling Association, and is used here with permission.

 

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Gerard Grigsby is a fourth-year doctoral student in the counselor education and supervision program at Ohio University. He is licensed as a professional counselor in Ohio and has worked in college counseling and community mental health settings. Currently, he works at a substance use treatment clinic, where he has the privilege of serving and learning from individuals in recovery. Contact him at ggrigsby@hrs.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.

Group counseling: Neglected modality in private practice

By Kevin Doyle March 7, 2017

After approximately 25 years of working in private agencies, I started a part-time private practice a few years ago focusing on my specialty area of working with clients with substance use disorders. Having worked largely with adolescents, I was looking forward to working more frequently with adults, especially after I had the realization that I was growing older and the adolescents were not.

One of my first efforts at outreach was to my state’s monitoring program for licensed health care providers (doctors, nurses, dentists, veterinarians and so on) because I was aware that these professionals are at high risk of substance use problems for a variety of reasons. Over the past eight-plus years, I have found this area of practice to be both stimulating and professionally rewarding.

As is the case in most states, my state mandates that health care professionals must, following an issue related to a substance use or mental health disorder, participate in its monitoring program for five years to ensure professional oversight during the transition back to practice. I quickly realized that the need for individual counseling throughout the full five years, although potentially appropriate in some cases, was likely not indicated in many instances. So, I approached several nurses in the monitoring program about starting a counseling group. They were open to the idea and even enthusiastic. Eventually, I asked them about including a physician. Their response to my question was memorable: “Don’t worry. We can handle him.”

Since that time, the group has grown to include several other health professions and has ranged in size from six to eight individuals. According to the participants’ report, it is helpful to be exposed to the input and perspective of others who have been through the process of addiction (sometimes diverting medications from patients and facing criminal prosecution) as they work to put their lives back together and obtain approval to return to professional practice.

Using this experience, I have subsequently established two more recovery support groups in my practice. Both groups are for men in early recovery from substance use disorders, which constitutes a large portion of my clientele these days. In talking with other counselors in private practice, however, I have learned that very few offer group counseling, preferring to stick to the traditional model of one-on-one counseling. Why don’t more counselors offer group counseling?

Potential advantages

The ACA Code of Ethics includes standards relating to group counseling, including A.9. (Group Work) and B.4. (Groups and Families). Although these standards identify responsibilities that counselors have when choosing to provide group counseling services, none of them includes any admonition for counselors to consider offering group work.

What, then, are the potential advantages? Let’s look at three that are most commonly identified.

1) Cost to the client/payer: A ballpark calculation, based on discussions I have had with other counselors, as well as rates posted on websites, is that the per person rate for group counseling is about one-third to one-fourth of the rate that counselors tend to charge for individual sessions. Using an example on the higher end, a counselor who charges $150 for a traditional therapeutic hour (a 45- to 50-minute session) would probably charge $40-$50 per person for group counseling. Many counselors also extend group sessions to 70-90 minutes to allow adequate time for each member to participate. In this day of tightly managed insurance benefits, the cost to the payer is much less in group counseling and tends to give clients the ability to participate for longer periods of time, which is often extremely beneficial.

2) Additional revenue for the practice: Not to be overlooked is the potential that group counseling offers for a practice to enhance revenues. There are only so many hours in the week and a limit to how many clients an individual practitioner can be effective in seeing. High-end estimates tend to run to seeing clients 25 to (at most) 30 hours per week, thus still leaving time for documentation, marketing, practice management, breaks, supervision, etc. Given overhead expenses such as liability insurance, rent, phone service, office supplies and equipment, internet/web access, licensing fees and more, it is challenging for counselors to make an adequate living without following sound business practices. One of these practices can be to offer group services.

3) Enhanced therapeutic value: Finally, as the ACA Code of Ethics stresses, we should ultimately make decisions with our clients in mind, keeping whatever is best for them paramount in our thinking. Both research and anecdotal evidence support the provision of group services as an important part of addressing many clients’ needs, with substance use disorder being a clear example. The experience of hearing from other people who are both struggling with the same issues and having success addressing those issues can be life-changing for clients. Likewise, establishing a support network that people can draw on outside of sessions can also be very therapeutic and is an important outgrowth of group work.

Potential disadvantages 

What, then, might be the disadvantages, and why do so few counselors in private practice offer group services?

1) Scheduling: One of the great benefits of owning a private practice for many counselors is the flexibility it affords them in both their personal and professional lives. In my experience, the days of the client who comes in every Wednesday at 10 a.m. are no longer; in most cases, they have been replaced with a more flexible, variable style. This also gives the counselor the ability to work around a full- or part-time job, family obligations, vacations and other scheduling issues.

Groups, however, typically do meet at the same time every week, every other week or monthly. Rescheduling a group involves potentially inconveniencing eight to 10 participants, as well as the counselor, and is much more complex and problematic than rescheduling an individual client. Although I will occasionally reschedule a group in my practice, I usually hire another local practitioner to cover the group, obtaining a release of information from group members to facilitate client coordination with the other practitioner. Having a substitute counselor can supply a healthy change of pace for groups and can enhance the group process in future sessions too.

2) Lack of comfort with group modality: Group counseling classes are included in most counselor training programs, but it is possible for counselors to move quickly into a comfort zone of providing services on a one-to-one, individual basis and allow their group counseling skills to grow rusty. For many counselors, the transition to private practice begins as a part-time arrangement in combination with another full-time job. Thus, it may be many years before the counselor is fully engaged in private practice work as his or her primary activity. This may further contribute to the lengthy delay between when a counselor receives group skills training and finally implements those skills in a private practice setting. This is not the only scenario under which counselors move into working privately for themselves, but this pattern may partially explain why so few private practitioners offer groups.

3) Too much effort to establish: Finally, and related to the scheduling challenges noted earlier, there is the effort required to get a group off the ground. Persuading clients that group counseling is an option worth considering can sometimes be a formidable obstacle.

I recall one particular client of mine who was dead set against group work, indicating that he did not want to share his “personal business” with a group of strangers. After nearly two years of relatively successful individual counseling related to his problems with alcohol, he experienced a serious relapse, leading to inpatient treatment — where groups were a large part of the service delivery system. Upon returning to the community, he has engaged with his group and finds it to be an essential part of his overall recovery program.

On a more mundane level, simply finding a time that works for all potential members and the counselor can be a significant challenge. I have had some luck holding groups early in the morning, before many people start their workdays. Other options might include lunch-hour meetings, evening sessions or even weekend slots. Sometimes, however, the difficulty of establishing a regular meeting time can be so daunting that it prevents counselors in private practice from even attempting to start groups.

Conclusion

In summary, groups can provide a tremendous therapeutic opportunity for our clients to address their issues with the assistance of others who are confronting similar problems. Counselors should consider this modality more frequently as they look to simultaneously improve their work with clients and solidify their private practices from both a quality and financial standpoint.

Opportunities for retraining for those professionals who have not had group experience since graduate school are abundant. These opportunities include myriad continuing education options such as conferences, webinars and self-paced reading. Additionally, counselors can partner with other professionals in a co-facilitation arrangement. This may negate some of the financial upside of group work, but it can also assist in providing built-in coverage should a counselor need to miss a session.

Ultimately, as we ponder as counselors how best to meet the needs of our clients, group work should be something that we all consider as part of our ethical responsibility.

 

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Kevin Doyle, a licensed professional counselor and licensed substance abuse treatment practitioner, is chair of the Department of Education and Special Education and an assistant professor of counselor education at Longwood University in Virginia. Contact him at doyleks@longwood.edu.

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

 

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

Behind the Book: Group Work With Persons With Disabilities

By Bethany Bray March 6, 2017

Group counseling can serve as a powerful antidote to the isolation clients often feel, whether they’re going through infertility, addiction or a range of other issues. This can be especially true for clients with disabilities, say Sheri Bauman and Linda Shaw, co-authors of the American Counseling Association-published book Group Work With Persons With Disabilities.

“For persons with disabilities, being in a group with others who have the same challenges can reduce the sense of isolation that often accompanies such circumstances,” they write in the book’s introduction. “… When members encounter others at different stages of dealing with an issue, they may develop a sense of hope that they, too, can make progress and feel more satisfied and fulfilled. For those whose disability may limit their opportunities to join with others, the feeling of cohesiveness that develops in groups can provide that sense of belonging that is so essential for optional human functioning.”

Bauman and Shaw are both professors in the University of Arizona’s Department of Disability and Psychoeducational Studies. They collaborated to write Group Work With Persons With Disabilities to use in a course they co-teach on group work.

 

Counseling Today sent them some questions, via email, to learn more:

 

The group dynamic in and of itself can be a powerful counseling tool. Please talk about how this can be the case, particularly, for clients with disabilities.

The therapeutic or curative factors in groups are well known. It’s not unusual for people with disabilities, particularly newly acquired disabilities, to feel that their experience is unique and that their disability can be socially isolating. Consequently, the following curative factors may be of particular relevance for persons with disabilities: universality (realizing one is not alone in their struggles); instillation of hope (seeing other members who are living full and productive lives, despite myths and misconceptions about disability); cohesiveness (the feeling of belonging that develops within a group); interpersonal learning (discovering, through group feedback, how others see them; having the opportunity to practice new skills in a safe environment); and the imparting of information (learning practical medical management skills and information about negotiating social and physical barriers in their environments). There are others but these are particularly relevant.

 

What would you want counselors to know about this topic — Especially counselors who may not have encountered it in graduate school?

Regardless of a counselor’s specialty area of practice, it is highly likely that sooner or later people with disabilities — who are about 20 percent of the population — will seek services from them and just like any other clients, many will be potential group members. People with disabilities have all the same kinds of issues any other person may have, so it is likely that they will appear in groups with a variety of themes. Often when people with disabilities seek assistance from a counselor, there is a tendency on the part of the counselor to assume that the disability itself is the source of the problem. Counselors should guard against the tendency to do this, as the issue may or may not be related to the disability. Just as they would approach any other client, the counselor must see and address the needs of the whole person. Including questions that invite discussion about disabilities (some are invisible) in screening interviews will alert the counselor that some accommodations may be needed, and give the counselor the opportunity to seek out additional information if unfamiliar with the needs of individuals with this particular disability as it applies to group participation. Although people’s disabilities are an important aspect of their identity, they are more than their disability. In our book, we provide counselors with background information and specific skills that will allow them to conduct groups with this clientele successfully.

 

In your opinion, what makes counselors a “good fit” for leading groups with clients with disabilities?

A counselor who is sensitive to diverse groups will be able to bring that sensibility to include persons with disabilities. Counselors who are able to reflect on their own potential biases and fears will bring honesty to the experience and serve as important role models to other group members. Counselors also need to be open to learning additional information that would increase their comfort level and competency in working with diverse group members, including those with disabilities.

People with disabilities are not different from other group members. Just as in working with any diverse group, having an understanding of the particular needs of these members is an important area of cultural competence.

 

Do you feel that, in general, counselors might have misconceptions or gaps in knowledge about group work with clients with disabilities?

Just as in the general population, persons with disabilities are often overlooked and misconceptions are common. Generally, people without disabilities tend to believe that disabilities have a much more negative impact on quality of life than do people with disabilities themselves, and they may see “successful” people with disabilities as heroic or especially admirable. Additionally, many people assume that the most important life task of a person with a disability is to “overcome” their disability. In point of fact, many people with disabilities see their disability as part of the natural diversity of people, and that the problem is not so much the disability itself, but rather the barriers to full participation in life created by physical and attitudinal barriers. Adjustment to disability is seen as a social, rather than a personal problem.

Many counseling training programs touch on disabilities only tangentially, and thus indirectly convey the message that this is not a group that counselors will encounter in their practices, unless they specialize in disabilities. The reality is that persons with disabilities may have relationship problems, financial problems, stresses, depression and all of the same kinds of concerns that bring nondisabled people to groups.

 

What advice would you give to a counselor who might want to refer a client to a group? What should they keep in mind? How can they find an appropriate group in their area?

Groups provide many opportunities for growth for persons with and without disabilities, as well as for the counselor. Groups offer many advantages over individual therapy, such as the chance to learn and practice new skills in a safe environment, to receive feedback from others, to learn from others’ experience, to develop relationships, etc.

Counselors referring a person with disabilities to a group should prepare the client just as they would any client when making a referral. In our book, we discuss a number of screening considerations, such the advantages of homogeneous vs. heterogeneous groups, which may be important in finding a good match for the client’s present needs. Logistical issues may also be important to consider, such as access, availability of public transportation, etc. These issues are discussed in detail in our book.

Be careful to avoid making assumptions about what a client can and cannot do; counselors sometimes underestimate the potential of clients to benefit from the group experience. The best expert on the client’s abilities and needs is the client him or herself.

 

What inspired you to collaborate and write this book?

[At University of Arizona,] we have graduate counseling programs in both school and mental health and rehabilitation specializations, and we both teach sections of a group counseling course that is required of students in both programs. When planning for this course, we were unable to locate a suitable supplementary text to address this important topic – so we wrote one! Additionally, we wanted to provide a resource to practicing group counselors who may feel that they would benefit from increasing their knowledge about disability and wish to expand their capacity for cultural competency and inclusiveness.

 

 

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Group Work With Persons With Disabilities is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222

 

Sheri Bauman and Linda Shaw will be signing books at ACA’s 2017 Conference & Expo in San Francisco on Friday, March 17 from 1 to 2 p.m. Find out more at counseling.org/conference/sanfrancisco2017

 

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About the authors

Sheri Bauman is professor and director of the counseling graduate program in the Department of Disability and Psychoeducational Studies in the College of Education at the University of Arizona. She has a background in public school counseling.

Linda Shaw is professor and department head in the Department of Disability and Psychoeducational Studies at the University of Arizona. Her background is in rehabilitation counseling; she is a licensed mental health counselor and a certified rehabilitation counselor and was a member of ACA’s Code of Ethics Revision Task Force in 2014.

 

 

 

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

 

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

 

 

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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.

 

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A counselor’s view of advanced breast cancer

By Cheryl Fisher February 29, 2016

Breast cancer touches all of our lives, and I am no exception. In February 1996, I went for my first mammogram. I was only 33 at the time, but I had read about the importance of having a baseline mammogram for early detection of breast cancer. Early detection meant cure, right? As a single mother of two young daughters, I was all about early detection and cures.

So, I went for a mammogram, astonished at how my 34B’s were able to squish like a schnitzel on the chilled mammography plate. The technician greeted me with a smile and warm hands, and for both I was grateful. The procedure, while uncomfortable, was not unbearable. I mean, I had given birth to Branding-Images_Canceran 8-pound baby without so much as an episiotomy. This was a simple walk in the park. The technician informed me that no news was good news, and I left feeling initiated (once again) into the sisterhood of womankind.

You can imagine my shock when I received a call mid-March that something unusual had been detected in my mammogram and that I needed to return for an amplification. The previously chipper technician met me with a solemn face and greeted me in almost a whisper. She did not make eye contact. The amplification was done in silence. Again I was told that I would be contacted if something was detected.

A week later, I was scheduled for a needle biopsy. As I lay facedown, my left breast dangling through the hole in the hospital table, thoughts raced through my head: “What if it is cancer? I can’t stop working. How will I take care of the girls?”

“No,” I told myself. “This is not cancer. I’m only 33 after all, and who gets cancer this young? I am a vegetarian. I am an aerobics instructor, for heaven’s sake! I don’t feel sick!”

I was provided with a bag of ice to place over the area of my breast that had been biopsied. They had found three suspicious areas and removed them, leaving a marker just in case … In case of what? I wondered. I left with my bag of ice and a fearful heart.

I started noticing articles in newspapers and magazines about young women with breast cancer. Had these always been there? Was I just now seeing them? I went home, hugged my daughters and cried. I cried the entire weekend as I waited for Monday’s pathology report.

I went alone to the hospital. I didn’t want to feel like I had to take care of another human being if my news was grim. I wasn’t sure I could take care of myself, let alone another person.

I went to the desk and announced my arrival. Again, the quiet whispered reception. I was immediately whisked away to a back office. Alone. Alone with a running video titled Living With Breast Cancer. Oh, my God! It’s true! I must have breast cancer. They’re preparing me by showing this video.

I began rehearsing how I would tell my family … my parents … my brothers … my daughters. The pathologist arrived and sat in a chair across from me. I took a deep breath. I don’t think I exhaled until I had been home for several days.

The pathologist began. “Well, we found three suspicious nodules and we removed them.” OK, buddy, so what are they?

“I’m curious,” he continued. “Have you ever experienced a trauma to the left breast?”

A trauma? You mean other than the needle biopsy that occurred the previous week? “No,” I replied in a small voice while still holding my breath. “Not that I am aware of. Why?”

“These are calcifications that appear to be from a traumatic blow to the breast,” he answered.

Let me get this right. I have been poked, prodded and petrified because of benign calcifications that possibly occurred during a Thanksgiving round of family football?

“So, I do not have cancer?” I whispered.

He shook his head and finally made eye contact. I was flooded with relief. I would live. I would raise my daughters. I would endure their teenage antics, their graduations, their weddings perhaps. I might even experience grandchildren!

What I wasn’t prepared for was the second wave of emotion that I experienced — anger. Anger at the time wasted, waiting and worrying for four excruciating days before I had to return to the hospital, find parking and sit in a room for 20 minutes watching a video about breast cancer. Anger at waiting for a doctor to hand over my fate. To me, this seemed so insensitive and cruel. What is wrong with health care that we treat the disease without treating the person?

However, I was 33 years old, a single mother, and I had just been told that I did not have cancer. I left that hospital, lived my young life and put breast cancer aside — until recently.

The call

I am a licensed clinical professional counselor. I had been in private practice for a few years when I received an email from METAvivor (metavivor.org), a local nonprofit group whose mission includes providing emotional support to individuals living with stage 4 metastatic breast cancer and promoting funding for research projects. The organization was looking for a therapist to facilitate a support group focused on meaning construction and stage 4 metastatic breast cancer.

Author and psychiatrist Viktor Frankl provided us with a foundational understanding of the importance of meaning construction in his classic book Man’s Search for Meaning. He proposed that the search for meaning was universal to the human experience and that it was a prerequisite for mental and physical well-being. Furthermore, an inability to make sense of our situation has been found to be associated with poor health. Therefore, a cancer support group that promoted meaning-making could provide patients with the necessary tools to experience a sense of well-being, even in light of their diagnoses.

My clinical practice had included counseling for bereavement and hospice care, but I had been spending more time working with survivors of trauma and had focused my advanced training in the area of trauma and spirituality. So, I wasn’t certain that I was going to be the best person to facilitate a support group for stage 4 metastatic breast cancer. Regardless, I agreed to co-facilitate
the pilot group with a colleague from a local hospice.

The pilot group lasted eight weeks. During that time, I became acutely aware that the youngest member of the group was experiencing her diagnosis in a much different way than her older counterparts were. She was a 30-year-old married woman who had been diagnosed with stage 4 metastatic breast cancer eight months prior to the launch of the group. She had a beautiful 6-month-old baby boy who provided all of us such joy when he visited our group. Her disease appeared to be relentless, however, resulting in a complete bilateral mastectomy and oophorectomy and causing her days of nausea and fatigue. She would come to group pale and weak, convinced that the last round of treatment had to be curative because of its great potency. She died two months after our group ended.

According to the Metastatic Breast Cancer Network, approximately 162,000 women in the United States are living with stage 4 metastatic breast cancer, and only 27 percent will survive as long as five years. This translates to one death from metastatic breast cancer every 14 minutes. Of this population, 5 percent are women younger than 45. Metastatic breast cancer is more aggressive the younger the person is at onset; only 2 percent of premenopausal women with metastatic breast cancer survive longer than five years following their diagnosis of advanced cancer. Most women living with breast cancer may share similar experiences regarding self-image, relationships and support issues, but unique needs appear to exist among young women living with advanced breast cancer.

As a result of meeting the young woman in our pilot support group, I conducted my dissertation research on spirituality and meaning-making in premenopausal women diagnosed with stage 4 metastatic breast cancer. I dedicated my dissertation to her and to all of the young women living with advanced breast cancer, and I committed my work to serve as the voice of those who can no longer speak. What follows is some of the wisdom provided to me by the women in my pilot group and research study.

I am woman?

The treatment for advanced breast cancer involves invasive surgeries that remove not only what many women described as their femininity (breast tissue and nipples) but also their fertility (ovaries and uterus). As a result of treatment, women were catapulted into early menopause and became subject to the physical and psychological manifestations of estrogen depletion.  These manifestations included weight gain related to decreased metabolism, hot sweats, dry skin, decrease in vaginal lubrication and decline in libido.

According to the women in my study, the experience of metastatic breast cancer had stripped them of their bodies, their fertility, their youth and their sexuality. Extensive research demonstrates that physical alterations of the body related to the treatment of breast cancer may have negative effects on identity, confidence, mood, esteem, sexuality, self-satisfaction and quality of life. Treatment may involve not only the removal of breast tissue and nipples, surrounding lymph nodes and ovaries, but also the insertion of an external port to receive chemotherapy. This may be followed by radiation therapy. The body is left scarred and burned with an existing portal that emerges from the upper trunk.

Many of the women in my study described feeling like a “freak,” a “mess” or a “patchwork quilt.” All of the women described feeling detached from their bodies following their treatments. The body that remained was described as lifeless and clinical, almost corpselike.

BFFs and other strangers

The struggle to cultivate authentic relationships was a common theme in this study. The women spoke of their desire to be able to discuss the genuinely harsh reality of their diagnoses with family members and friends. However, the women felt that a substantial portion of their circles of support were unable (or unwilling) to assimilate adequately and comprehend the grave world of living with advanced cancer. The women were asked (directly and indirectly) by family and friends to compartmentalize their experience with cancer and to act as if they were not ill. Such requests led at times to feelings of anger, resentment and, eventually, rejection and isolation.

Sexuality

In addition, there appears to be an absence of sensuality as it relates to the body that remains. This, combined with decreased libido, proved to be a common issue for all the participants in my study. The women expressed a desire to resume an active, healthy sex life with their partners, but they struggled with experiencing a lack of sex drive and feeling unattractive.

Research indicates that women younger than 45 who are diagnosed with breast cancer have more difficulty adjusting than do older women. These younger women have lowered overall quality-of-life ratings linked to concerns about body image, partner relationships and sexual functioning, and they also exhibit less adaptive coping styles.

It also appears that having casual sexual encounters becomes less attractive when living with advanced cancer. One of the women described the need to feel emotionally safe before allowing a stranger into the scarred world of breast cancer. She noted, “I will need to trust the person to tell my whole story.”

Legendary living

Engaging in honest dialogue regarding the fears experienced by a person living with a life-threatening illness seems to provide some degree of anxiety relief for the person. This appears to be the result of directly identifying and addressing that which concerns the individual.

For example, many of the women in this study spoke of their fear of being forgotten and not having a part in the rearing of their children. This discussion provided opportunities to identify ways that might allow their values and beliefs to continue to exist even after their lives ceased. Among the ways these women attempted to provide continuity of their presence in the lives of their families was through writing letters, keeping journals and signing cards for future events.

In addition to memory-making projects, all of the women in the study were involved in using their stories to promote education and awareness of the specific needs of young women living with stage 4 metastatic breast cancer.

Pink isn’t my color

In addition to feeling isolated from family and friends, these young women living with advanced breast cancer described feeling alienated from the breast cancer community as a whole. The “pink” model of breast cancer awareness strives to inspire hope of survival and a cure. However, these women live with a diagnosis that mandates that they are not in remission and that the cancer has spread to other organs. For them, there is no cure at this time. One woman in the study described the pink ribbon as “a noose that is killing me.”

Faith and peace

Psychiatrist and author Irvin Yalom proposed, “If we must die, if we constitute our own world, if each is ultimately alone in an indifferent universe, then what meaning does life have?”

As one of the study participants said, life-threatening illness can “suck the meaning out of life, making the person feel already lifeless.” In facing death, we are faced with making sense of life, and it would appear that we make choices about how to live our lives until death. Therefore, anything that affirms life force, meaning and importance to others can counter the sense that death has made its claim.

Frankl reminds us that we have the ability to choose how we respond regardless of our circumstance. This can be empowering even when facing death. The women in my study discussed the role of choice. One woman described using humor to help her cope with the chemotherapy. Another described an attitude of gratitude: “I show gratitude more often. … It is liberating to know I can choose happiness.”

The women spoke of feeling a sense of being part of a bigger, universal plan. In particular, they described feeling that a divine presence was actively participating in their illness. Some women in the study felt that their diagnosis was a wake-up call to be more present in their lives and to be closer to the transcendent. Each described a restoration process of reclaiming and redefining her life.

Other women in the study believed that their spiritual faith gave them the strength to endure the changes brought about by their illness and its subsequent treatment. Interestingly, all of the women described experiencing a richer, more authentic life that a “loving presence” had transformed from the ashes of advanced cancer.

Conclusion

As counselors, we have an incredible opportunity to help support young women living with advanced breast cancer in the following ways.

Body talk: We can help these women (and their partners) reconnect with their bodies in a healthy and empowering manner. We can talk about sexuality and recognize the role that it plays in our emotional, spiritual and physical well-being. To support premenopausal women who are living with advanced breast cancer, we need a greater understanding of their fears around rejection and increased recognition of the role that sexual intimacy plays in their lives. This is a focus of my current research.

Bittersweet friendships: We can validate the changes that occur in these women’s friendships and offer grief work around these losses. We can help clients establish healthy boundaries in relationships that feel authentic and protective. In addition, we can promote the strengthening of those relationships that are nurturing and empowering.

Legacy work: We can help clients cultivate strategies for legacy. Lillie Shockney, administrative director of the Johns Hopkins Breast Center, has written an exceptional book titled 100 Questions & Answers About Advanced and Metastatic Breast Cancer that helps clients and families navigate the challenges of advanced breast cancer. It also provides excellent ideas for being present and remembered beyond the cancer. In addition to her book, Shockney hosts exceptional retreats for families living with advanced breast cancer and provides a forum for discussion, connection and community to these patients and families.

Beyond the pink ribbon: We can connect young women who have advanced breast cancer to communities that are validating and supportive. Wonderful online communities include Young Survivors Coalition (youngsurvival.org) and the Pink Daisy Project (pinkdaisyproject.com).

Faith and justice: Facing death directly can be strangely comforting and empowering. However, counselors may be uncomfortable facilitating a candid dialogue that might be painful for their clients. Furthermore, counselors need to be open to their own discomfort in discussing death and dying. Counselors are encouraged to work from a conviction that they are helping rather than hurting clients by asking them to lean into the discomfort that comes from confronting one’s death. These clients are faced with family members and friends who are reluctant or unable to join them on this journey of facing death. Counselors have the opportunity to embody the existential experience and join the client on this difficult journey. The essence of relational, embodied theology is not captured simply by the empathic presence of the counselor, nor the rites and rituals that inspire spiritual and psychological nourishment. The essence of embodying suffering is to give voice to marginalized persons and to tell their stories. Better still, counselors can be instrumental in nurturing the intrinsic divine wisdom that is present in all of us and empowering clients to tell their own stories.

 

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. Additionally, she is a visiting full-time faculty member in the pastoral counseling program at Loyola University Maryland. Her current research is titled “Sex, spirituality and stage 3 breast cancer.” Contact her at cyfisherphd@gmail.com

Letters to the editor: ct@counseling.org

 

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

Behind the Book: Group Counseling With LGBTQI Persons

By Bethany Bray August 10, 2015

The group dynamic can be a counselor’s ally — a powerful setting that induces growth and change for clients.

It is no different for counselors who lead groups with lesbian, gay, bisexual, transgender, questioning and intersex (LGBTQI) clients. However, there is a void of literature and counselor training on group work with this population, according to Kristopher Goodrich and Melissa Luke. This prompted the two counselors to write Group Counseling With LGBTQI Persons, published by the American Counseling Association earlier this year.

From relationships and developmental issues to grief or career readiness, counselors need to keep specific needs and considerations in mind when working either with LGBTQI groups or groups that Branding-Box_LGBTQI_groupfeature a mix of LGBTQI and non-LGBTQI clients.

“Not only is it probable that a group leader will work with LGBTQI group members, but the group leader is also likely to encounter a larger number of group members who live with and love LGBTQI persons,” the duo write in the book’s introduction. “Thus, we approach this book with a belief that without more knowledge, awareness and skills in working with LGBTQI persons, group leaders are at risk of stereotyping and perpetuating societal misattributions, which both can be harmful to individuals and groups. [This] book is also predicated on the belief that with increased knowledge, awareness and skills, group leaders can utilize the unique properties and growth-promoting experiences for all group members, specifically LGBTQI members.”

Goodrich and Luke’s book contains chapters focusing on a range of issues, from groups that focus on addictions or coming out/disclosure to school and residential settings.

 

Q+A with Kristopher Goodrich and Melissa Luke, co-authors of Group Counseling With LGBTQI Persons

 

What about the group setting works well for fostering growth and change for LGBTIQ clients?

Melissa Luke: Group work has been supported by research as an effective modality of treatment for most presenting issues and a particularly effective treatment modality for clients who struggle with core issues that manifest with interpersonal and relational challenges. Accordingly, most LGBTQI+* persons have grown up and live in cultures and societies that are rooted in heterosexist, transphobic and gender normative assumptions and, further, many are part of families and educational or work institutions wherein ongoing discrimination, bias and harassment exist. It is therefore not surprising that these experiences can contribute to not only intrapersonal risk factors but also can generate interpersonal challenges as well.

While individual counseling offers a means to address the former, group work is distinctive in its ability to offer an in vivo space to explore, develop and try out new ways of being with and relating to others in a therapeutic setting.

 

*The + in LGBTQI+ is used to encompass all the identities that are part of the LGBT community; for instance, the Q can mean queer or questioning.

 

In what ways does group work meet the unique needs of LGBTQI clients?

Kris Goodrich: Group work can uniquely meet the needs of LGBTQI+ clients in a variety of ways. In regard to LGBTQI persons, it allows for the individual to learn they are not isolated or alone, [and] the presenting concerns they may have can be identified and felt by others. In addition, it allows the individual to role-play and practice new ways of interacting with others, as well as practice revealing additional aspects of themselves with feedback from others.

Interventions at the couples and family level allow group members to come together and process what it is like to be part of a system and have the helpful feedback from others in similar situations as well as the group leader; to note processes that may be occurring without their awareness; and to learn new ways [of] responding as a couple/family system. Finally, group work for non-LGBTQI+ persons allows [them] to understand new ways of understanding and interacting with LGBTQI+ persons and also helps to teach the group leader/counselor ways to use systems interventions to advocate with, and act as allies for, LGBTQI persons. Pulling from ecological counseling theory, we know that systemic interventions can be extremely powerful and, in many ways, more influential for long-term change processes. Group interventions are one way to address LGBTQI concerns at a larger systemic level than traditional individual counseling.

 

What inspired you to collaborate and write this book?

ML: First of all, Kris Goodrich is not only my academic partner but also one of my dearest friends, and that enriches our work together. We have also discovered that both our interests and work styles have proven to be productive complements to one another. In my mind, these aspects are foundational to good and enduring collaboration.

That said, Kris and I have worked together now for over a decade on many different projects, and through that work, we became aware of a number of gaps in the literature. One gap being the ways in which group work could uniquely meet the needs of LGBTQI+ persons, and another gap being the lack of training and resources for group counselors to develop their skills to more effectively respond to the unique needs that LGBTQI persons bring to group work. Given that Kris and I both thrive from challenging ourselves, we decided to endeavor to fill that gap. That was the genesis of the book.

 

What do you hope readers take away from the book?

KG: Melissa and I hope that readers take away the fact that there are many different presenting issues and concerns that LGBTQI+ clients bring with them to group counseling situations, and that group leaders are uniquely trained to address these issues using the power of group dynamics to allow for corrective experiences of LGBTQI+ clients and those close to them. Our book has a number of new group interventions, most not published elsewhere, using group dynamics to address a variety of presenting issues or concerns not often discussed in the group or LGBTQI+ counseling literature. We hope that readers will be able to take away that LGBTQI persons have more presenting concerns beyond identity development, coming out and relational concerns, and that systemic interventions can be more powerful than interventions at the individual level.

 

In the book’s introduction, you write that counselors who do not have enough skills or awareness about working with LGBTQI persons are at risk of “stereotyping and perpetuating societal misattributions” in group settings. Can you elaborate?

ML: Just as most LGBTQI+ clients grow up and live in cultures, societies, families and work environments that reflect institutionalized heterosexist, transphobic and gender normative beliefs and practices, so do most counselors. As such, no counselor is immune to the arguably insidious effects of such. It is our belief that without ongoing and intentional efforts, we are all at risk of stereotyping and misunderstanding others, including LGBTQI+ persons.

Recently, there has been increased media attention on LGBTQI+ persons and a number of well-publicized and historic events relating to LGBTQI+ concerns. However, when we refer to LGBTQI+ persons, this encompasses many different communities and identities, not all of whom have the same circumstances and needs.

In addition, the field is continually evolving in our knowledge about LGBTQI+ identity, as well as the ways in which we as counselors can more effectively work with LGBTQI+ clients across the life span. As such, we believe [that] to ethically and effectively meet the needs of our clients and to fully enact our multicultural, social justice and advocacy competencies, we counselors must commit to lifelong reflective practice, including supervision, lest we risk inadvertently reifying the same oppressive beliefs and practices that have historically marginalized LGBTQI+ persons.

 

What do you want counselors to know about this?

KG: Melissa did a very good job addressing this issue in the previous question. The only thing I might add is that within the fields of counseling and psychology, there is a focus on issues relating to microaggressions. This comes from the work of Derald Wing Sue and his colleagues in regard to race but has also been applied to sexual/affectual orientation by Kevin Nadal and others. Just as we as counselors are vulnerable to unconsciously perpetuating racial microaggressions, the same can be said for affectual orientation or gender concerns.

Understanding the nuances about LGBTQI identities is the first step toward self-awareness and affirmative practice on this journey. However, it does not end there. Group leaders and counselors need to interact with the material, which often means interacting with LGBTQI+ persons, to better understand LGBTQI persons’ needs and concerns, as well as any unconscious processes that might influence how that counselor may interact with clients (in individual or group counseling settings) in the future.

Counselors must know that regardless of our identities or background, we are all vulnerable to uninformed or misaffirming beliefs or behaviors due to the heterosexist, transphobic and gender normative culture we have grown up and lived in. This isn’t said to disparage counselors or question their ability to effectively work with LGBTQI+ clients but to form awareness that for each of us, there is always more to be aware of [and] to learn [so we can] continue honing our skills with others.

 

Who is your target audience for the book? What type of counselors?

ML: The primary audience for this book is practicing counselors, counselors-in-training and those who educate and supervise counselors. The book includes chapters that address specific counseling contexts (e.g., school, community), as well as varied types of group work (e.g., gay-straight alliances, coming out groups, family groups, grief and loss). While the book is clearly focused on group work with LGBTQI+ clients, we are very careful to remind readers that whether or not they recognize it, it is likely that all group work involves some LGBTQI+ clients.

Also, we have been told that much of the content in the book — each chapter begins with a literature review, includes sample interventions and then concludes with a case vignette illustrating application of an intervention — is easily adaptable to work with all clients across a variety of treatment modalities, not solely group work. We are also very pleased to learn that the book has been well-received by other human service practitioners who work with LGBTQIA (the A stands for ally/asexual) persons in group contexts, such as educators and community organization workers.

 

How might the book be helpful for counselors who primarily work individually and do not practice group work?

KG: When we wrote the book, we really tried to address many issues that LGBTQI+ persons might interact with over their life course. This information is helpful for both individual as well as group counselors. The interventions, although written for a group counseling setting, can easily be applied in individual counseling, with the group leader acting as the “chorus” of group members, pushing individual clients to see insight in their beliefs and actions.

 

Do you feel this topic is adequately covered in today’s graduate school programs and counselor training?

ML: Said simply, absolutely not. Recent research has identified that although the identities and needs of some LGBTQI+ persons are more included in counselor preparation than in the past, bisexual, transgender and intersex identities are much less discussed.

In addition, though counselor educators increasingly report including LGBTQI+ content in their course work, [we, together with] Janna Scarborough (2011) found that this was typically attempted in a single, three-hour class session and that the focus of this work was on counselor knowledge and awareness, not counselor skills. Todd Jennings (2014), a teacher educator who conducted a replication study with a different sample, found similar results. Further, participants in this study identified the importance of personal engagement, well-developed training resources, as well as experiential and iterative learning. Sadly, research has demonstrated that these opportunities are lacking in counselor preparation and supervision with respect to LGBTQI+ persons and related topics.

 

What would you want recent grads and new counselors to know about working with LGBTQI clients in group settings?

KG: As these concerns are typically not covered in a comprehensive fashion in counselor training, we would like recent graduates to know about this material and introduce new ways of interacting with LGBTQI clients. We also would love to instill the idea and passion for continuing education, as there is never a time when one [can] know everything about how to work with clients, especially from multicultural groups.

As Melissa noted above, many identities addressed within this book (e.g., bisexual, transgender, intersex, etc.) are not covered or receive very little attention within counselor training programs. That is problematic because if we do not know about these identities, we are likely to perpetuate stereotypical or biased behavior against these clients or unconsciously commit microaggressions against them. That could influence both our relationship with our client [and any future potential relationship that those clients might have with counselors. It can steer whole groups of people away from counseling.

This is most pronounced in the transgender community, as so little information is known by counselors, and counselors can be seen as gatekeepers by those individuals who have interest in pursuing gender conforming treatments. Of course, gender confirmation procedures are not pursued by all trans* clients, as addressed in our book, but it is one example of when a client might present to counseling and feel mandated to do so. Having an awareness of the history, the concerns and affirmative ways to interact with clients not [only] allows one better relationships with one’s own clients, it also opens that client to future counseling experiences if needed in the future.

Overall, we want new counselors to know that their training and education are not done, and there is always more to know. We also would like them to recognize the differences between affectual orientation and gender identity and how these two concepts interact with one another. And, finally, we would like to provide them some tips and tricks to add to their toolbox, as there are some very creative interventions in the book that could be utilized by anyone with an interest in creativity in counseling.

 

*trans* (with an asterisk) has become more commonly used than “transgender,” as it stands for the different variations of the transgender identity, according to Goodrich.

 

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Group Counseling With LGBTQI Persons is available from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222.

 

 

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About the authors

Kristopher Goodrich is the program coordinator and assistant professor of counselor education at the University of New Mexico. A licensed mental health counselor (LMHC) and an approved clinical supervisor (ACS), he is president of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling and president-elect of the Rocky Mountain Association for Counselor Education.

Melissa Luke is an associate professor of counseling and human services and the coordinator of school counseling at Syracuse University. An LMHC and ACS, she is the president of the North Atlantic Region of the Association for Counselor Education and Supervision.

 

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

 

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