Tag Archives: Human Development Across the Lifespan

Human Development Across the Lifespan

Starting post-college life in a pandemic

By Bethany Bray August 3, 2020

Spring 2020 college graduates have emerged into a world turned upside down by COVID-19. The job prospects and post-college lifestyles these graduates were imagining for themselves just a few months ago are today largely nonexistent.

Unprecedented seems to be the buzzword of the season, notes Roseanne Bensley, assistant director of New Mexico State University’s (NMSU’s) Center for Academic Advising and Student Support. The coronavirus pandemic has affected everything from relationships to career planning for new graduates.

“It’s not one part of their life, it’s every part of their life,” Bensley says. “Employers have uncertainty and don’t know, day to day, when things will lift. … No one has enough information to give answers. This is new territory for employers and job searchers.”

However, Bensley would like to add a second buzzword to the class of 2020’s lexicon: resiliency. As she points out, these students, many of whom had to unexpectedly finish their senior year coursework online, can claim an advantage when it comes to adaptability and comfort with technology.

Because of COVID-19, “New jobs and new ways of doing business are opening up. This is going to cause a new wave of change, and [employers] may not be going back to the way it was,” Bensley says. “These students are ahead of the curve. … They will be resilient with what they’ve learned.”

At a loss

Licensed professional counselor (LPC) Patricia Anderson recently worked with a new college grad who was experiencing a resurgence of anxiety this past spring during the pandemic. The young woman had switched jobs, and the restrictions associated with COVID-19 meant that she was unable to meet any of her new co-workers in person. Her entire hiring and onboarding process had been completed via video and electronic communication. She had also recently moved into her own apartment and begun living away from her family for the first time.

The client was stressed out, anxious, and struggling with her self-confidence, recalls Anderson, an American Counseling Association member who has a private practice in the Georgetown section of Washington D.C. In working through her feelings in counseling, it became clear that the young woman — an extrovert by nature — was experiencing grief over the large-scale absence of social connection, both at work and in her personal life.

During the pandemic, the client had stopped using an online dating platform. This resulted in her experiencing a sense of loss regarding opportunities to meet people and a decrease in the confidence she normally gained through interacting with dates and new relationships. Anderson worked with the client to establish a self-care plan that included making time for hobbies and exercise, as well as maintaining social contacts and reconnecting with friends with whom she had lost touch.

Anderson also focused on boosting the client’s confidence and equipped her with strategies for keeping her self-talk from becoming self-critical. In addition, Anderson helped the client recognize that what she was feeling was grief, which can arrive in waves. Together, they connected some of the client’s feelings to family-of-origin issues that were contributing to her stress.

Anderson also helped the client focus on the reality that her current situation wouldn’t last forever. “We talked about things she can look forward to in the future: going back to online dating, figuring out a new normal, looking forward to meeting colleagues face-to-face, planning a trip, and working on another business opportunity,” Anderson says. “Time spent away [from dating] had eroded the confidence she once had and had kicked up her anxiety. Staying ‘in the game’ can be beneficial for some [clients]. It’s a way to get to know themselves and push themselves socially.”

Many of Anderson’s clients are young professionals, current college students or recent graduates. Throughout the spring and summer, many of these clients have been wrestling with feelings of loss, she says. This includes the loss of rites of passage such as graduation ceremonies and in-person celebrations, the loss of internships and immediate job prospects and, for some, the seeming loss of entire career plans.

“Their world and their [sense of] structure have been upended, and they’re not really knowing which direction to move in,” Anderson says. “Some days, they feel like, ‘OK, I got this,’ and then other days, they have doubts about ‘Where am I going?’ The floor dropped out of what they thought was going to happen. … They have anxiety over the fact that everything got pulled out from underneath them, and now they don’t have a road map.”

It is vitally important that counselors first help these clients process their feelings of loss before trying to guide them to reconsider their job options or life path, Anderson says. Among the most consequential actions counselors can take are to listen to, validate and normalize the emotions that these young adults are feeling in the wake of COVID-19.

“Be with the client where they are,” Anderson says. “If they’re unable to go with a job that didn’t happen or was rescinded, really sit with them in that space before opening up and looking at the possibilities of ‘what else?’ It’s difficult to do that until they know that you understand them and where they’re coming from.”

All feelings of loss should be treated as real and valid, Anderson says, even if clients themselves express guilt over feeling that way or dismiss those feelings as being trivial when the world is facing weightier issues. For example, some graduates may still be dealing with disappointment that they missed out on a final chance to take a spring break trip with friends or weren’t able to study abroad because of the coronavirus. Counselors should reassure these clients that it is OK to have these feelings and then give them space to talk about it, she emphasizes.

“[Help them] know that they’re not alone and that it totally makes sense to struggle right now. They also may be scared at feeling unsettled, which may be a new feeling for them,” explains Anderson, who does contract work for the QuarterLife Center, a Washington, D.C., therapy office that specializes in working with young professionals in their 20s and 30s.

In addition to normalizing feelings, Anderson has been providing clients with psychoeducation on self-care, the nonlinear aspects of grief, and the importance of maintaining social supports and a structured daily schedule. She checks with clients to ensure they are staying connected with friends and family via technology and that they are equipped with coping mechanisms such as meditation and self-reflection exercises. She also asks if they are eating well, engaging in physical activity, getting outside, and taking part in other wellness-focused activities.

As Anderson’s clients talk in sessions, she listens for hopeful language that might indicate they are ready to rethink their futures. “I try to help them broaden their scope a little, if they’re ready for it. I let them talk about what they need to talk about, but then spend some time looking at other pieces of what else might be possible. [I] try and get them out of their heads just a little bit,” Anderson says, “because if I [as a client] always thought I was going to be a dentist, and come to find out that I’m not going to be a dentist, I have to grieve. But at the same time, maybe there are some things that free me up about not being a dentist.”

“If you can create a trusting relationship with a [client],” she says, “they know that you understand them, and we can explore all kinds of things, whether they [previously] seemed unrealistic or not.”

Rethinking career plans

Flexibility must be the watchword for recent graduates who are looking for jobs, says Lynn Downie, associate director of career and professional development at Presbyterian College in South Carolina. In her work with undergraduates and alumni of the small, rural college, Downie is finding that those who had a “hard and set, defined path” in mind, such as entering the health care or hospitality industries straight out of school, are struggling most.

Those who are currently seeking jobs can benefit greatly from the guidance and encouragement provided by a counselor, says Downie, who recently finished a two-year term as president of the National Employment Counseling Association (NECA), a division of ACA. “Give them reassurance that things haven’t changed completely. Highlight [the idea] that pathways to a particular goal aren’t always the same. There are other distinct pathways,” she says.

Downie is helping her clients identify workarounds as they adjust their perspectives to become more flexible and less discouraged by rejection letters or the idea of taking a job that might not have appealed to them previously. Some of her clients have readjusted their career plans to take entry-level or short-term work in positions or fields they wouldn’t have considered six months ago. Others have pivoted to opportunities in national service programs such as AmeriCorps.

Downie, a member of ACA, also reminds recent graduates that they just need to find a fit for right now. That doesn’t mean their long-term career goals have to change. “Help [these clients] realize that they’re not making a choice for the rest of their lives when they choose a job, or [especially] their first job,” she says. “Their life is going to be full of all kinds of pivots. Some are planned and some are unplanned and forced. There is a big arc from 18 to 65 or retirement age. … You can [still] have aspirational goals that are for down the line.”

Downie has worked with several business students who had hoped to go into health care administration, but because the industry is so in flux currently, there aren’t many administration jobs open at the entry level. With these students and graduates, Downie has focused on ways that their administration skills could be used in alternative settings, such as nonprofit, community development or public health organizations. Another tactic is taking lower-paid medical aide or assistant jobs in settings that are currently short-staffed (such as nursing homes) and that do not necessarily require special certification. As Downie points out, even working as a contact tracer as part of the COVID-19 virus response — a job that didn’t exist six months ago — could help these new graduates gain experience.

Similarly, a job in pharmaceutical or medical sales could provide these graduates with valuable exposure. “They would still be interacting with those in the medical field, instead of applying for jobs that don’t exist,” she points out.

Bensley notes that going with a “Plan B” job in a field or setting that a graduate didn’t originally intend to work in can demonstrate to other potential employers that the graduate possesses a good work ethic and thinks outside the box. She also urges students and recent graduates to widen their searches to consider temporary, freelance or even gig work instead of focusing solely on full-time employment.

“[A first job] may not be professional, but it’s work, and [the individual] can be introduced to people through that work,” Bensley says. “It also tells a [future] employer that you’re a hustler and not waiting for the golden egg to show up.”

When counseling clients who are rethinking their career plans, Downie finds it helpful to have them identify a theme they feel drawn to and then consider various types of work that fit that theme. For example, a graduate who enjoys building relationships can use that skill in any number of job settings. They might start out in sales but advance to building teams as a manager or even pivot to cultivating client relationships as a professional counselor.

“Find a theme for your life — that one thing you cling to, what you’re good at,” Downie tells her clients. “You can work on that in all types of settings. A core skill can translate into different fields, and sticking with it will give you a sense of continuity and purpose.”

Networking during a pandemic

Bensley often tells students at NMSU to think of how professional athletes are handling the pandemic: Their season may be on hold or even canceled, but they’re continuing to stay in shape.

“Just because the competitive side of their sport has stopped, they’re not watching Netflix for 10 hours a day. They are still keeping their skill set up, working out, training and preparing,” Bensley observes.

That same philosophy should apply to career planning during the pandemic, she emphasizes. Now is the time for job candidates to put even more energy into enriching themselves and expanding their professional networks.

“Don’t limit your strategy to just sending out résumés and waiting for a response,” urges Bensley, an instructor for the global career development facilitator credential through NECA. “While employers may have slowed down their original hiring plans, it does not mean that a candidate should also slow down. If anything, it means you might need to work harder at following employers on LinkedIn, reviewing their homepages and [thoroughly] reading job postings to determine if you have the skill set that employers require.”

Bensley suggests it is also the perfect time for recent graduates to flip the usual dynamic and reach out to interview professionals who are already working in their desired field. Job seekers can identify contacts through LinkedIn or other networks and ask if these professionals have 20 minutes to talk about their job or industry.

Bensley urges students and recent graduates to start with professors and mentors whom they already know or have worked with. They can then use those connections to secure introductions to other professionals in their desired field. Those professionals can recommend still others they would recommend connecting with, and so on, in a widening circle, Bensley says.

Professionals are especially open to such requests right now because many are working from home and are free from in-person meetings, conferences and business travel engagements. In many ways, motivated students and recent graduates currently have a “captive audience,” she says.

“This shows curiosity and a desire to learn about your craft, gets your name out there, and helps you evolve and have insights on what they [professionals] consider to be important,” Bensley says. “If an employer said, ‘We really value teamwork,’ there’s a hint: Everything [you might say in a job interview] should be focused on teamwork. Instead of saying, ‘I did X,” say, ‘We did X.’ That can be the small percentage you need to get ahead — understanding the value system of the employer because you’ve talked to them about it.”

Forward vision

As counselors offer support and reassurance to recent graduates and young professionals struggling to adjust to personal and professional lives upended by COVID-19, here are some important points to keep in mind:

>>  Focus on listening. Downie urges counselors to slowly ease in to therapeutic or career work with these clients. She often opens her sessions with a question: “What do you want to talk about today?” With so many concerns currently weighing on these clients, their answers might be unexpected and diverge entirely from the topics they have discussed in session previously, she says.

“Give them the floor to talk about whatever they want. We [counselors] always have to be good listeners, but now as we’re isolated, there’s a real temptation to give advice,” Downie says. “What is needed now, during this crisis, is to listen — listen more and not give advice. That’s been essential. Students who were slow to open up to begin with now need additional time to be comfortable. We need to build [therapeutic] relationships but also step back and allow for quiet. Right now, there’s so much chatter, [clients] need time to catch their breath before speaking.”

>> Consider the whole picture. College students and recent graduates may unexpectedly find themselves living at home and navigating family stressors, Downie notes. Regardless of the presenting issue that brings these clients to counseling, counselors should ask questions that will help them understand clients’ situations in full. Downie says she has worked with students who have needed to finish college coursework while sharing a computer with family members or to conduct their entire job search on a cellphone. Others found themselves scrambling to secure temporary work — long before they expected to start a career — to supplement household income because their parents had been laid off.

“When students went home and courses went online, family structures were being upended,” Downie says. “It took an emotional toll. … The level of stress has been enormous, even from day one” of the pandemic.

Some students and recent graduates have expressed feeling pressure from parents about their job searches or life choices (even if parents haven’t necessarily voiced those concerns) that they wouldn’t have felt living on campus. Counselors should be mindful that living at home adds an entirely new dynamic to these clients’ experiences, Downie says.

Administrators at Presbyterian College, including Downie, split up the student body roster and called every student to check in through the spring semester. This endeavor confirmed a saying that Downie had been hearing from colleagues: “We’re all in the same storm but not in the same boat.” The needs and stressors that students were experiencing varied widely, depending on their circumstances, she says.

“Really quickly, I realized the truth of that saying. For some, doors opened that weren’t there before. There were some who found themselves with new opportunities, yet their best friends were experiencing a very different [reality],” she explains.

>> Make clients the authors of a story in progress: Tina Leboffe, an ACA member and a counselor pursuing licensure under supervision at a therapy practice in Douglassville, Pennsylvania, uses narrative therapy with clients, many of whom are college students concerned about finding a job after graduation. “I see my clients as the meaning-makers in their own lives. When working with loss [related to the COVID-19 pandemic], I feel that it is important to walk with the client as they tell the story of their experience, while supporting their exploration of what they want this loss to mean for their life story. This can look like allowing space for the client to be present in feeling the emotions caused by loss and also to look forward at what they want their lives to look like as a result of the loss,” says Leboffe, an associate addiction counselor.

“When working with a client to refocus and reimagine their future, we can listen as they add context to their story,” she says. “Despite the setting of their story shifting, the client is still the author. We can support our clients as they integrate a new reality into their life story by asking questions that refocus on the client being the expert of their life. As counselors, we might not be able to change the job market, but we can guide our clients in an exploration of what they want their life to look like given the changes that have occurred. We can assist them in identifying decisions they want to make in the face of change.”

>> Seize the opportunity to explore identity: Leboffe and Anderson both note that while this is a time of stress and upheaval for young clients, it can also afford opportunities for personal growth. Counselors can help support and encourage that process.

“This is a good time for them to learn about themselves, learn about what their values are and what is important to them. … [It is] a time to explore their internal world and let them find out what their 22-year-old self is like,” Anderson says. “How are they with stress? How do they handle ambiguity? How are they capable and able to move forward and readjust in such a difficult time? Giving them space to talk allows them to process [these things].”

“In my experience working with young adults and recent grads — and being one myself not long ago — I have found that this time in their lives can be filled with identity exploration and transition,” Leboffe says. “They may be faced with new levels of independence and responsibility that can evoke questions like ‘What do I want my life to look like?’ or ‘Who do I want to be?’ This can be important to keep in mind as we work with or parent recent grads because it can serve as underlying context to help us be empathetic to their lived experiences while they are developing their sense
of identity.”

>> Remember that productivity is relative. Anderson has found it helpful to remind young clients that even though they’re spending much more time at home, they may need to temper their expectations about productivity.

“This shouldn’t be a time when you plan to be super productive. That’s hard to do when you’re going through something so emotional and so taxing,” Anderson tells clients. “It’s not a time to learn six new languages, clean your entire house or finish a major art project. Instead, focus on what works for you. What are things that calm you and help you [that] you can do routinely? Be less hard on yourself. At the same time, it’s a great time to try something new if you have the motivation to.”

>> Build confidence. Bensley urges counselors to focus on the positive when communicating with college students and recent graduates during the pandemic. “The No. 1 thing we can do for clients is help build their confidence,” Bensley says. “The tone of my emails has been, ‘Hey, you’ve got this. I’m cheering you on.’ I’m trying to use my language to be that [needed] encouragement, even if they don’t ask for it or seem to need it.”

>> Take them seriously. Transitioning to adulthood is hard enough without the added concerns and stresses of COVID-19. Validation from a counselor is pivotal during this time of life, Anderson says.

“Take their concerns seriously. We know in general that people will land on their feet and things will turn out OK as they make their way in the world. [But] they need to be held in the emotional space where they are right now,” Anderson says. “Moving into adulthood is really hard. It can be a very tumultuous time — and one that promotes growth.”

“[These clients’] struggles and needs are serious,” she continues. “Figuring out dating, jobs and social stuff — it’s all important. Stay with them in their space and create that [trusting] relationship. Know that their concerns are valid, even if we have all the confidence in them in the world that they’re going to figure this out. They really are worried that they’re not going to figure this out in the right way. And that’s valid [because] they haven’t been here before.”

 

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Entering the counseling profession amid COVID-19

Graduates from counseling programs certainly aren’t immune to the stresses and uncertainties that 2020 graduates in other fields are facing.

Darius Green graduated from James Madison University (JMU) with a doctorate in counselor education in May. Green says that he and many other counseling graduates feel the pressure of finding jobs that can provide financial stability “rather than being able to choose what positions best fit [our] personal and professional goals.”

I do not come from a background of financial privilege, so this rose to the top of my priorities,” says Green, a member of the American College Counseling Association, a division of ACA. “I [have] noticed a mix of success and difficulty among some of my peers in the job search process. For those who started early and found a position that matched what they were looking for, the process seemed easy. For my peers who had not been able to start searching early or just had not found the ideal position, there seemed to be more difficulty. … I struggled with finding a position that I wanted and carried out my job search longer than I had planned.”

This summer, Green is living in Harrisonburg, Virginia, where JMU is located, holding down both a full-time instructional faculty position with JMU’s Learning Centers Department and working part time as a counselor with the ARROW Project, a community mental health organization roughly 30 miles away in Staunton.

Green hopes that in this time of crisis, professional counselors who are already established will remember the role they play as advocates for the profession and will look out for new counseling graduates trying to enter the field.

“I think that counselors who are already working can be aware and sensitive to how stressful being in such a position [graduating during a pandemic] can be. I also feel as if counselors can advocate within their agencies or communities to do our part in making sure that existing opportunities are made known to recent graduates,” Green says. “That could include reaching out to counseling faculty members to share information or even connecting with colleagues who may know of new counseling graduates in need.”

“One thing that I would want [counselors] to keep in mind is that not everyone has connections to others in the counseling profession and other mental health fields,” he continues. “Some students come from backgrounds that may have lacked opportunities for networking or that may not value the mental health professions. I think it would be important to pay particularly close attention to those students so that they do not fall through the cracks or face another layer of oppression.”

 

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

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

Counseling Connoisseur: Autumn lessons in turning inward and letting go

By Cheryl Fisher November 27, 2019

“At first we do not know what deeds or misdeeds, what destiny, what good or evil we contain, and only the autumn can show what the spring has engendered; only in the evening will it be seen what the morning began.” —  C.G. Jung

The leaves rustle in the trees as the wind grazes the tops, now bleeding color from the stems. Golden, russet and brown shades color the tips of the horizon as the seasons move from summer to fall. The earth begins to bring its energy toward its center as it prepares for the cooler months.

I begin my rituals of nesting. I cover the herbs and berry plants with straw and fill the feeders—assuring my feathered friends will have seeds and full bellies. Salads and light fair are replaced with soups and stews. The house is filled with the alchemy of savory and sweet spices.

I don shawls and pashminas and shuffle around in fleece-lined footwear. The shift toward autumnal consciousness brings quiet and an inward focus that is forgiving of extra pounds hidden under tunics and capes. I welcome the harvesting and gathering by all creatures as we prepare for the often-dreaded winter months that lie ahead.

Nature’s seasons offer guidance and are witness to the phases of change in our human experience. The first half of our lives—the spring and summer of our youth and young adulthood fade into the beginning of the second half—an autumnal middle adulthood that can offer peace and solace as we learn to turn inward. Just as the last of the leaves gently fall to the ground, we learn to let go of that which we no longer need. We let go of judgment and self-loathing, external validation and the defenses of the ego of youth.

The arrival of autumn

Our early years are characterized by quick growth and the establishment of our own separate identity. We build our sense of self from numerous factors: I am female. I am tall. I am a writer. I am a helper. I am a hard worker.

Once we have established our place in the world—one that centers on our individuality—a shift in perspective occurs. Autumn has arrived and we begin to look for greater meaning.

In “Falling Upward: A Spirituality for Two Halves of Life,” Richard Rohr, a Franciscan priest and founder of the Center for Action and Contemplation, says that the shift [to the second half of life] “… feels like a return to simplicity after having learned from all the complexity.” According to Rohr, life’s second half offers the understanding that peace and tolerance far outweigh an air of judgment and righteousness. Knee jerk reactions are replaced with contemplation and discernment. We begin to welcome the wisdom gained from many years of experience and coaching from others. We have started to cultivate our own sense of internal guidance and others may look to us for mentorship. We may recognize a sense of power — a force acting from within that we know is not our ego, and we begin to trust it.

 

A time of change

As we enter our middle to later adulthood, we may find judging people more difficult and that accepting people as they are is more in keeping with our heart’s desire. We no longer have to prove that our ethnicity, religion or socioeconomic group is superior to another. We have a greater understanding of our narrative and the mistakes we’ve made and are more able to view the errors of others in the context of humanity. According to Rohr, “Creating drama has become boring!”

During this time, we may begin to see love as something to be offered unconditionally, rather than given only for what we receive in return. Erik Erikson theorized that in middle adulthood — by his definition a span encompassing the ages of 40 to 65 years old — people begin to develop concern for others that extends beyond self and family. He called this need to nurture others—particularly the next generation—generativity. Erikson believed that this desire to give back to the world is so strong that if we are unable to contribute to the greater good, we feel a sense of failure and “stagnation.” Alfred Adler wrote extensively on the value of Gemeinschaftsgefuhl, or social interest — extending beyond oneself to creating a useful lifestyle. As counselors, we can help clients identify their gifts and find ways to make offerings to the world.

A different compass

According to Rohr, the first half of life is constructed through “impulse controls; traditions; group symbols; family loyalties; basic respect for authority; civil and church laws…”

However, in the second half of life, rules as a basis for action give way to authenticity and power directed from an internal moral compass. With age comes the understanding that there can be a difference between what is legal and what is moral. For example, there was a time in the not-so-distant past when it was illegal for black Americans to eat in the same restaurants as white Americans. While this was the law, it certainly challenges my moral compass. Throughout history, many activists—such as Martin Luther King, Jr.; Mother Teresa; Mahatma Gandhi; and Jesus Christ—have broken the laws of their time to move society toward higher moral ground.

The test of time has provided us with the experience of knowing to pick our battles. No longer feeling the need for competition and keeping up with the Joneses, we are able to enjoy just being in the general dance. We feel at peace more often with what is, and we appreciate things the way they are in the moment. We look to simplify our lives—making space for relationships and pleasure. Much needed playtime re-enters our calendars that have suffered years of overcommitment. We turn inward and welcome the peace.

As we work with clients who are transitioning from the summer of their youth to the autumn passage of middle adulthood, we can remind them of their strengths and the gifts they have cultivated throughout their lives. We can promote their generous offering of time and talents in service to their communities. We can help them identify their beliefs and values, and challenge the dissonance between their internal moral compass and the life they live. We can encourage their inner dialogue and the wisdom that they possess. As counselors, we can promote these changes by offering affirmation of their strengths and the beauty of coming into one’s own self in a way that is authentic, liberating and powerful.

Perhaps this is what the poet Jenny Joseph intended to capture in “Warning,” written in 1961 when she 29.

When I am an old woman I shall wear purple
With a red hat which doesn’t go, and doesn’t suit me.
And I shall spend my pension on brandy and summer gloves
And satin sandals, and say we’ve no money for butter.
I shall sit down on the pavement when I’m tired
And gobble up samples in shops and press alarm bells
And run my stick along the public railings
And make up for the sobriety of my youth.
I shall go out in my slippers in the rain
And pick the flowers in other people’s gardens
And learn to spit.

You can wear terrible shirts and grow more fat
And eat three pounds of sausages at a go
Or only bread and pickle for a week
And hoard pens and pencils and beermats and things in boxes.

But now we must have clothes that keep us dry
And pay our rent and not swear in the street
And set a good example for the children.
We must have friends to dinner and read the papers.

But maybe I ought to practice a little now?
So people who know me are not too shocked and surprised
When suddenly I am old, and start to wear purple.

 

 

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Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.

 

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

Understanding the gap: Encouraging grad students to work with an aging population

By Neha Pandit August 20, 2019

It often feels like an uphill battle to be attending graduate school, working, sifting through large amounts of data about practicum (and then internship) placements, and weighing options all at the same time. As a graduate counseling student, there are recurrent moments of panic and thoughts of What am I going to do? Where should I apply? and the unavoidable, multifaceted What if … ?

As someone who has advised graduate students, supervised future counselors throughout their clinical training process, and practiced for over a decade myself, I try to break this process down into questions such as: What do you hope to achieve? What interests you? What type of work do you see yourself doing when you graduate? These questions illicit responses that span from the specific (e.g., “I want to work with kids who are struggling with an addiction”) to the more general (e.g., “I want to get experience doing actual therapy”).

Many clinical training directors will tell you that what we less frequently hear is counseling students who say they want experience working with older adults. When I suggest that this is a growing field with extremely diverse opportunities — from setting (hospital, community, private) to format (individual, family, group) — what I often get in return is a perplexed look, a head shake, and a facial expression that seems to suggest anxiety. This is accompanied by a statement to the effect of, “I’m just not comfortable counseling an old person. What could I possibly say to them that they haven’t already heard?”

 

Uncertain about the uncertainty

The reasons behind this uncertainty are not simple. First of all, what does being an “old person” or “geriatric” even mean? Society most often measures these constructs in terms of years. According to the World Health Organization, the beginning of “old age” typically hovers somewhere between 60 to 65 years old, coinciding with average retirement age in many cultures. But even this age range is slowly shifting upward as we live longer and healthier lives. According to the U.S. Census Bureau, in 2017, 15.6% of the U.S. population was 65 or older. By 2030, this number is estimated to grow to 25% of the population. The Stanford Center on Longevity estimates that 10,000 Americans turn 60 every day.

Given the many opportunities to enhance their clinical skills with such a large and diverse population, how can we understand the hesitation that counseling graduate students may show toward working in organizations that aim to provide services to those over 65? Is the hesitation connected to an internal fear of the unknown — growing older themselves or thinking about loved ones aging and not being ready to face those prospects? Or does it involve assumptions made about people based on age? In speaking with students and fellow counseling supervisors, I think it has to do with a combination of those two reasons.

We all get nervous about working with unknowns, of course. Applied to this situation, the origins of this uneasiness seem obvious: Graduate students have all experienced being children before, but few of them have experienced being old. When a shared reference point is not available, assumptions are all too often generated from stereotypes. The same holds true with words such as “old,” “geriatric” and “elderly.” The problem is that the almost automatic images associated with these descriptors — and with presumptions about fragility, sickness, and resistance to change — are not appropriately reflective of older adults in general.

Given the inevitability of aging and the astounding need for more counselors with geriatric training and experience, I often wonder what we can do to challenge such inhibitions and encourage more students to pursue opportunities to work with older adults.

 

Challenging myths

It is vital to this discussion to debunk age-related myths. This involves challenging the veracity of automatic links and images that students may generate related to the mental and physical well-being of aging adults.

One way to accomplish this is by discussing the basic statistical concept that the variability of differences within a group is much greater than the variability between groups. Said another way, it is more likely that a graduate counseling student will have more in common with an older person than it is for a group of older adults to have a lot in common with each other. This concept should already be a learning objective that is core to any multicultural counseling class. Ensuring that graduate counseling classes that focus on matters of diversity also include exploration of what aging does and does not mean could go a long way toward breaking down uncertainty that is based in incorrect automatic images and assumptions rather than in reality.

Scientific and technological breakthroughs mean that what once seemed to be inevitable byproducts of the aging process are no longer homogeneously applicable. Here are two examples of myths with associated reality checks:

 

Myth: Old people are fragile and are probably ill.

Reality: Some diseases, infections and conditions that were not understood or treatable 50 years ago are now completely preventable or treatable at any age. The National Institute on Aging states that the average age of onset of many chronic illnesses (for example, arthritis and heart disease) has increased incrementally by 10 years over the past 80 years. This means that people are staying healthier for longer and have freer will to control environmental factors that can facilitate good health.

 

Myth: Old people are set in their ways and don’t want to change.

Reality: Personality characteristics usually remain stable over time. Someone who was generally resistant to change over the course of his or her life is likely to remain resistant to change. However, the converse is also true: Someone who generally welcomed change over the course of his or her life is likely to continue to welcome change.

 

Getting personal

Normalizing the fear of the unknown, identifying experiences that may affect this, challenging the rationality of assumptions around aging, and having frank discussions about the universality of “experience” are all pivotal to encouraging graduate students to work with an aging population.

By “universality,” we are not just referring to the inevitability that, with luck, we will all get older. Rather, it refers to the reality that we are all subject to similar challenges and emotions that can arise at any point in our lives. For example, relationship difficulties, depression, anxiety, trauma, illness and loss are life challenges that a 5-, 25- or 75-year-old can face. Therefore, a 5-, 25- or 75-year-old could benefit from treatment.

Erik Erikson recognized this lifelong process of continuous development, growth and reflection through the “integrity versus despair” stage in his theory of psychosocial development. According to Erikson, around age 65, individuals begin to profoundly reflect on the meaning in their life thus far. Someone who is able to find this meaning and look back on life with few regrets moves toward integrity. If, on the other hand, individuals feel they have wasted their time and are full of regret, they will be more prone to despair. Meeting the developmental needs of older adults as they negotiate this critical phase elucidates a common clinical issue that both current and future counselors will always face: perception of meaning in life.

We want our counselors-in-training to mature in their reflective capacity skills and to strive to understand internal variables that they may bring into sessions. By the time they are in the classroom with us, most graduate students have had the experience of seeing loved ones age, and those who have not could be anxious about the certain reality of having this experience at some point in the future. This gives counselor educators and supervisors the opportunity to explore with students how their reactions to these inevitable realities are collective in nature and how they are shared by many people, regardless of age. A counselor-in-training with good reflective capacity can harness the associated emotions and funnel them into an invaluable therapeutic tool: empathy.

 

Recommendations and tips

As mentioned earlier, the diverse options for working with older adults better enables us to match student interests with appropriate placements. I had a student who was interested in getting clinical experience with family therapy and older adults in hospital settings. The student was able to find a placement in a hospital working with families in which one of its members had been newly diagnosed with Alzheimer’s disease. Another student had strong interest in getting experience working with addictions. The student was able to find a placement at a methadone clinic and was assigned a good caseload of older clients who were in recovery. My point is to communicate to students that the variety of placements available for working with older adults mirrors the diversity of today’s older adult population.

The passage of time inevitably brings change and, with that, different challenges and fluctuations. As counselor educators and supervisors of future practitioners, it is our responsibility to challenge and prepare graduate students to tackle these issues. Whether it’s a student seeking guidance or a person seeking counseling, assisting in increasing their reflective capacity, adaptation or coping with these challenges and changes is core to what we do as educators and practitioners. Regardless of how old the person sitting in our office or classroom is, engaged learning can happen in countless forms, as can growth through stepping out of one’s comfort zone.

 

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Neha Pandit is an assistant professor at Robert Morris University, working mainly in the master’s counseling psychology program. She also has more than 15 years of clinical experience and is currently working at a practice in Wexford, Pennsylvania. Contact her at pandit@rmu.edu.

 

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

Culturally competent end-of-life counseling

By Ashley C. Overman-Goldsmith May 1, 2019

End-of-life counseling is an important area of our profession. Unfortunately, it is also an area of the profession that is underdeveloped and seldom researched. Consequently, few resources are available to professional counselors that specifically address multicultural competence in end-of-life counseling.

I first became interested in end-of-life counseling while working as a bereavement program manager and counselor in a private hospice setting. As a bereavement counselor, I worked not only with the families of patients receiving hospice services but also with higher risk patients (those who struggled with psychological and physical pain). The private hospice organization provided social services for patients, but our social workers had large caseloads and found it difficult to meet the emotional and psychological needs of patients and family members who required ongoing therapeutic intervention. To meet those needs, I developed an end-of-life counseling program in which I personally worked with patients and family members deemed medium to high risk.

I currently practice counseling at Sea Change Therapy PLLC, where I help individuals who are struggling with life transitions, including the end of life. In addition to my clinical practice, I am conducting research in end-of-life counseling under the advisement of my dissertation committee at North Carolina State University.

The list of reasons for counseling at the end of life can be similar to the reasons that individuals seek out counseling earlier in life. The largest difference, of course, is that with end-of-life counseling, the client is facing his or her death. This makes this area of counseling all the more challenging. Because these clients die at the end of counseling, counselors are responsible for so much more than just helping clients pursue improvements in a relationship or changes to an existing issue. Counselors are helping these clients achieve goals that may improve the possibility of them experiencing peace before they die. This is a major undertaking.

As an end-of-life counselor, I have witnessed the impact that clients’ lived experiences and aspects of their identity have on their end-of-life experiences. These experiences are personal, unique events that require counselors to be skilled in addressing a multitude of issues regarding both a client’s identity and the dying process. Multicultural and social justice competence is key to counselors being able to provide effective end-of-life counseling and help clients navigate end-of-life experiences successfully.

The Multicultural and Social Justice Counseling Competencies (MSJCC) endorsed by the American Counseling Association are a set of guidelines for developing and maintaining multicultural and social justice competence as counselors. The MSJCC framework aids in understanding the complexities of the counseling relationship, specifically with counselor–client interactions. The MSJCC support counselors in addressing issues that are often not well-recognized but that have a significant impact on the client. These issues include power dynamics, privilege and oppression. The MSJCC are well-supported by our profession and are a very useful tool for promoting cultural competence for counselors.

The Handbook of Thanatology, a resource created for practitioners by the Association for Death Education and Counseling, provides detailed, thought-provoking suggestions on how to be culturally competent when working with clients at the end of life. The handbook includes a combination of research findings, practical implications and recommendations for end-of-life practice.

Using the MSJCC and suggestions from the Handbook of Thanatology, counselors can ensure that they are providing culturally competent and effective end-of-life counseling services to their clients. Using these references, along with information from my professional experience as an end-of-life counselor, I have developed a simple framework for culturally competent end-of-life counseling practice.

Education

Education is an important component of culturally competent practice. Continuing our education beyond the completion of the master’s degree requirement is necessary for growth and effective practice in this field.

As professional counselors, we are required to complete a specific number of continuing education credits yearly to maintain state and national licenses. For many of us, a certain number of these continuing education credits are required in the area of multicultural competence. Continuing education in end-of-life practice is increasingly available, and there are many opportunities for growth across disciplines in this specialty area. For example, there are distance learning programs that provide thanatology coursework, including multicultural competence in end-of-life care. During my personal search for continuing education, I have come across numerous courses or sessions that are outside of the university setting. Professional memberships, local funeral homes, palliative care programs and medical facilities all offer continuing education opportunities, sometimes at little to no cost.

In addition to the more formal avenues for advancing your education, there are ways to learn and grow in the understanding of other cultures through observation, immersion and self-education. The Handbook of Thanatology says that if we want to better understand the beliefs and practices of a particular cultural group, immersing ourselves in that group can aid in this quest. Obviously, that approach is time-consuming and not feasible for all counselors. However, I would recommend, at minimum, that counselors observe and investigate the beliefs and practices of the clients (and clients’ family members) with whom they are working. Don’t fear asking questions that will improve your knowledge.

We are encouraged as counselors to be well-informed about what is going on in the world around us and to consider the ways in which events may affect our clients. For example, changes in health care coverage and policies can impact terminally ill clients and their families. Seeking out details on these changes and working to stay informed not only can help us to prepare for what our clients may be facing but can also provide us with information that could be important to pass along to our clients. Social, cultural and political developments may also influence our clients’ emotional and psychological states. It is important that we maintain an awareness of how these developments could affect clients from varying groups in different ways.

Possessing knowledge of both historical and current events — particularly those resulting in the oppression of a group of individuals due to their race, ethnicity, socioeconomic status, gender or sexual orientation — can help us better understand the lived experiences of our clients. Linking historical and current events can provide us with a clearer perspective on the adversities that our clients and their families continue to face. These adversities are woven into their personal narratives and are often revisited at the end of life. Our clients may want to remember the happy experiences they have had, but they may also recall the adversities they have confronted. Our clients’ worldviews, values, beliefs, and marginalized or privileged statuses (lived experiences) all have an impact on their perceptions of death and dying. In turn, their perceptions of death and dying have an impact on their end-of-life experiences.

Education is the foundation of culturally competent end-of-life counseling. Developing knowledge of the impact of history, events, culture, religion/spirituality and other influencers on our clients’ lived experiences can help us reach a better understanding of their end-of-life experiences. Possessing a solid knowledge base — and continuing to expand that base by seeking out educational opportunities — has a direct impact on the effectiveness of our practice as counselors.

Practice

This section of the framework is designed to be used in addition to the approaches and interventions that end-of-life counselors are already trained in and currently practicing. Like other areas of the counseling profession, end-of-life counseling is not limited to one single approach or a specific set of interventions.

Culturally competent end-of-life counselors embrace the fact that multiculturalism and social justice are central to end-of-life counseling. In culturally competent end-of-life counseling, counselors work to be aware of the many identities that counselors and clients possess, as well as their privileged and marginalized statuses. These identities and privileged or marginalized statuses enter into and influence how each individual will experience interactions that occur during the counseling relationship. Culturally competent end-of-life counselors skillfully facilitate discussions about these identities and statuses. They share information about their own identities, allow clients to explore their personal identities, and work to identify and overcome any barriers that may arise in the counseling relationship.

The knowledge that culturally competent end-of-life counselors possess and continue to build upon (addressed in the education portion of the framework) aids them in better understanding clients’ identities. Open dialogue about these identities can help counselors gain insight into an individual’s unique background. Through this work, clients may even come to recognize their diagnosis or terminal illness as a new identity or way in which they see themselves. When this happens, counselors can help clients examine this new identity and use interventions that are helpful in exploring clients’ perceptions of what this new identity means to them.

Occasionally during this time in the counseling process, clients will discuss experiences that led to their understanding of these identities. These experiences and others that are shared during counseling are the clients’ lived experiences, which may influence how they view themselves and their end-of-life experience. Making space for these discussions (or even initiating them) and asking questions to better understand our clients helps us to become more culturally competent counselors. As a result, trust is built between the counselor and the client, and the counseling relationship is enhanced.

In end-of-life counseling, these discussions usually take place early on in the counseling relationship. In fact, faster development of the counseling relationship can be more critical in end-of-life counseling than in other areas of counseling practice. Allowing opportunities for these discussions early on may greatly enhance the client’s comfort in sharing with the counselor and may aid in achieving the goals of counseling in the limited time available.

The ultimate goal of end-of-life counseling is to facilitate psychological and emotional healing that will allow clients to experience peace. Counselors and clients work together to identify sources of stress or any psychological disturbances (e.g., depression, anxiety) that are preventing the client from achieving peace. Reasons behind the presence of disturbances such as depression or anxiety may vary. Clients might express fear of death, a sense of isolation, a loss of purpose or meaning, struggles with feelings of guilt, conflict in relationships or other concerns. Occasionally, struggles in relationships, personal regrets, feelings around a loss of independence, feelings of loneliness, or emotions connected to experiences with racism, sexism, religious oppression or other forms of oppression may also surface at the end of life.

Culturally competent end-of-life counselors understand that clients’ lived experiences (inclusive of issues such as oppression and discrimination) are unique and personal and should be handled delicately. Providing a safe space for clients to express their feelings surrounding these experiences is an important step in helping them achieve peace at the end of life. This safe space is created early on in the counseling relationship through structure, support, encouragement and unconditional positive regard. It is enhanced when counselors effectively and openly discuss identities, privileged or marginalized statuses, and issues such as oppression and discrimination. Allowing space for the anger, frustration, sadness and other feelings that clients may feel when sharing about these experiences is very important.

The MSJCC emphasize the need for counselors to work outside of the office, meeting directly with the client’s family members and friends (with permission from the client) to determine what relationships exist that will either support the client’s progress in counseling or present barriers to change. With end-of-life counseling, counselors are more likely to work with the client outside of the office. This might include meeting in hospice facilities, nursing facilities, assisted living facilities, hospitals or clients’ homes. As a result, end-of-life counselors are occasionally afforded opportunities to observe interactions that clients have with their family members and friends. If clients have identified resolution of conflict in a relationship as a goal of end-of-life counseling, then counselors are able to intervene.

By facilitating these discussions early on in the counseling relationship, counselors can create the solid foundation necessary for various counseling approaches and interventions. Counselors should ensure that they are using approaches and interventions that are culturally appropriate and that empower clients.

Advocacy

Advocacy at the end of life can be complicated, but it is important that we make sure our clients’ voices are heard. End-of-life counselors often are responsible for updating the interdisciplinary team about the client’s emotional and psychological well-being and the progress being made in counseling.

The interdisciplinary team (sometimes referred to as the multidisciplinary team) generally consists of medical professionals (doctors and nurses) and a group of supportive services professionals that can include some combination of social workers, counselors, psychologists, and clergy or spiritual care counselors. These teams are usually organized and assigned through hospitals and palliative care/hospice organizations. Team members work together to ensure that they are meeting the needs of individuals enrolled in services. Team meetings can vary in approach, but in my experience, each team member is asked to provide an update on the services for which they are responsible, along with any concerns they have about the needs of the individual who is facing end of life.

As counselors, we are often uniquely cognizant of the emotional and psychological needs of our clients. This gives us the ability to identify additional issues that are affecting our clients’ well-being. We can share these concerns and challenges with the interdisciplinary team in many ways. For example, we can relay information about the progress our clients are making in sessions by tracking their levels of depression or distress via simple assessments and then presenting our data during team meetings. We can also bring up any concerns that our clients have voiced during sessions regarding their care or interactions with other team members.

Our role on the team also gives us opportunities to educate the other team members on cultural considerations. The cultural insights we provide may influence discussions that these other team members have with our clients and their family members. Because of our greater level of understanding of the lived experiences of our clients and the impact these have on our clients’ end-of-life experiences, we can provide guidance to the team on how best to provide individualized care to clients.

In our role as advocates, we can also give voice to our clients’ end-of-life wishes. This may sometimes require us to relay difficult and sensitive information (again, with the client’s permission) to family members, team members and caregivers. This might involve the client’s desire concerning the presence or absence of certain individuals during the end-of-life experience, the environment in which the person wishes to die, requests for final meals, the kind of medical care or interventions the person would like to receive, and so on. As advocates, it is important that we relay this information in ways that are sensitive while also being true to our clients’ voices.

In addition to our responsibility to give our clients voice, it is also important that we work to improve the understanding of the attitudes, beliefs, biases and prejudices that exist in our communities, not just in our places of work. Among the ways we can do this are advocating for policies and procedures that rectify existing inequities, offering additional support to marginalized clients, and collaborating with others to address issues of power, privilege and oppression in advanced care settings. Some examples of how these issues arise in advanced care settings include the ways in which information is relayed to marginalized clients and assumptions that all clients have strong support systems, the same knowledge of or experience in health care settings, and similar perspectives on the end of life. Providing education on culturally competent practice to others who work in end-of-life care can also serve as advocacy. Advocacy is a part of cultural competence, and it is an important role that end-of-life counselors can play for clients.

Summary recommendations

Key considerations for providing effective, culturally competent end-of-life counseling are as follows:

  • Seek out educational opportunities that challenge and expand your understanding of multicultural and social justice issues in end-of-life counseling settings.
  • Treat the “whole” client and not just the parts of the client with which you are comfortable.
  • Integrate discussion of both the client’s and counselor’s worldviews, beliefs, attitudes, and marginalized or privileged statuses.
  • Help clients explore their lived experiences and the impact these have on their end-of-life experiences.
  • Advocate for clients by giving them a voice and pursuing social justice in end-of-life policies and practices.

Conclusion

Counselors should continue to strive to be culturally competent to provide the best services possible to our clients. Being culturally competent involves not just our professional selves but also our personal beliefs, values and worldviews. As we become more culturally competent and actively engage in multicultural and social justice advocacy, we will become more well-rounded, effective counselors.

 

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Ashley C. Overman-Goldsmith is a licensed professional counselor, a national certified counselor, and a doctoral student at North Carolina State University. She is the owner and lead therapist at Sea Change Therapy PLLC. Her current research centers on honoring the lived experiences of terminally ill clients while helping these clients resolve issues that affect their end-of-life experience. Contact her at seatherapychange@gmail.com or through her website at ashleyoverman-goldsmith.com.

 

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

 

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

Talking about menopause

By Laurie Meyers January 7, 2019

Sleepless nights. Sudden temperature spikes and night sweats. Fluctuating moods. Brain fog. Sudden hair loss (head). Sudden hair growth (face). Dry skin, leaky bladder, pain during intercourse.

This litany of symptoms may sound like the signs of a mysterious and slightly terrifying disease, but they’re actually all possible side effects of a normal, natural life transition: menopause.

Menopause is an inevitable part of life for women — or, more precisely, people with ovaries — but chances are, many clients who show up to counseling know little about it. “The Change,” as it is sometimes called, isn’t taught in sex education classes and is rarely brought up by doctors. Even friends don’t always tell other friends about it. Unprepared for this disruption that usually coincides with a life stage already known as a major time of transition, clients may turn to counselors for help navigating this natural biological process.

Understanding the process

Therein lies the first lesson: Menopause is part of a process. Menopause refers to a specific point 12 months after a person’s last menstrual cycle. Perimenopause, which can begin up to 10 years before menopause, is the transitional time during which most menopausal symptoms occur. Perimenopause usually begins in a person’s 40s but can start as early as a person’s mid- to late 30s.

“During these years, most women will notice early menopausal symptoms such as hot flushes, night sweats, sleep disturbance, heart palpitations, poor memory and concentration, vaginal dryness and … depression,” says American Counseling Association member Laura Choate, a licensed professional counselor (LPC) who has written extensively about issues that affect women and girls.

According to the National Institutes of Health, other perimenopausal symptoms include irregular menstrual periods, incontinence, general moodiness and loss of sex drive. Some people also experience aches and pains and weight gain, particularly in the abdominal area, although experts are unsure whether these effects are tied directly to perimenopause or are instead caused by aging.

LPC Stacey Greer, whose practice specialties include assisting clients with issues related to perimenopause/menopause, says that many clients show up to her office because they’ve been feeling “off” or “not like themselves.” Some of these clients may even have received a perimenopause diagnosis, but most still are unaware of the symptoms and don’t understand the process, she says.

Both Greer and Choate believe that knowing what to expect in perimenopause can in itself ease some of the discomfort of the transition. Choate notes that for those who are unaware of the signs of perimenopause, many of the symptoms can be alarming. Some clients’ symptoms may be mild, but for others, they are severe and can significantly interfere with clients’ functioning and quality of life, Choate says. She adds that symptoms usually peak about a year before the last menstrual period and begin to ease significantly in the second year of postmenopause.

Is it hot in here?

Knowing what to expect from perimenopause is all well and good, but in this case, forewarned doesn’t mean forearmed. Clients still have to live through the symptoms.

Counselors can help with that. Greer says that charting is an excellent tool. She gives clients a chart listing perimenopausal symptoms and asks them to note all the ones that they experience over the course of a month. This allows her to identify and focus on a client’s specific problems.

Hot flashes, night sweats and trouble sleeping are some of the most common complaints. Choate says research has shown that cognitive behavior therapy (CBT) can help with hot flashes and night sweats. She recommends the techniques contained in Managing Hot Flushes With Group Cognitive Behavioral Therapy: An Evidence-Based Treatment Manual for Health Professionals by Myra Hunter and Melanie Smith. The book highlights the importance of identifying and reframing thoughts that occur during a hot flash.

When hit with a hot flash, instead of thinking, “Not other one!” or “I am going to pass out” or “This will never end,” clients can tell themselves, “It will pass” or “Menopause is a normal part of life” or “The flashes will gradually go away over time,” Choate explains.

“In addition to changing self-talk, it is helpful to have an attitude of calm acceptance, mindfully accepting the hot flash instead of trying to push it away or become upset by it,” she says. “There is evidence that mindful acceptance and allowing the flash to ‘fall over you’ helps women cope more effectively. Also, using paced breathing to elicit the relaxation response helps women cope as they focus on their slowed breathing instead of the discomfort that accompanies a hot flash.”

Many people also experience problems sleeping during perimenopause. According to the National Sleep Foundation (NSF), this is not only because of nighttime hot flashes but because of decreasing levels of progesterone, which promotes sleep. The NSF recommends the following for menopause-related sleep problems:

  • Stay cool. Keep a bowl of ice water and a washcloth near the bed for quick cool-offs when awakened by a hot flash. Also maintain a cool, comfortable bedroom temperature (ideally between 60 and 67 degrees), and keep the room well ventilated.
  • Choose the right bedding. Skip thick, heavy comforters and fleece sheets and go for bedding made from lighter materials, such as breathable and fast-drying cotton. This prevents overheating.
  • Eat soy. Eating soy products such as tofu, soy milk and soybeans may help combat dropping estrogen levels. Soy products contain phytoestrogens, which have weak, estrogen-like effects that may ease hot flashes.
  • Consider a natural remedy. Natural hot-flash helpers include botanicals such as evening primrose and black cohosh. Make sure that clients consult a physician before taking these or any other supplements because they are not regulated and may interfere with other medications.
  • Try acupuncture. This ancient Chinese remedy uses tiny needles to unblock energy points in the body and may help balance hormone levels to ease hot flashes and trigger the release of more endorphins to offset mood swings.
  • Balance hormones. Clients should consult a physician for sleep problems that last for more than a few weeks. A physician might recommend hormone replacement therapy (HRT), which helps stabilize decreasing hormone levels and lessen the severity of hot flashes. Other medication options such as low-dose antidepressants and even some blood pressure drugs have also been shown to alleviate menopausal symptoms.

Good sleep hygiene habits are also important. The NSF recommends the following:

  • Get earplugs or a sound conditioner to maintain a quiet environment. Extraneous noise in the bedroom can disrupt sleep.
  • Keep overhead lights and lamps in the home dim (or turn off as many as possible) in the 30 to 60 minutes before going to bed.
  • Position the alarm clock so that it’s difficult to see from bed. Watching the seconds and minutes of a clock tick on and on while trying to fall asleep can increase stress levels, making it harder to get back to sleep when awakened.
  • Keep a consistent sleep schedule. Going to bed and waking up at the same time every day — even on the weekends — reinforces the natural sleep-wake cycle in the body.
  • Develop a bedtime routine. Running through the same set of habits at night helps the body recognize that it is time to unwind.
  • Stay away from stimulants such as nicotine and caffeine at night. Avoid drinking tea or coffee, eating chocolate or using anything containing tobacco or nicotine for four to six hours before bedtime. Alcohol can also disrupt sleep, so avoid more than a single glass of liquor, beer or wine in the evening.
  • Get regular exercise, but not too close to bedtime.

Greer also recommends relaxation techniques. She works with clients to help them focus on the things they can control and let go of the things they cannot control.

Many people find significant relief from hot flashes, sleep problems and mood disturbances by taking HRT or antidepressants, but clients often need help sorting through their options, Greer says. It’s not uncommon for clients to come to counseling with a whole sheaf of information from their OB-GYN, much of which can be difficult to understand. Greer helps clients navigate the material and identify any follow-up questions they have for their physicians. “This can help them feel more empowered and have a voice in their treatment,” she says.

“Speaking to a trusted medical and mental health professional is important at this time,” says Joanna Ford, an LPC whose practice specialties include assisting clients with issues related to menopause and perimenopause. If her clients don’t already have a physician, she suggests that they ask family members and friends or even consult social media for recommendations. In fact, some of Ford’s clients have created circles on social media that offer recommendations on physicians and treating menstrual issues.

Depression risk

Choate, who is currently writing a book on depression in women across the life span, says that depression is a common perimenopausal symptom. “There is an increase in depressive symptoms, first-time episodes of major depressive disorder (MDD) and … risk of recurrence of MDD in women who have a history of MDD,” she says. “Symptoms of depression occur at a 40 percent greater rate [among perimenopausal women] than in the general population, and the prevalence of depression increases 2-14 times in women during perimenopause versus the premenopausal years.”

Interestingly, perimenopausal depression presents slightly differently than depression as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. In perimenopausal depression, clients are more likely to be irritable or hostile, have mood lability or anhedonia, and have a less depressed mood than is commonly seen in MDD, Choate explains. “Therefore, without a predominantly depressed mood, depression during the transition can be overlooked or misdiagnosed,” she says.

“Counselors can help women focus on self-compassion and self-care during this time, as studies show that there is an increase in negative life events for midlife women compared to other times in their lives,” Choate continues. “This could include children leaving home, caring for aging parents, the death of parents, personal illness, divorce or separation, [and] loss of social or financial support. With the increase in stressful life events, paired with the biological changes of perimenopause, women are more likely to experience distress.”

But all hope is not lost, Choate says. “I think it is helpful to be aware of studies that indicate that while women do experience a decrease in their mental health during these years, recent longitudinal studies show that depressive symptoms decrease as women age out of the perimenopausal years and enter their late 50s, 60s and 70s,” she says. “It is helpful to view this time as a window of vulnerability that does dissipate as women age and as they learn to view mid- to later life as a time of renewal and vitality.”

Sense of self and sexuality

It is not uncommon to feel grief about the menopausal transition. Greer says that some of her clients describe feeling “old” and struggle with their identity as women. “I try to help them work through the grieving process and work toward an acceptance of what is happening to their body,” she says. “It [the transition] does not change who they are, just how they see themselves.”

It isn’t difficult to understand why perimenopausal women feel old. As Choate notes, in Western cultures, youth is viewed as highly desirable, particularly for women, who continually receive the message that signs of aging should be avoided and obscured as much — and as long — as possible.

“The anti-aging industry is designed to perpetuate the myth of eternal beauty — that women can and should maintain a youthful, thin appearance regardless of their age,” Choate says. “The myth implies that women should exert the energy needed to conceal signs of aging, and if they don’t, then they are to blame.”

Women are socialized to prevent or repair skin changes such as wrinkling, sagging and age spots, all of which are natural signs of the aging process. Thinning and graying hair and weight gain are other results of aging that are considered undesirable, Choate notes.

Women “are taught that as they lose their youth, they will also lose their physical beauty, their sexual appeal, their fertility and their overall use to society,” she says. “In contrast, in cultures in which older age is revered, women report fewer symptoms during the menopausal transition. Cross-cultural studies show us that when older women are valued for their wisdom and contributions, they have more positive expectations about aging and menopause, and they also experience few menopausal symptoms. The message from these cross-cultural studies is that when women welcome aging as a natural process, not a disease, and accept naturally occurring changes to their weight, shape and appearance, they are less likely to experience negative symptoms associated with menopause.”

Women may know all of this intellectually, but the societal message is hard to ignore: Youth = beauty = power. Even women who habitually kept these weapons sheathed may feel the shift as they enter the perimenopausal transition.

“Body issues are important to address during this transition time,” emphasizes Ford, a member of ACA. “Aging is part of every life. The culture that we are surrounded by may impact our image of ourselves and our self-value. If we can increase our awareness about how we speak to ourselves about our bodies, it is possible we can accept the changes instead of fighting them.

“People may feel invisible before entering perimenopause, and it can increase feelings of depression and isolation. It is imperative to find a support system that encourages an individual’s values based on a variety of things, such as personal interests, skills, spiritual or religious beliefs, occupation, artistic or creative pursuits or any topic people can connect through.”

Body image issues can become part and parcel of the sexual changes that accompany perimenopause. “Menopause is reached upon the cessation of a woman’s menstrual cycles for 12 consecutive months. This means that menopause culminates in the loss of fertility,” Choate says. “For many women, this is a difficult role transition, particularly if they have based their identity upon a youthful appearance, which is often associated with fertility. For other women, the end of the childbearing years is a welcome change, as they become free from monthly menstrual cycles and also gain freedom from the need for birth control and other pregnancy concerns. They may experience negative biological sexual changes but may be more motivated to seek treatment for these changes as they begin to explore their sexuality apart from its association with childbearing.”

“Women often report a decrease in libido during this time,” Choate continues. “Some of this is due to physical factors — pain during intercourse, vaginal dryness — and some is due to psychological factors, including poor body image, beliefs and expectations about aging and sexuality, stress, fatigue from night sweats, and sleep disruption.”

Estrogen replacement therapies can help with many of the physical factors, but addressing the psychological factors is equally important.

“CBT is also helpful in examining a woman’s expectations for menopause, aging and her sexuality now that her sexuality is no longer linked to fertility and youth,” Choate says. “She might need to change her beliefs about women and aging, viewing menopause as a natural process that occurs to all women but does not indicate a disease, nor does it necessitate a view of herself as an aging, asexual woman. She might benefit from discussing her concerns with her partner to clear up any miscommunication about her partner’s expectations or attitudes toward the changes that are occurring in her body.”

It is essential — but sometimes difficult — to talk about those negative biological sexual changes, Ford notes. “Testosterone and estrogen levels are decreasing at this time and can lead to a change in libido or discomfort during intercourse,” she explains. “I do think people have to ‘re-envision’ their sexuality because hormonal changes are always happening.”

Of course, sex does not mean just intercourse, Ford continues. Embracing different ways of sexual expression can be helpful if intercourse becomes painful. People for whom intercourse is painful may also want to consult their physicians about lubrication or hormonal therapies, she says, adding that she recommends clients read The V Book: A Doctor’s Guide to Complete Vulvovaginal Health by Elizabeth G. Stewart and Paula Spencer.

Ultimately, counselors can help clients see not just the losses associated with menopause but also the opportunities.

“Now that you are entering a new life stage, what new opportunities do you want to seek out for yourself?” Choate asks. “What can you explore and enjoy during this next life phase? Research shows that while women do experience increased unhappiness during their early 50s, longitudinal studies show that they are happier than ever in their mid-50s and into their 70s and benefit from decreased caregiving and work responsibilities in their later years.”

Greer reassures clients that even though the menopausal process may sometimes seem as if it will go on forever, the stage is temporary. “There is life after menopause,” she emphasizes.

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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