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Wellness

Wellness: Aiming for an ever-moving target

By Bethany Bray January 3, 2022

The COVID-19 pandemic has disrupted nearly every aspect of life, from parenting and family relationships to personal finances and career trajectories. Self-care and coping mechanisms that people previously relied on were often set aside or became harder to access because conditions related to the coronavirus were (and to a certain degree still are) in a constant state of flux. Answers to worries such as “Is it safe to go to the dentist?” or “Will I put my grandmother at risk if I visit her in person?” continue to change with each new phase of the pandemic — the initial uncertainty, the availability of vaccines, the rise of multiple variants, the reopening of schools and workplaces, and so on.

It has all made client wellness a moving target over the past two years. As a result, counselors might consider rethinking how they approach wellness — and all its dimensions — and foster collaboration with other professionals to help clients maintain their mental and physical health even as they are repeatedly thrown curveballs that interrupt their life patterns.

The domino effect

Wellness counseling looks beyond a client’s diagnosis or presenting concern, using a strengths-based approach to view clients holistically. The approach focuses not only on an individual’s mental and physical health but also on their spirituality, social connections, work life, financial situation, home environment and numerous other factors that vary slightly depending on the wellness model the practitioner uses.

And all of that — from clients’ social-emotional health to their financial stability and sexual wellness — has been affected by the COVID-19 pandemic over the past two years, says Christine Ellis, a licensed professional counselor (LPC) who is the founder and clinical director of a counseling practice in Wisconsin.

Ellis’ practice uses the National Wellness Institute model, which concentrates on six dimensions of wellness: emotional, occupational, physical, social, intellectual and spiritual. Because all the dimensions of wellness are interconnected, distress in one area has a domino effect on the others, Ellis says. For example, a client who feels heightened anxiety over the safety of their children returning to in-person school might also experience weight gain and other physical manifestations of stress or increase their intake of alcohol or other substances.

These circumstances have also resulted in Ellis receiving additional referrals and seeing more new clients at her practice. That has been something of a silver lining to the pandemic’s storm cloud, she says: “People have looked at their own wellness … [and] felt, finally, for the first time, ‘OK, now I have an excuse to ask for help.’”

Ellis says she and the other counselors at her practice have been intentional about maintaining a nonjudgmental atmosphere as clients talk through their pandemic-related stressors, which often include frustrations that stem from feeling limited or disrupted in their goals or life plans.

“We have been using a ton of distress tolerance techniques during the last couple of years,” says Ellis, a member of the American Counseling Association. “It’s been hard during COVID. How do you change when everyone is stuck? … When we hear clients say, ‘that’s not possible,’ our job is to validate that and recognize it as suffering. Then, we focus on small changes.”

Equipping clients with new and different coping mechanisms and talking through what they can and cannot change has been extremely important over the past two years, Ellis says. It has all been done with an eye toward empowering clients and giving them a sense of ownership over their own wellness. For some, this also included working on identity-related issues, such as no longer being a soccer mom and taking the kids to sports activities regularly or not being as productive or successful in their career while working from home.

Ellis has found that pandemic-related stress has been acute for clients who struggle with focus or attention challenges such as attention-deficit/hyperactivity disorder. She believes anxiety and distraction have heightened for these clients because routines have been upset and there have been so many unknowns over the past two years, such as “Will I get COVID-19?” or “Will my child be able to wear their mask at school?” Young and adult clients alike have needed to go back to the drawing board to find new coping mechanisms, Ellis says, because many of the tried-and-true tools they had been using no longer worked under such extenuating circumstances.

Clients’ mental well-being also took a hit when the pandemic disrupted or canceled activities that previously boosted their wellness, such as fitness or art classes, community parenting groups and church coffee groups, Ellis notes. Helping clients identify substitutions and replacements for these activities was vital in the early days of the pandemic and continues to be important now because routines are still in flux.

Perhaps a client previously maintained their physical and social wellness by attending a favorite fitness class, but the class got canceled or they no longer feel safe attending. Under that scenario, Ellis would validate the client’s feelings of loss and ask questions to spark ideas of alternative ways to attain those same benefits. She may ask, for instance, “How can you replace your water Zumba class? What about it do you like, and how can you find that elsewhere? How can you achieve the same things that you know you value, just differently?” Perhaps the client could call or video chat with a friend from the class or set up an area in their home to exercise on their own, she suggests.

A big part of this work, Ellis notes, is helping clients make the shift from an external source of motivation (relying on a class to boost their wellness) to an internal one (finding ways to boost wellness on their own).

Black Salmon/Shutterstock.com

Christie Kelley, an LPC who uses a wellness approach at her solo private practice in Bristol, Connecticut, says her clients have been experiencing many of the same feelings and challenges that Ellis describes. Kelley has also seen an increase in new clients recently because, she says, many people are evaluating aspects of their lives and wellness and finding areas they feel are lacking or that need changing.

Many of Kelley’s clients felt they had more options — and more motivation — to tend to their wellness at the start of the pandemic, she says. It was easier to schedule breaks to get outside and engage in physical activity with their children while they were all home together or to do exercise classes at home via Zoom. But as more schools and workplaces began to reopen, the novelty of incorporating wellness into daily life faded for many people. 

More of Kelley’s clients now view wellness as separate from or less intertwined with their daily routines, she notes. This includes approaching physical activity as one more thing to add to their to-do list rather than weaving it into the workday, such as by walking a few flights of stairs during their lunch break.

Kelley has found she needs to emphasize to clients that wellness remains an interconnected part of life. “In my area, I’m really noticing more of an impact with the pandemic now. Many of the people I’m working with are experiencing more problems and hardships now,” says Kelley, an ACA member. “Where I have seen people struggle is getting back to this ‘new normal.’ They developed some ways of being healthy in their homes during the pandemic, but now many are going back to work and struggling with balance.”

Getting creative

Many clients have needed support and guidance from a counselor to manage their wellness because so many aspects of daily life have been disrupted during the pandemic. Ellis has found it helpful for counselors and clients alike to consistently seek fresh ways of looking at challenges and stressors.

If clients are feeling stuck or unmotivated, Ellis suggests asking them to name one thing they could do within the hour or that day to boost their wellness. It might be as simple as drinking some water, planning a healthy meal or finding a book to read that gives them more information and ideas on a wellness topic.

“We’re still going through this wave. … Things are not how we want them to be every day. How do we deal with that [through] a compassion-focused lens?” Ellis asks. “Have a beginner’s mind every day. Promoting how to look at something [as if it’s] the first time brings a freshness. That big picture view keeps us from being stuck and getting stuck. … Get away from the entrenched perspective.”

“We [counselors] can help clients see things that way: They can simply put their shoes on and walk around the block. You don’t have to run a mile, but take one step toward wellness,” Ellis says. “Wellness is also about allowing ourselves to sit with the discomfort of an emotion or feeling and simply working to observe it, asking it what it has to teach us — as [Buddhist teacher] Pema Chödrön’s work models — and then it can be used as fuel to motivate a new wellness behavior, activity, attitude or belief.”

Kristin Bruns, an associate professor and college counseling and student affairs program coordinator at Youngstown State University in Ohio, stresses that counselors not only need to get creative with their approach to client wellness but also ensure that the work is client driven and culturally sensitive. Counselors shouldn’t make assumptions about what wellness activities might or might not work for a client, Bruns says.

For example, a client may not feel comfortable or safe going back to the gym even if it has reopened. Or they may have lost their job during the pandemic and no longer have the financial means for a gym membership. A counselor’s role is to explore that with the client and prompt conversations to find other avenues that will work for them, Bruns says. An important aspect of this work is for counselors to be aware of resources within their communities — especially free and low-cost offerings — such as programs and groups at libraries, community centers and local nonprofits, she adds.

“Also, ask clients what their self-care looked like before the pandemic, what it looks like now and what would they like to change. That can help us work with them to figure out what they want to reengage in and what they might want to look different,” says Bruns, a licensed professional clinical counselor who sees clients part time and uses a wellness approach at a private practice outside of Akron, Ohio. “Use those basic counseling skills — really listen to what the client is telling us, and help [them] think of things that might fill that need. It’s easy to want to throw out suggestions, but it’s more powerful when clients come up with [solutions] themselves. It’s really powerful when we let the client be creative.”

Kelley agrees that it’s helpful to ask clients about their self-care prior to the pandemic and to work on “translating” it for the current environment. Sometimes there is a need to expand clients’ understanding of self-care, she notes.

In the past two years, Kelley has noticed that her clients’ view of self-care has oscillated between basic tasks such as showering and getting dressed to more cliché ideas such as doing yoga — endeavors, she says, that are helpful but not the be-all, end-all.

Kelley begins conversations about self-care by asking clients about their hobbies and interests and the things that bring them joy. Then, she uses one of their answers to apply a clinical focus. For example, a client who loves tea or coffee can use their time spent with a warm mug to pause and do a mindfulness exercise.

“I’ve needed to challenge people’s understanding of self-care and wanting it to fit into a mold. My challenge is to try and help them expand their thinking process, their idea of what self-care is,” Kelley says. “Self-care is anything that you do for yourself; it doesn’t have to be this one thing. I try and help them have a broader idea of it.”

The use of telebehavioral health during the pandemic has helped in this realm, Kelley notes. Doing sessions via video has given her insights into clients’ environments, including elements that have sparked ideas to boost wellness and self-care. In one case, a client had set a goal to incorporate more mindfulness into his life, and during one of their video sessions, Kelley and the client started discussing a seating area in his house, visible in the camera, that he could use for that purpose.

“I never even [asked], ‘Could you use that spot [for mindfulness]?’ … [The conversation] just naturally went there. One of his goals for that week was to prepare it and use it for wellness,” Kelley recalls. “I’ve really been trying to work with people in a very organic and personal fashion, as opposed to a generalized idea of wellness. … It’s one thing to ask if they have a pet at intake [during in-person counseling] but another to see a pet on screen during video therapy. You can incorporate it into conversation or therapy goals. It’s something that they already [got] enjoyment [from], but now they can think of it as self-care.”

The use of telebehavioral health has also prompted Kelley to get creative and modify the wellness-focused activities she previously used with clients during in-person sessions. When teaching breathing techniques, she encourages clients to lie down or otherwise get comfortable off screen, if space allows, while she talks them through the exercise.

“It has been helpful for clients because they’re in their own space and are comfortable, but it also shows that they can do it in their home,” Kelley says. “It’s not as disconnected as sitting in therapy and having the thought that they’ll do it at home, but then they get busy and don’t. They’re more likely to do it outside of therapy [sessions] when they’ve already done it
at home.”

Addressing all aspects of wellness

As the pandemic drags on, clients are processing its effects more and more. Wendy Thorup-Pavlick, an ACA member with a wellness coaching practice in the western suburbs of Chicago, says many of her clients have become more aware of their own wellness. As a whole, they are also more open to a mind-body focus to help them make changes and find solutions for symptoms related to physical and mental stress, sleep problems, mental health challenges and other issues that have spiked during the pandemic.

“For many clients, the pandemic was the catalyst toward embracing a healthier, more balanced lifestyle,” says Thorup-Pavlick, an LPC and adjunct faculty counselor at the College of DuPage in Illinois. “Good health and wellness are more than the absence of disease or illness; it is multidimensional and interconnected. Wellness is a conscious, self-directed pathway to optimal living, and integrating a wellness approach allows clients to use wellness principles to build resilience and thrive amidst life’s challenges. Adopting wellness practices provides additional support to clients who may be feeling abnormal and continuous levels of stress caused by the pandemic.”

This unprecedented time affords counselors an opportunity to dig into wellness-focused techniques with clients to help them cope with stress, manage their emotions and attend to the whole self. One such tool involves keeping a food-mood diary, says Thorup-Pavlick, a certified health and wellness coach. Her clients have benefited from recording their food intake and sleep habits, emotions, moods and other mental and physical symptoms to observe patterns and connections during the pandemic.

Thorup-Pavlick says clients have particularly needed support related to sleep hygiene during the past two years. Adequate sleep is tied to wellness in numerous ways, including supporting a healthy immune system and cardiovascular health, improving cognitive function and emotion regulation, and managing weight gain, she notes. Counselors can provide psychoeducation that it is not only important to prioritize sleep and maintain a consistent sleep schedule but also helpful to limit caffeine intake before bedtime, engage in physical activity during the day, keep naps short, and foster a relaxing environment in their sleeping area, including turning off computer and smartphone screens.

Motivational interviewing can be a helpful technique for asking clients about their sleep habits and finding out what they already know about sleep hygiene. If the client is open to it, the counselor can offer more information, Thorup-Pavlick says. If clients wear a fitness-tracking device, such as a Fitbit, asking about the sleep data it has collected can also be a way to introduce the topic, she notes.

In addition, Thorup-Pavlick often asks clients the following questions:

  • What does your sleep schedule look like?
  • Tell me about your sleep environment.
  • How rested do you feel on a scale of 1-10?
  • What’s working well for you at the moment?
  • What isn’t working well at the moment?
  • On a scale of 1-10, how motivated are you to improve your sleep habits?
  • What do you think you should do first?
  • Whatever your first step is, is there anything that might stop you from doing it?

“The idea is not to become a sleep expert but to know when the client may need to seek additional medical attention for sleep-related issues and how those issues may impact the client’s emotional well-being,” Thorup-Pavlick says.

Those interviewed for this article agreed that counselors need to be proactive and ask clients about aspects of their wellness — including use of alcohol and other substances — both at intake and regularly throughout therapy.

Counselors can also prompt discussions about wellness with clients by creating a wellness wheel in sessions, Thorup-Pavlick adds. During this exercise, the practitioner guides the client to create or fill in a circle diagram based on the health of the different dimensions of wellness in their life, including occupational, physical, social, intellectual, spiritual, emotional and other realms.

“When life is in balance, the wellness wheel will be round; when out of balance, the wellness wheel may look and feel a little more like a flat tire,” she explains. “It can inform the mental health practitioner how ‘in balance’ each wellness dimension is for the client. … The wellness wheel is a tool that will help identify how clients view themselves and how satisfied they are in each dimension of wellness.”

From there, Thorup-Pavlick often prompts clients to create a “wellness vision” for themselves that connects to their core values. This involves talking through not only a client’s desired wellness outcomes but also the challenges and knowledge gaps they might face and the strengths, motivators and supports they can rely on as they work toward their goals. Creating a personalized plan helps clients make sustainable progress toward wellness, she notes.

“The focus should be on what the client wants to achieve and not what they want to eliminate,” says Thorup-Pavlick, a member of the Illinois Counseling Association and a board member of the Illinois College Counseling Association. “As clients begin to get excited about their desired wellness outcomes, they can incorporate behavioral changes that will move them toward achieving these wellness goals.”

Forging connections with the medical community

In addition to the physical health concerns related to the coronavirus itself, the pandemic has caused a wave of negative outcomes that might have been prevented or caught earlier if people hadn’t postponed or skipped routine health appointments and screenings, such as mammograms and colonoscopies, during the past two years. These distressing outcomes are higher among people of color and those of lower socioeconomic status. 

Professional counselors have a role to play in ensuring that clients are tending to all aspects of their wellness, including physical health, as the pandemic continues to disrupt life patterns, says Deanna Bridge Najera, an ACA member who works as a physician assistant (PA) in emergency medicine at a hospital in Maryland.

People have been canceling or delaying medical care for a wide variety of reasons, including resistance or discomfort with telemedicine or the inability to pay for services or prescriptions, Najera says. At the same time, medical offices have been overwhelmed, so it can be hard to get an appointment, and some have stopped accepting new patients, she adds.

This unprecedented time presents the counseling profession with an opportunity and a responsibility to forge connections with the medical community and do more interdisciplinary work, Najera asserts.

Not only do counselors have a responsibility to ask clients if they have a primary care provider and other questions about their medical care, but they should also be proactive and advocate to help them overcome barriers when there are gaps in that care, says Najera, who has a master’s in clinical mental health counseling as well as a master’s degree and licensure as a PA.

The first piece of this work is for counselors to become familiar with and connect with medical providers and other support services in their community. It also can involve advocacy with individual clients, such as helping them find health care services or supporting them while they call a pharmacist or a provider who prescribes psychiatric medicines.

In addition to her work as a PA, Najera provides psychiatric medication management services part time at a community mental health agency and is a backup psychiatric provider for Shippensburg University and Gettysburg College. She is also employed part time in the Carroll County Health Department in Maryland, working with clients in the reproductive health program. “We [professional counselors and medical providers] have to both play in the same sandbox,” Najera says. “It’s about meeting [clients] where they’re at and best supporting them on their journey. It has to be a team taking care of the whole person. We have to play well together … [and] it works a lot better when we all have open communication with each other.”

Ellis says that part of working as a wellness-focused counselor is serving as a catalyst to connect clients with medical care and other essential services. “We [counselors] are active listeners, so we are often the first people to hear about problems they’re experiencing,” she notes. “We are ethically bound to connect with other practitioners, help make connections and referrals, and have good relationships with [interdisciplinary professionals] in the community.”

For instance, if a client were to mention during a counseling session that they are suffering from back pain, Ellis says she would first provide empathy and prompt the client to talk about how the physical pain has been interfering with their everyday life and affecting their moods, sleep and other aspects of wellness. Then, she would shift the conversation to focus on how the client can advocate to find solutions to move toward how they want to feel. This may include making phone calls together during session to schedule appointments or ask questions of medical providers, she says.

“When people are not taking care of themselves, sometimes they need that little piece of support and the message that ‘I’m worth it,’” Ellis emphasizes.

Najera believes counselors should build connections with clients’ primary care providers, and if they don’t have one, explore why that is and support them in finding one. Ensuring a client’s medical provider is aware of their counseling goals also affords counselors the chance to consult or hand off care if things go beyond their scope of practice, she adds.

“As mental health professionals, we [counselors] cannot prescribe medical things,” Najera continues. “It makes sense to tell clients to go take a walk, but if they go out and have a heart attack, you may be at risk for being accused of giving medical advice.”

“It’s a gray zone,” Najera admits. “Talking about a sleep schedule or healthy diet is fine [as a counselor], but making recommendations about specific things to eat isn’t OK. You don’t know if they might have blood pressure issues or diabetes” or other diagnoses that require a specific diet.

Counselors can still work from a wellness perspective without advising clients beyond their scope of practice — it just takes a little creativity, Najera says. For example, suggesting breathing exercises to a client who struggles with lung function may go beyond a counselor’s scope. However, studies show that singing can help with improving lung function after illness or injury, diaphragmatic breathing, and one’s mental wellness and ability to cope with stress. Using music therapy or encouraging clients to sing to a favorite song to boost their mood would be a creative way to reap those benefits without overstepping professional boundaries, she says.

Listening for client statements such as “My doctor told me to walk every day, but it’s been too hard” can also give counselors an avenue to talk about the reasons why it’s been a challenge and support the client in reaching their walking goals without making medical recommendations, Najera says. She recommends counselors ask clients about their goals and any potential barriers by saying, “It sounds like this is important to you. How do we work on that goal and support you? What would keep you from doing it?”

Najera also suggests counselors ask permission to contact a client’s medical provider(s) on intake forms. Once permission is granted, the counselor has a “permission slip” to make phone calls or send emails or faxes to connect with other providers. However, Najera reminds counselors that doctors and other specialists are often busy and “off limits” for direct contact. Instead, they can work with nurses and other support staff. Many medical offices’ automated phone systems have an option for other providers (e.g., “Press two if calling from another provider’s office”); counselors shouldnt hesitate to use that option, she says, because they are part of the client’s care team.

Najera also recommends that counselors write a standard letter or email for collaborative care: “Dear Dr. so-and-so, I am now meeting with your client, so-and-so. What recommendations do you have to benefit their overall health and wellness?” Even if that initial communication doesn’t result in a reply, “it creates an avenue for conversation and opens the door,” she says.

When looking to consult on a client’s wellness goals, counselors should make it easy for the provider to respond, Najera advises. “It may be as simple as [sending] a fax or email saying, ‘I’m seeing Jane Doe, and we’re talking about exercise. Is it OK to recommend walking X times per week?’ That way, the provider is able to answer with a simple no or yes and sign off that they are OK with the recommendation,” she says.

Counselors could also prepare letters outlining their contact information, services and areas of specialty and drop them off at local medical offices. This serves not only to spread awareness of their availability for referrals and other patient care but also to offer counseling services to medical staff themselves, many of whom are burned out right now, Najera notes.

“What would be amazing is to say [to medical staff], ‘We recognize that this is a really crappy time for you, and I’d be happy to see you for counseling sessions.’ Being flexible and willing to offer sliding scale and/or evening appointments makes the point that we’re all on the same side,” she says.

Extending counselors’ reach

Interdisciplinary work extends beyond just medical providers, Najera says. Counselors could partner with school-based and community mental health providers, hospital case managers or local law enforcement to help with issues such as crisis management and evaluation.

If a counselor runs a therapeutic group for teenagers who struggle with eating disorders, for example, they could reach out to other local providers and agencies that serve youth to see if they have any clients who might benefit, she says. Or a counselor who specializes in trauma could forge a connection with a wound care center in their area to counsel patients and help them work through the range of emotions associated with losing a limb.

“There’s a lot of ways counselors can stretch and grow and expand their services,” Najera points out. “We [counselors] don’t need to stay in our offices. Integrated care is meeting people where they’re at.”

Bruns is co-directing a federally funded grant to foster wellness on the Youngstown State University campus. She says one of the project’s biggest takeaways so far has been the importance and power of interdisciplinary partnerships. Sharing resources and working across specialties enriches and strengthens services on both sides.

“Don’t take for granted what we [counselors] know about wellness. We have a lot to share. Don’t underplay the value of wellness and self-care, both in our own lives and for our clients. The impact of small changes in self-care and wellness can shift a person’s life, and there’s so much power in that,” Bruns says. “On an individual basis, you can create a culture of wellness wherever you are. We have a part to play, to create a culture of wellness one person at a time. We all have a space where we can make that difference.”

 

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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.

Returning to campus with a wellness focus

By Bethany Bray December 16, 2021

Youngstown State University (YSU) held most of its classes virtually throughout the 2020-2021 school year to ensure the safety of students and staff during the COVID-19 pandemic.

In some ways, this has led to two classes of freshman on the campus this year, says Kristin Bruns, an associate professor and coordinator of the College Counseling and Student Affairs program at YSU: True freshman who are beginning their college careers and sophomores who are interacting with peers on campus potentially for the first time.

Last year, YSU students did not have regular access to the locations and activities that often foster friendships and connection organically, such as eating in dining halls and in-person events organized by student affairs offices. That shift, along with the overall stress of the pandemic, has affected student wellness across the board, most notably in the realms of mental health and social wellness, notes Bruns, a licensed professional clinical counselor (LPCC).

YSU’s student counseling center saw such an increase in demand for services last year that they contracted Bruns and Amy Williams, a colleague who is an LPCC and assistant professor in YSU’s Department of Psychological Sciences and Counseling, to counsel students in addition to their teaching duties.

When Bruns and Williams applied for and were awarded a federally funded COVID-19 relief grant this past summer to support students’ mental health as the YSU campus reopened in the fall of 2021, they knew the project should have a wellness focus. The result is a campus-wide program with dozens of initiatives focused on student wellness, including a depression screening event; sessions on conflict resolution, stress management and many other topics; and incentives for students to engage in wellness-focused activities.

The YSU Department of Campus Recreation was already using a wellness model with nine pillars (emotional, career, spiritual, physical, financial, aesthetic, environmental, social and intellectual) prior to the COVID-19 pandemic, so it was a natural fit to use that same model for the grant program, Bruns says. Each month has roughly 10 activities or initiatives focused on one of the wellness model’s pillars.

“From a college student development lens, we know that learning is not just academic learning,” Bruns says. “Students learn through being engaged on campus. The [grant program’s] focus is to get them engaged not just with wellness topics but [also] with peers.”

“Given that many things happened virtually for over a year and many are still happening in a virtual format, there have been challenges to get students reengaged on campus,” she continues. “Students talk about how difficult it is. They’re learning or relearning what opportunities exist for being engaged on campus. For those who have been online primarily at the end of the high school experience and then entrance to college, they may be learning how to make friends in this atmosphere. We have needed to equip them with skills on how to ask questions [and] how to approach a professor or a peer.”

Adding to this learning curve is the fact that some students are still struggling with the impacts of the COVID-19 pandemic, including increased anxiety, loss over last year’s missed experiences and financial worries, Bruns adds.

When planning the grant program, aptly named “Bouncing back from COVID-19,” Bruns and her cohort partnered with more than 20 different offices on the YSU campus to create and help promote wellness-focused activities. They are also making the program’s resources and materials available to YSU staff, and some professors have been incorporating lessons on topics such as resilience and stress management into classes.

Ten YSU counseling graduate students are involved and help run activities and information booths, such as a monthly table events with resources and giveaways.

Program organizers are intentional about distributing resources and information about how to find support, both on the YSU campus and in the local community, at each wellness activity, Bruns says. They also hosted a workshop for faculty at the start of the year on students’ needs in the midst of the pandemic, including a recommendation to check in with students regularly and information on how best respond to student concerns.

Campus-wide workshops for students have included sessions on making smart choices with substance use, organization and time management, mental health and mindfulness, and physical health, including the importance of hydration, sleep, healthy eating and physical activity.

Bruns, Williams and their cohort will report the full results of the grant program later in 2022, but so far, they’ve seen it boost student engagement and make campus reentry a little easier for all involved.

“Our wellness focus is trying to take away the stigma of [help seeking] and understand that an approach through a self-care and wellness lens can help better manage symptoms and mental health,” Bruns says. “We are engaging students by bringing the opportunities to them in a variety of ways (e.g., to the classroom, tabling in the student union, hosting small groups and campus-wide workshops). We wanted to make the materials and information accessible to the students and for them to have these types of conversations to see they aren’t alone in their wellness journey. We knew that it was a need.”

 

Find out more about the grant program at ysu.edu/bouncing-back.

 

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Look for an in-depth cover story on addressing client wellness in the upcoming January issue of Counseling Today.

 

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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.

Wellness: Getting beyond the buzzword

By Bethany Bray November 20, 2020

When Amazon’s Prime Day arrived in mid-October, media outlets from NBC News to Health.com reported on the “wellness deals” — on everything from sneakers and wristband fitness trackers to yoga pants and weighted blankets — not to be missed during the online behemoth’s annual spate of sales.

The term wellness is frequently tossed around (some would say a little too frequently) in the popular lexicon. But it’s no wonder that the aura of wellness is so often touted to attract consumer attention. After all, who doesn’t want to be well?

Of course, in the realm of counseling, wellness encompasses way more than yoga pants and running shoes. But what does wellness mean exactly? When counselors say they are practicing through a lens of wellness, what sets that apart from any other therapy framework? Most importantly, how does wellness counseling help clients?

Defining wellness

The ACA Encyclopedia of Counseling refers to wellness as “a state of positive well-being … in which body, mind and spirit are integrated.”

While often used as a buzzword in modern culture, wellness is nothing new. The ancient Greeks, including the philosopher Aristotle, wrote of the importance of a prevention-focused approach to health.

As Jane Myers, perhaps the individual most associated with wellness in the counseling profession, wrote in the Encyclopedia’s wellness entry, “The main qualities defined by the ancient Greeks remain the hallmarks of wellness today. To live long and live well, individuals need to attend to their physical, cognitive, emotional and spiritual selves.”

As Myers went on to describe, wellness counseling incorporates a strengths-based approach. Because each area of wellness affects the others, counselors can assess a client to find one area of wellness in which they are strong and use that as a tool to boost other realms of wellness in the client’s life.

Myers and her husband, Thomas J. Sweeney, are known for their development of the Indivisible Self, an evidence-based model of wellness.

A helpful approach to wellness leverages a client’s existing strengths, values and resources, says Michael Desposito, a licensed professional counselor (LPC) who pulls from several wellness models, including Myers and Sweeney’s, in his work with clients at his Canton, Ohio, private practice. What wellness counseling is not, he stresses, is adding things to a client’s regimen that could ultimately subtract from their wellness. Simply recommending physical activity or other wellness-focused activities for wellness’ sake — “additive subtractions,” as Desposito calls them — is not wellness counseling, nor is it helpful, he asserts. Adding something that isn’t already part of a client’s daily life may not be maintainable for them, he notes. In addition, counselors must remember that some clients might not be able to afford gym memberships, massages or other services frequently promoted under the wellness umbrella.

Additionally, viewing wellness as an either-or concept — such as either going to or skipping yoga class — does a disservice to clients, Desposito says. Wellness is not something to be added or subtracted, but rather honoring the client and improving their functioning in the now, he explains.

A wellness framework works best “when you can bring in the client’s own unique strengths and resources that they have,” says Desposito, a member of the American Counseling Association. “They know themselves the best. Have them show you that.”

Beyond diagnosis

Wellness counseling is a framework that clinicians use alongside and in addition to their preferred theoretical orientation. At its root, wellness counseling views clients holistically, focusing not only on an individual’s mental and physical health but also on their spirituality, social connections, work life, home environment and numerous other factors that vary slightly depending on the wellness model used.

In essence, wellness counseling looks beyond just the client’s diagnosis or presenting concern. However, as Desposito points out, to function as practitioners — and, particularly, to be reimbursed by insurance companies — professional counselors often follow the medical model, which is driven by diagnosis.

“Over time, that culture starts to inundate how we [counselors] look at people,” he says. “It can cut people down to a symptom instead of a whole person.”

Wellness is integral to the person, says Desposito, who co-presented the session “Factoring Wellness Into Treatment Planning” at ACA’s 2019 Conference & Expo in New Orleans. He often tells his clients: “At the end of the day, just because I decrease a symptom, it doesn’t increase your health.”

Desposito offers some examples to further illustrate a wellness framework. Perhaps a college-age client struggles with social anxiety and is uncomfortable presenting or speaking in class. A practitioner without a wellness focus might equip the client with adaptive coping tools or challenge the client to push themselves and speak to three peers or classmates in between counseling sessions. As a wellness-focused practitioner, Desposito would instead find ways to leverage a strength that is already present in the client’s life. For instance, if the client enjoyed playing video games, Desposito might “assign” social exposure challenges outside of sessions that involved playing video games online and chatting with other players.

Similarly, if a client was drawn to making to-do lists at home and work, Desposito would leverage that in session to have the client make lists of therapeutic goals. Checking items off their list would provide the client a sense of achievement and build momentum toward growth, he says.

“Simply decreasing anxiety [or other presenting concerns] will help them feel better, but is it holistically helping the client? … Just because you reduce their symptoms doesn’t [necessarily] make the client’s life any better, and it makes them open to going back into old patterns if life doesn’t get any better,” explains Desposito, who is active in the Association for Humanistic Counseling and is a past president of the Ohio branch of the Association for Spiritual, Ethical and Religious Values in Counseling.

Desposito recently worked with a transgender client in his 20s who was taking a semester off from college. After moving home, he found himself apart from his friends and social supports. The client’s family did not support his transgender identity, so he spent much of his time alone in his bedroom playing the video game Animal Crossing. (Note: Identifying details have been changed to preserve confidentiality.)

Desposito began seeing the client after he had been hospitalized for suicidal intent and multiple suicide attempts. His presenting issues were self-injury, gender dysphoria, suicidal ideation and major depression. In their work together, Desposito listened for and pulled out the client’s existing strengths. This led to the client rekindling his love for drawing and painting. As their work progressed, the client would show Desposito some of his drawings in session, and they would discuss them together. “The wellness model helped him look at what he was getting out of life versus everything that was going wrong,” Desposito says.

Due to the coronavirus pandemic, all of Desposito’s sessions with this client occurred virtually, and a major turning point happened in real time during a video session. The client opened a drawer in his bedroom to look for something and came across a box cutter. His anxiety spiked as he realized he had overlooked this one implement when ridding his bedroom of all of his self-injury tools.

Desposito helped the client process the feelings he was experiencing, and the client came to a realization: The box cutter had been in his drawer the entire time, and he had forgotten about it because he never felt the need to use it.

Desposito says it was an incredible feeling to hear the client, while still in session on his phone, walk down the hallway, give the box cutter to his father and state, “I don’t need this anymore.”

“That was a first major turning point for this client,” Desposito says. “What was being utilized by this client [instead of cutting] was other skills he had been taught [in counseling]. He recognized that he didn’t feel trapped in his bedroom anymore. … He opened the drawer and, boom, ‘Oh, my gosh!’ he saw the knife and realized that he had been doing a host of other things and didn’t need it.”

Leveraging strengths

Cristal Clark, an LPC, counselor supervisor and founder of a private practice in Fort Worth, Texas, describes her approach to wellness as working with clients to “fix the why, not the what.”

Wellness, Clark says, is “peace — but not contentment. It’s being joyful and thriving in the circumstances where you are.”

The approach’s focus on leveraging client strengths can include reconnecting them to interests they once enjoyed, such as hobbies they previously engaged in before having children or encountering other life changes, explains Clark, an ACA member and a practitioner of eye movement desensitization and reprocessing.

Ann Church, a licensed clinical mental health counselor and co-founder of a wellness-focused therapy practice in Charlotte, North Carolina, notes that leveraging client strengths can also involve helping clients identify things that are already part of their life that they haven’t previously recognized as a strength. For instance, counselors may need to encourage clients to reach out to a friend in their church or spiritual community or reconnect with former classmates through an alumni group. Counselors can also ask, “Who is your favorite person in your family?” Most clients have a ready answer to that question, Church says, and counselors can follow up by suggesting that they call this family member to reconnect and find support.

A focus on client strengths also requires forging a strong therapeutic bond to discover what their strengths truly are, Clark says. “What appears to be someone’s strengths at the outset really could [just] be something that they’re good at,” she notes.

Clark once worked with a female client who had a doctorate and a successful job at a local university. The client was very logical, calculated and organized — a type eight on the Enneagram — but she was also very sad and wrestled with suicidal ideation.

Clark’s counseling work with this client focused on emotion regulation, managing her anxiety triggers and drawing on her spirituality. As they formed a therapeutic bond, Clark began to understand — and, in turn, helped the client understand — that the client’s organization skills weren’t actually her strength.

“She had to have things exactly the way she wanted to manage her fear,” Clark recalls. “Her organization was a coping skill to keep anxiety at bay. Her true strengths were listening and helping her students identify goals and creating plans to get there. When she is in that helping mode and giving control to other people, she is able to find peace.”

At intake, the client had exhibited strong suicidal ideation. Six months later, she came into a session with Clark in tears and exclaimed, “This is the first time in 30 years I haven’t felt suicidal.” Those feelings had ebbed because the client had learned to regulate her emotions and, in turn, her self-esteem had grown stronger, Clark says.

The client’s history included abuse and neglect, and she had “spent her whole life proving that she’s worthy,” Clark says. “Now, she believes that she’s worthy. That’s the shift in the paradigm, from an external to an internal confidence.”

The client has gone on to complete a second master’s degree and has adopted a habit of walking every day.

“To be able to use a client’s strengths [in counseling], you have to build a rapport with them to hear their story and hear what their strengths truly are,” Clark says. “We looked at her overall picture of wellness to find what she wanted [to improve about her life]. The root of it was that she wanted to stop feeling these painful feelings and didn’t want to die [by suicide].”

Counseling a client without considering all of the facets of their wellness is like buying a car based on color instead of its gas mileage and other factors, Clark says. “It’s not just the person in your office; it’s their job, their family [and] entire system. If you don’t ask the questions to get to know the whole person, if you don’t look at outside factors and provide tangible opportunities to reach what they need and want … it [counseling] won’t break the cycle.”

The whole picture

Research continues to confirm what wellness practitioners have long acknowledged: “Physical health, spirituality, social supports, mental and emotional health, and all of these systems are interrelated and they impact one another,” Church says.

“If we’re talking just about a client’s feelings or, for example, anxiety … it’s really important to understand what the root of that anxiety is, but also what are the contributing factors around that that can help them manage that? [Ask clients,] ‘What are your social supports? How much caffeine are you drinking? What is your sleep like?’ We know that all has an impact on how you feel. … If you [the counselor] are not taking all of that in, you’re missing a key factor in helping people feel well,” Church says.

Hailey Shaughnessy, a licensed mental health counselor in Florida, sees the benefits of a holistic focus all the time in her work as a therapist in the cardiology unit at Sarasota Memorial Hospital. The hospital uses Dr. Dean Ornish’s program for treating heart disease, enrolling patients not only in medical treatments but also in a multidisciplinary regimen that includes exercise instruction, nutrition counseling, and therapy sessions focused on reducing stress, regulating emotions and boosting mental health.

Shaughnessy, who also has a private counseling practice in Sarasota, says many of the cardiac patients she sees for therapy at the hospital are dealing with emotion management issues (especially around anger) and stress. Patients are also screened for anxiety, depression and other mental health conditions. Prior to treatment, Shaughnessy says, patients often don’t realize that emotions have a direct impact on their physical health, most notably on the heart.

In sessions with cardiac patients, Shaughnessy sometimes reads sections of Deb Shapiro’s book Your Body Speaks Your Mind: Decoding the Emotional, Psychological, and Spiritual Messages That Underlie Illness. In response, Shaughnessy often sees these patients nodding or hears them say, “That is me.”

Patients often see vast improvements, not only in their physical health but in their overall life quality as well, and in a shorter time than if they didn’t receive multidisciplinary treatment, according to Shaughnessy.

“The brain is not separate from the body. Your emotions affect your brain and then, in turn, your body,” says Shaughnessy, an ACA member whose first career was as a personal trainer and fitness instructor. “[Wellness] is something that I deeply believe in, and I practice it myself. I know how much better I feel when I work out. I know how much more confidence I have when I’m [physically] strong,” she says.

Shaughnessy grew up in a family in which girls weren’t encouraged to play sports. When she began exercising in college, she noticed a corresponding boost in her mood. “I’ve seen myself how these different things affected me personally, and I truly believe if they can help me, they can help others,” she says.

Asking the right questions

In addition to drawing upon client strengths, many of the counselors interviewed for this article associate a wellness focus with a thorough intake process. That involves asking targeted questions to understand and monitor all domains of a client’s wellness, from whether they have a primary care physician and take vitamins regularly to their social supports, home environment and family of origin.

Jen Monika McCurdy is an LPC who works within a wellness framework at her St. Louis private practice that specializes in maternal mental health. Her intake form includes entire sections with detailed questions asking about clients’ medical health and histories (including any prescribed or nonprescribed medicines they are taking), exercise habits and other areas of wellness. In the section about sleep, she asks clients how easily they fall asleep, whether they dream and if they feel refreshed when they wake up. McCurdy mostly counsels female clients, so she also asks targeted questions about their menstrual cycle and how it affects their mood and functioning.

All of this information helps her treat clients holistically, beyond their diagnoses or presenting issues, McCurdy says. When working with peripartum clients, the wellness framework is a natural fit, she explains, because social supports, sleep patterns, prenatal vitamins, water intake, nutrition, exercise and other wellness indicators are all integral for breastfeeding mothers, clients undergoing fertility treatments and those struggling with postpartum stress.

“With a wellness approach, you’re not just working with anxiety [or another presenting issue], but the whole person,” says McCurdy, a member of ACA. “It’s empowering them that their illness does not define them, empowering them to tell their story.”

Church also uses a thorough intake questionnaire with clients and notes that open-ended questions help clients tell their story. Beyond simply asking about a client’s sleep, she’ll ask them to walk her through their evening and bedtime routines. Do they log on to Facebook or have a glass of wine after putting the kids to bed? How much caffeine do they normally consume, and at what time of day?

From there, Church will transition to providing psychoeducation to clients, talking about what a normal sleep cycle looks like (and confirming that it’s normal to have periods of wakefulness in the night), alcohol’s effect on metabolism, and how both alcohol and the blue light emitted from electronic devices can disrupt sleep.

“If I were talking to a beginning practitioner [about wellness], I would say, ‘Mind, body, spirit — bringing those things into intake and sessions is really important,’” says Church, an ACA member. “Because we can teach all the skills and coping mechanisms and all sorts of models to people, but if we’re not helping them use [and draw from] other aspects of their life, we’re really seeing them through a narrow, narrow lens. We’re seeing them as a diagnosis rather than as a whole human being.”

Several of the counselors interviewed for this article noted that a wellness perspective also involves working closely with other helping professionals to refer or co-treat clients. This can include a range of practitioners, from chiropractors and medical doctors to massage therapists, acupuncturists and physical trainers. Shaughnessy often works with a nutritionist who can advise her private practice clients about their diet and map their gut microbiome, as well as a specialist who conducts sleep studies. McCurdy, as a maternal mental health specialist, has forged connections with infertility clinics and OB-GYN practitioners in her area.

“It’s so helpful to look at a client as a team,” McCurdy says. “I can’t be their sleep specialist, but I can talk [in counseling] about the importance of sleep. But if they have a potential sleep issue, then I’ve got to get them support [from a specialist]. It’s my value and my duty to get them that support.”

For McCurdy, one of the most important parts of the wellness framework is for counselors to be willing to practice what they preach, encompassing everything from self-compassion and working to maintain social relationships to having a meditation practice and getting consistent physical exercise.

Counselors also need to show empathy regarding how difficult it can be to talk about, and monitor, aspects of one’s lifestyle that are very personal. “If you’re going to preach wellness to someone, you have to believe it’s important and share that value with them,” McCurdy says. “When you have a wellness perspective, you’re always thinking of how things are going to work systemically — how an intervention will work in [a client’s] life, their family, their community. We have to hold that truth to ourselves as well … acknowledging that it’s not easy to go for a run, not drink beer, and eat healthy when you’re mentally struggling. Honor the concept of where the client is, where they want to be, and hold hope for them [that they can get there].”

Desposito acknowledges the importance of asking questions about diet and other domains of wellness, but he warns that too many questions can cause clients to become discouraged. He uses wellness models, including the eight dimensions of wellness (social, environmental, physical, emotional, spiritual, occupational, intellectual and financial) referenced in the Substance Abuse and Mental Health Services Administration wellness initiative, to assess which areas of a client’s wellness are strong and which may need extra attention.

Wellness goes far beyond exercise and other physical indicators, says Desposito, who recently co-authored an article on promoting identity wellness in LGBTQ+ adolescents in the Journal of LGBT Issues in Counseling. “If I am only looking at physical factors, I am only making a composite of my client,” he says. “We can’t say, ‘This is the best answer.’ We have to value what the client values. We have to help the client find their values and adapt [our counseling] to their values, but temper that with a multicultural lens. Yes, it’s great to take vitamins, but what if you can’t afford them?”

“A wellness framework doesn’t say, ‘That’s wrong,’” Desposito continues. “It says, ‘What can we do to use that [aspect of a client’s life] to help?’”

Counselors must also remember the parameters of their role and refrain from making medical or other recommendations that are outside their scope of practice.

From questions to psychoeducation

For Church, a powerful first step with clients is often normalizing the feelings they are experiencing and explaining their biological connections. For example, she says, a client who overexercises may not realize that the nervous system interprets that physical stress the same way it does the stress a person experiences at work or when going through a divorce.

“Normalize those feelings and don’t pathologize them. Explain [to the client], ‘This is your body motivating you to make a change,’” Church says. “Then, explore the changes they can make. Maybe it’s creating a support network, or whatever it takes for that person.”

Wellness counselors look not only at what brought a client into therapy but also at the connection that issue has to the client’s spiritual life, emotional health and other domains of wellness, Church emphasizes. “We are very intentional about bringing those aspects into the session, raising awareness with clients around those issues that may or may not be impacting why we’re here, and then following their lead.”

Church once worked with an adult client who sought counseling after the breakup of a long-term relationship. He was experiencing intense feelings of shame, vulnerability, anxiety and grief. He was also confronting a loss of identity, having trouble “figuring out who he was” outside of the relationship, she says. All of this resulted in frequent bouts of weepiness.

As a wellness counselor, Church helped the client understand the biological and physical connections to the emotions he was feeling and how they could be harnessed to move him toward healing. Part of this, Church says, was offering psychoeducation about how the nervous system and our fight-or-flight response work, and how that was leaving him on edge and “emotionally all over the place.”

The client was also having trouble sleeping and was turning to alcohol to cope. In sessions, Church explained that a lack of sleep inhibits the body’s ability to deal with stress and discussed how alcohol further exacerbates that cycle. She also worked with the client’s physician when a psychiatric medication was prescribed to help the client.

In counseling, Church and the client worked on identifying and managing his anxiety triggers and finding connections beyond his ex-partner. The relationship had represented his entire immediate social circle, so they worked on rebuilding that based on ties he already had through work, family and old friends.

This also included the client getting back into bike riding, an activity he had once enjoyed but had largely stopped engaging in while in a relationship. Getting back on his bike not only lifted the client’s mood and alleviated his stress but also helped him forge an identity outside of his relationship with his ex-partner. It also led him to find social connection when he started riding with a local biking group.

Over time, the client progressed to being able to make decisions based on a thoughtful response instead of emotional reactions, Church says. “This is a person who [previously] didn’t share a lot about how he felt. Now he’s able to manage big feelings and not get overwhelmed,” she says. “He’s able to start incorporating his physical and emotional sensations and thoughts in a way that is helpful and utilize some of his physical wellness things, such as bike riding and moderating his alcohol intake, to bring that all together. Also, it has really opened him up [to see] what is a meaningful life for him.”

For McCurdy, psychoeducation with clients often involves the power of journaling. She asks clients to track their eating, exercise and other day-to-day indicators in a journal, along with their emotions and mental state. This helps clients connect the dots, she says. For example, clients might notice that their mood worsened the day after they drank alcohol.

Shaughnessy also recommends journaling to her clients, along with tracking their sleep, exercise, food and vitamin intake, and moods. Counselors typically check in with clients about how they are reacting to any psychiatric medications they may be taking. Similarly, Shaughnessy says, counselors should check in about the holistic aspects of their clients’ daily routines.

In keeping their journals, McCurdy tells her clients, “All of your thoughts matter — the hopeful ones and the scary ones.” In sessions, she asks clients to talk about something that’s going well, “even if it’s the tiniest of things.”

She also prompts clients to make lists of things for which they’re grateful in their journals. This is all with an eye toward empowering clients and focusing on their strengths, especially when circumstances such as a miscarriage or infertility make them feel like so much is out of their control. McCurdy’s work with peripartum clients often includes regulating their self-talk and equipping them with positive affirmations, such as “I will survive this” or “I can get through this.” For clients going through infertility treatments, she works to plan ahead with them so they will have a toolkit of coping mechanisms — especially social supports — for the two anxiety-provoking weeks between when the fertility treatment occurs and when it’s time to take a pregnancy test.

With all clients in session, McCurdy says, “I listen to what’s working for them and hone in on that. I often ask clients, ‘What is going well for you today? What is your happy? What went well, and what can we do more of?’ … And [I] celebrate their wins too. I tell clients that I’m proud of them, in awe of them. The fact that you were able to put your hair up, put on your shoes and get outside is a win. Just walking to the mailbox is a win. Honor the courage that it took for them to do that.”

More than massages

The word wellness is in the very definition of counseling used by ACA and developed more than a decade ago during the 20/20: A Vision for the Future of Counseling initiative: “Counseling is a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals.”

Wellness is sometimes viewed in simplistic terms, but in reality, it is tied to the profession’s call to social justice, Desposito says, “because you’re meeting [clients] where they’re at and honoring their experience.”

“Wellness can be very abstract, [but] that holistic piece, how the whole person is working together, social justice is paired with that,” he says. “Wellness is often assumed to be self-care or taking a vacation. Wellness is often viewed as this thing that you do on the side. … Wellness can’t just be, ‘Oh, just go get a massage.’ You [the counselor] have to honor the multicultural aspects of a client and discover how you can find wellness [for them] right here in this moment.”

 

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Action steps for more information:

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Contact the counselors quoted in this article:

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Related reading

Book titles recommended by the counselors quoted in this article:

  • Your Body Speaks Your Mind: Decoding the Emotional, Psychological, and Spiritual Messages That Underlie Illness by Deb Shapiro
  • Spark: The Revolutionary New Science of Exercise and the Brain by John J. Ratey
  • Why We Sleep: Unlocking the Power of Sleep and Dreams by Matthew Walker
  • Intuitive Eating by Evelyn Tribole and Elyse Resch
  • The Body Keeps the Score by Bessell Van der Kolk
  • Start Where You Are: A guide to compassionate living by Pema Chodron
  • Exercise-Based Interventions for Mental Illness: Physical Activity as Part of Clinical Treatment by Brendon Stubbs and Simon Rosenbaum

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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.

Digesting the connection between food and mood

By Lindsey Phillips December 31, 2019

For most of her life, the woman would not let herself eat cake. She feared that if she started, she would never be able to stop. The presence of cake at every birthday party she attended tormented her. She grew so preoccupied with thoughts of cake that she had food fantasies about eating it.

The woman’s unhealthy relationship with food eventually led her to Michele Smith, a licensed professional counselor who operates a private practice called The Runaway Fork in Westfield, New Jersey. With Smith’s guidance, the woman decided to conquer her fear by eating a sheet cake while she was alone.

The client took her first bite, but it wasn’t the experience she had fantasized about. It tasted artificial and waxy. She thought perhaps it was only the frosting that she didn’t like, so she took another bite, this time focusing more on the cake itself. It only confirmed the horrible taste from her first impression. The woman ended up throwing out the entire cake.

The client’s craving for cake had caused her years of suffering, yet when she finally ate it mindfully, she discovered that she didn’t even like it, says Smith, who is also a licensed mental health counselor in New York.

“There’s all this unnecessary suffering around food, weight and body,” Smith continues. At the same time, “there seems to be a lack of services available for everyday people who do not have eating disorders [but] who want to discuss and heal their relationship with food, body and weight.”

For this reason, Smith, a certified mind-body eating coach and a member of the American Counseling Association, created her private practice to help people who struggle in their relationship with food. She doesn’t have a precise phrase to explain this special niche she has carved out with her counseling practice, but she says it differs from nutritional counseling, which focuses on helping clients figure out what to eat. Instead, Smith attends to who clients are as “eaters.” This includes connecting their relationship with food to other life domains and psychosocial factors — such as anxiety, depression and trauma — that professional clinical counselors work with every day.

Researchers are not completely sure how food fits into the overall mental health equation, but recent studies suggest a strong connection. In general, food can promote wellness in three ways: 1) by providing the brain with nutrients it needs to grow and generate new connections, 2) by tamping down inflammation and 3) by promoting gut health.

In 2017, the world’s first study of dietary intervention for clinical depression, called the SMILES trial, found that a modified Mediterranean-style diet (which encourages whole grains, fruits, vegetables, legumes, low-fat/unsweetened dairy, raw unsalted nuts, lean red meat, chicken, fish, eggs and olive oil, while discouraging sweets, refined cereals, fried foods, fast foods and processed meat) resulted in a significant reduction in depression symptoms when compared with the typical modern diet loaded with fast food, processed foods and refined carbohydrates.

A randomized controlled trial published last year in PLOS ONE supports the findings of the SMILES trial. Researchers found that adults who followed a Mediterranean-style pattern of eating for three weeks reported lower levels of anxiety and stress and a significant decrease in their depression symptoms.

These and other findings suggest that counselors should no longer think of mental health in isolation but rather as part of a complex system that includes what people eat.

A missing piece of the mental health puzzle

Lisa Schmidt, a licensed associate counselor, certified whole foods dietitian nutritionist, and instructor in the School of Social Work at Arizona State University, points out that people seldom think about what they eat. “The act of eating is considered a nuisance. It’s something people don’t have time for until they’re just so hungry, they have to eat something, and when you get to that point, you often make very poor nutritional choices,” she says.

For instance, people may grab fast food and eat it in the car on the way to their next meeting or to pick up their kids. Then, when they have trouble sleeping later that evening, they assume it is related to their feelings of anxiety, thus overlooking any possible connection to food, Schmidt adds. 

“Most people don’t know that the kind of foods we choose [to eat] can help us regulate our nervous system and perhaps is the missing link in mental health care,” Schmidt notes.

Schmidt, an ACA member in private practice in Scottsdale, Arizona, says that mood-related disorders often have a food component to them because nutrition-poor diets affect mood. The standard American diet, often aptly referred to by its acronym SAD, frequently leads to people being hungry and tired and having dysregulated moods, she continues. People often alternate between periods of escalation, during which they fuel themselves with caffeine, processed sugar and refined carbs, and periods of starvation. This unhealthy pattern leads to dysregulated moods, Schmidt explains.

In addition, stress (which is common in fast-paced, disrupted lifestyles) dysregulates people’s nervous system responses. When people are stressed and in fight-or-flight mode, their bodies secrete glucose into the bloodstream, fueling them to run away from real or imagined danger. Then the pancreas secretes insulin as it tries to regulate blood sugar levels, Schmidt explains. These swings in blood sugar levels affect mood and can lead people to become “hangry” — hungry and angry, she adds.

Two researchers at the University of North Carolina at Chapel Hill recently set out to study the underlying mechanism behind the complicated “hangry” reaction, and their results challenge the theory that hanger is the result only of low blood sugar. They found that hunger-induced feelings can lead to tantrums and anger when people are in stressful situations and are unaware of their bodily state. In other words, hunger pangs might turn into other negative emotions in certain contexts.

This suggests that people should slow down and pay attention to both their physical and their emotional cues. Smith advises her clients to carefully set the scene before eating, telling them that eating should be stress free, relaxing and pleasant. To achieve this, they might consider using a candle or playing calming music. They shouldn’t be using their phones, watching television or walking around, she says. And although some families use dinner as a time to reprimand their children, there shouldn’t be any arguing while eating, Smith adds.

Because the quickest way to relax the body and mind is through breathing, Smith instructs clients to take as many deep breaths as they need to calm down before they begin eating. She also recommends that clients put their forks down between bites or use their nondominant hand to help them slow down and fully experience their food.

Mindful eating also involves approaching the meal with all of the senses, Smith says. She often illustrates this type of eating in session by having clients — especially those prone to eating quickly or eating distractedly as they work or stare at a screen — engage their senses while eating a Girl Scout Thin Mint cookie. During this activity, Smith asks clients to forget about their ingrained diet rules, negative self-talk, or whatever else might be in their heads and focus on their bodily experience of eating.

First, she has clients look at the cookie so the brain will register that food is present. Next, she has them touch the cookie and notice its texture. Then Smith asks them to smell the Thin Mint because scent affects our pleasure or displeasure with food. Once clients put the cookie in their mouths, they slowly roll it on all parts of their tongues without biting into it. When they finally bite the cookie, they listen to the sound it makes and notice how it tastes and when the taste starts to diminish. At the end of the exercise, Smith asks clients to rate their experience as pleasant, unpleasant or neutral. 

This simple exercise is an eye-opening experiment for most of Smith’s clients, who often admit they would normally just throw the cookie in their mouths and not think twice about it. When people learn to slow down and eat mindfully, they become better at noticing when they are full or if they are no longer tasting their food. Smith says one of her clients discovered through the exercise that she actually didn’t like Thin Mint cookies, even though she had eaten them all of her life.

It’s one thing to tell clients what mindful eating is; it’s another thing for them to experience and feel it for themselves, Smith says. “Mindful eating as a practice can be helpful at reawakening [our] appreciation for food,” notes Schmidt, author of Sustainable Living & Mindful Eating. “As we wake up to how we feel and what we experience, we have the possibility of change.”

The emotional toll of restrictive eating

“Every diet is some form of food restriction,” Smith asserts. “When you eliminate certain foods or when you deem certain foods bad or forbidden, you’re actually going to create the overeating through that sense of deprivation.” For example, the night before someone starts a no-carb diet, he or she might binge on bread as a “farewell” (often referred to as “Last Supper” eating). People on diets never reach habituation, so when they are exposed to restricted foods, they may overeat them, which only reinforces the idea that they can’t be trusted around a particular food, Smith adds.

Licensed clinical professional counselor Heather Shannon wrote a book chapter on nutritional stress management strategies for volume one of the book Stress in the Modern World: Understanding Science and Society. She says the all-or-nothing, judgmental thinking that is common with most diets often creeps over into character judgment: “I’m bad because I ate that carb” or “I feel horrible that I cheated on my diet by eating that cupcake,” for example.

Shannon, who offers coaching and teletherapy as a psychotherapist at Lotus Center in Chicago, had one client who was fit and healthy but fixated on losing three pounds. One morning, the client woke up feeling great, but the second she stepped on her scale and saw she had gained one pound, her mood changed. She went from feeling wonderful to feeling horrible in two seconds.

Fixating on an outcome, such as the number on the scale or the number of times a person has gone to the gym that week, is a big part of anxiety, Shannon says, and it opens up the possibility of good and bad labeling (e.g., “I’m bad because I went to the gym only once this week”). Instead, she helps clients focus more on their habits and which habits make them feel good, healthy and connected to their bodies. “If you’re treating your body really well, then whatever the results are is how your body is supposed to be,” she says.

Smith, a certified intuitive eating counselor, helps clients let go of the dieting mentality and reawaken their intuitive eater. In the intuitive eating model, there are no “good” and “bad” foods. Smith describes it as “a non-diet, flexible style of eating where you follow your internal sensations of hunger and satiety to gauge what, when and how much you eat.”

Smith points out that not every client will automatically be ready to put all foods back on the table. Under those circumstances, counselors can instead help raise awareness around dieting and how it may be interfering in clients’ lives. For instance, counselors might ask: How has your diet affected or changed your relationships with others? How much time and money have you spent on diets? How has it affected your social life and mental health? What in your life has changed because of dieting?

Schmidt also tries to help clients adjust their mindset around food. “Nourishment is not determined by one episode,” she says. “It’s an eating pattern over time.” For this reason, she advises clients to follow the 80-20 rule, in which 80% of the time people make choices that are whole foods (mostly plant-based), and then they don’t need to worry about the 20% of the time that they have a treat or indulge.

“We eat for reasons that are other than just to feed our bodies,” Schmidt says. “We eat as part of celebrations, and food is pleasurable. So, adopting a very restrictive, Spartan way of eating” — particularly one that demonizes any particular food group — “… can become disordered eating and cause problems for some people. … And research shows eating this way will fail 95% of the time.”

Instead of adopting the latest diet fad, people should find a way to eat that they can follow for the rest of their lives and that simultaneously supports their health and mood, Schmidt says.

Using foods to cope with moods 

If clients understand biological hunger and still reach for food without feeling hungry, then they are often engaging in emotional eating, Smith says. This may mean that a client eats because of unresolved trauma or grief. Maybe the client has perfectionist tendencies and uses food to manage his or her anxiety. Or perhaps food is the way a client copes with being in a marriage or job that makes them unhappy.

Smith works with clients to figure out what they are feeling — such as anxious or lonely, for example — when they experience emotional hunger. “This is where the mental health piece comes in,” she says. “You’re talking about eating, but the root cause of the eating is really psychological issues. … They’re people pleasing. They need boundaries. They need to be assertive. They need to say no to people and they can’t, so they use food to cope.”

Shannon, author of the ACA blog posts “Nutrition for Mental Health” and “How Does What You Eat Affect How You Feel?” finds the internal family systems approach effective for uncovering underlying issues associated with emotional eating, especially if clients have a playful side. She first helps clients identify the part of themselves that is overeating by asking what this eating part of them feels like in their bodies. One client might feel it in their stomach, whereas another client might sense it as a coach whispering in their ear.

Shannon also instructs clients to personify the part of them that is overeating by naming it (for example, the Snacking Part, Cake, or even a human name such as Maria). Then, both she and the client can easily address and reference this personified part.

Shannon might ask the part, “What is going on when you overeat?”

And the part almost always provides an answer. For example, “Well, I feel like I work too hard, and I need this because it’s my pressure release valve” or “I feel like I can’t count on people, so I’m counting on food.”

Smith and Shannon both caution against having clients keep a food journal that tracks food intake or weight. They say that activity takes clients out of themselves rather than tuning inward. In addition, they warn, it can promote obsessiveness. But they agree that clients can benefit from journaling about their emotions and feelings associated with food. For example, a client could write down what he or she feels right after overeating as a way of identifying what emotions are associated with the behavior. 

Schmidt has clients keep a food and mood journal, but not to track food intake or to promote weight loss. Instead, the goal is to help clients build an awareness of when they’re eating and how they feel before and after eating. This ultimately gives them a better understanding of how food affects their mood and how mood can affect their eating habits.

She provides an extreme but not unusual example: While journaling, a client noticed that they did not eat anything until 2 p.m. They felt terrible but only had 10 minutes to eat, so they ingested a protein bar and soda. Immediately afterward, they felt good, but an hour later, the client was starving, mad and stressed again.

“Most people … spend less than two minutes a day thinking about what they’re going to eat. They just react,” Schmidt says. “So, building awareness of all our habits, including our fueling habits, is really important.” 

In addition, if people are not fueling their bodies in a healthful way, it will create difficulties for them, Schmidt says. Chronic pain, substance abuse, anxiety and depression are all issues for which food is a huge component, she asserts. Schmidt had a client who would eat seven to nine bowls of Froot Loops for breakfast while in recovery from drug use. People recovering from substance use may often transfer their addiction to food, especially highly processed, sugary types of foods, she says.

Smith encourages her clients to approach their relationship to food with a compassionate curiosity. Clients can view nutritional changes as an experiment to figure out how their bodies react or what works best for them, she explains. Also, if clients haven’t fully mastered their new coping skills and continue to engage in emotional eating, then Smith advises them to be compassionate with themselves and say, “I’m reaching for food, and I know I’m not hungry. I look forward to the day when I can cope with my emotions without using food.”

Staying within scope

Smith has noticed that many counselors shy away from discussing any issue related to food with clients, reasoning that it falls outside their scope of practice and because becoming a certified eating disorder specialist or nutritionist requires specialized training. But she encourages counselors to rethink this mindset. “It’s not out of [counselors’] scope of practice to talk about people’s relationship with food. It’s such a critical part of everybody’s day. So, to not look at it is missing a big part,” Smith says.

“You don’t have to talk about the grams of protein per se, which is out of our scope … to really help somebody,” she continues. “Because [clients are] dying to talk about it, and they need that space. And it’s connected to so many other life domains [e.g., trauma, grief, anxiety, depression, stress] which counselors are more than equipped to talk about.” 

As a certified health coach, Shannon says she would never prescribe foods for clients or tell them what they should or shouldn’t eat, but that doesn’t prevent her from talking about food in session. In fact, on her intake form, she screens for potential issues with food by including general questions such as: What do you generally eat for breakfast, lunch and dinner? Do you snack or skip meals? Do you overeat or under eat? Then, in her first session with clients, she discusses this information and asks follow-up questions to gain a better understanding of clients’ relationship with food and the way this could be affecting their mental health.

“Even if you’re not a nutrition expert, we all know some basic stuff. We all know whole foods are better than processed foods. We all know excess sugar is not helpful,” Shannon says. For this reason, she recommends that counselors screen for basic nutritional information to see if food might be a piece of the client’s mental health puzzle. 

Rather than telling clients what to eat, Shannon takes a behavioral approach and asks, “What are you eating, and how is that working for you? What do you think might work better?” Sometimes, she will also provide clients with helpful resources and advise them to talk to their doctor or a nutritionist about other options they could pursue.

Schmidt finds that discussing alcohol use with clients can serve as a great segue into talking about their diet in general. In her experience, alcohol often comes up with clients who have mood disorders, and because alcohol is a nervous system depressant, it is not advised for these clients. While discussing their alcohol use, Schmidt will ask other questions about their diet, such as if they eat breakfast consistently or if they eat lots of processed, high-sugar foods. From there, she might suggest that clients try to limit the amount of food with added sugars that they eat and experiment with eating fresh fruit as a snack or dessert most days of the week. Schmidt will also use the Healthy Eating Plate (created by Harvard Health Publications and nutrition experts at the Harvard School of Public Health) as a way to help clients visualize how to build meals that support balanced moods.

Schmidt recommends that counselors interested in the food-mood connection experiment with their own eating habits to see how this affects their mood. “It is particularly difficult for a counselor who has a poor diet to talk about the food-mood connection with a client,” she says. Similar to how counselors practice meditation themselves before teaching it to clients, Schmidt believes counselors should first reorganize their own way of eating to include mostly foods derived from plants, to limit caffeine, and to limit or eliminate alcohol.

After counselors have experimented on their own with the food-mood connection, Schmidt says, then they can ask clients to do a chain analysis. For example, if a client is having panic attacks, the counselor might ask, “What do you remember doing just before the panic attack? Did you have anything to eat or drink? If so, what did you eat or drink?” Maybe the client will say that he or she remembers drinking coffee or alcohol before the panic attack happened. The counselor could follow up and ask whether the client noticed any change in how he or she felt after drinking three cups of coffee or drinking alcohol to excess before having a panic attack. This technique will help clients connect their dietary choices, which are ultimately under their control, to the way their mood is affected, Schmidt says.

Smith acknowledges that counselors’ scope of practice does limit just how far they can go in addressing food issues with clients. For instance, counselors cannot provide nutritional advice to clients. “That creates this barrier that is hard to get around,” she says. “So, then, you do have to reach out to other professionals like nutritionists and dietitians and really work as a team.” She says counselors can either work with a nutritionist to determine what nutritional treatments and approaches are best for the client, or work with clients to ensure they are advocating for their own dietary preferences (such as using plans that focus on well-being instead of weight loss) with the nutritionist or speaking up when they feel a certain nutritional approach is harming or not helping them.

But at what point should counselors refer to a nutritionist? Counselors have referred clients to Schmidt, in her role as a nutritionist, because they suspected their clients had an eating disorder or were binging on foods. Schmidt thinks it is a good idea to also refer to an eating specialist if clients talk about food or their bodies frequently in counseling, are extremely overweight or underweight and the condition is disruptive for them, or have suddenly lost a significant amount of weight.

When finding referral sources, Schmidt recommends that counselors look for professionals trained in the Health at Every Size approach, which promotes size acceptance and serves as an alternative to the weight-centered approach.

Smith agrees that “the focus always has to be on wellness, not weight loss.” She advises counselors against referring clients to dietitians, nutritionists or doctors who track calories, encourage weigh-ins, or engage in fat shaming. Instead, she suggests looking for health professionals who teach intuitive eating and operate from a weight-neutral model.

Adding in the nutritional piece

People routinely look for mental shortcuts or a magic bullet to solve their problems, and this tendency extends to food consumption. From research, we know that people will tend to eat 30% more of a food that they deem “healthy,” Schmidt notes. Researchers even have a name for this tendency to overestimate the overall healthfulness of an item based on a single claim such as being low calorie or low in fat: the health halo effect. This halo effect appears to encourage people to eat more than they otherwise would because they feel less guilty about consuming the food.

Clients often come to see Smith because they are confused and don’t know what to do. They have dieted for years with little or no success, and they are confounded by all the conflicting nutritional advice. For Smith, it comes down to a core question: “How does this [food] feel in your body?”

“You’re making peace with food,” she says. “This is your journey of one, and only you can know whether pizza feels good or depleting and when and under what circumstances.” Counseling can help clients tune in to their own unique nutritional needs and preferences and connect this piece to how their mood is affected, Smith says.

Schmidt advises counselors to focus on the big picture and not get caught up in one particular approach to eating. Instead, it is about helping clients make their own connections between what they are eating and how it affects their moods.

Also, because everyone is unique, the nutritional advice that has benefited a counselor personally may not help the counselor’s clients. However, the majority of clients (and all people) need to eat more fruits and vegetables, so if counselors encourage them to do that, it could have a huge impact on clients’ health and mood, Schmidt asserts.

“Having a personal connection to food and its life-giving properties is one of the most amazing gifts we can give ourselves, as well as elevating the status of food and eating for our clients,” Schmidt says. “Helping clients understand that the process of food and feeding is a central part of their recovery is a message that’s independent of what they should be eating.”

“Nutrition is always a piece of the puzzle,” Shannon adds. “So, by understanding the nutrition …
even a little bit, you’re going to be potentially twice as effective working with your clients.”

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

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

Interventions for attachment and traumatic stress issues in young children

By Cirecie A. West-Olatunji, Jeff D. Wolfgang and Kimberly N. Frazier April 2, 2019

Although mental health professionals acknowledge that clinical issues often look different in young children, treatment practices continue to rely heavily on adult literature. These mostly miniaturized forms of adult treatment are often scaled down using more basic language and vocabulary, but they still depend on discovering ways to encourage the verbal communication of children. Furthermore, major deficiencies exist in the mental health care delivery system for children. General neglect and fragmentation of services create obstacles to effective service provision for this population.

Over the past decade, scholars have begun exploring early childhood development and effective counseling interventions, the role of traumatic stress in the presentation of emotional and behavioral symptoms, and the prevalence of attachment issues for young children. In this article, we aim to provide a brief overview of these key advances in what we have named “pediatric counseling.” We also offer 10 evidence-based counseling interventions that stem from our work with young children over several decades.

Early childhood development and counseling

Children are not miniature adults, meaning a paradigm shift and specialized skills approach are required to help them most effectively. Children also go through rapid developmental stages, strengthening the argument that therapy with children should be vastly different from therapy with adults. Thus, professional counselors and other mental health professionals must consider various concepts, issues, techniques and interventions that are cognitively, emotionally, psychologically and developmentally appropriate for children.

During early childhood, defined as birth to age 5, rapid development of gross motor skills (running, climbing, throwing) occurs. Fine motor skills (drawing, writing, manipulating small objects) are slower to develop at this stage, but children should be able to copy letters and small words sometime during the latter half of early childhood. Cognitive development at this stage is based primarily on preoperational thinking. Hence, children in this stage rely heavily on what they see. They can now recall past events and anticipate future experiences that may be similar. At this stage of development, children are very egocentric, commonly overestimate their abilities (e.g., thinking they can carry things that are too heavy for them), and gain increased control of their impulses.

Play is extremely important to social development during early childhood. At about 3 or 4 years old, children engage in associative play in which they learn how to share and interact with one another. During associative play, there are no clear goals for the play and the roles of those engaging in play are not assigned. At about age 5, children begin to create games, form groups and take turns. Children are expanding their vocabularies at this stage, but the words and phrases used to express feelings and emotions remain limited. Because of their limited emotional vocabulary at this stage, children are more prone to act out their emotions behaviorally.

Deficiencies in service delivery:
Some of the major deficiencies in the mental health care delivery system for children include:

  • How children are categorized (i.e., poor conceptualization of children within their ecological context, including culturally marginalized children being overrepresented in the most severe clinical categories)
  • Environmental factors (such as racism and poverty)
  • Lack of empirical data
  • Fragmentation of services

First, children are typically placed in categories of clinical, subclinical and at risk, and they are often in need of services such as remediation and prevention. However, they are largely neglected within the system. This is partly due to clinicians’ lack of training to provide developmentally appropriate clinical care for this age group. Lack of adequate funding and poor communication between providers (such as pediatricians, child care workers, parents/caregivers, social services personnel and professional counselors) are also factors.

Second, some environmental factors associated with higher rates of mental health problems include poverty, racism, abuse and familial problems. Systemic oppression is also linked to both behavioral and affective problems. However, insufficient research has been conducted with young children to provide adequate information about how these environmental factors affect them. 

Third, there is a lack of empirical data on effective treatment for young children. Although the literature is replete with community agency programs and hospital-affiliated programs designed for young children and their families, there is insufficient support for the effectiveness of the treatments and interventions provided.

Finally, there is fragmentation of the services that exist for this population. Mental health services for young children should be initialized by a social service agency or primary care physician. However, this rarely happens. Even when it does, it is unlikely that these professionals have included or interacted with counselors. Thus, many children slip through the cracks and remain unidentified until a crisis arises, meaning they are most likely to receive psychological first aid via psychiatric services.

Counselor training: Experts stress the need for counselor trainees to acquire foundational skills that serve as underpinnings for effective counseling of this population. The major challenge within the discipline of counseling is how to transform these base-level skills into effective techniques and interventions for young clients. Many beginning counselors feel ill-prepared and are often frustrated when they encounter child clients — and preschool-age children in particular. Most counselors begin their training by practicing their counseling skills on classmates and never encounter younger client populations until they are out in
the field. 

Traumatic stress issues

Researchers have suggested that symptoms of traumatic stress in early childhood include interrupted attachment displays of distress such as inconsolable crying, disorientation, diminished interest, aggression, withdrawing from peers, and thoughts or feelings that disrupt normal activities. Traumatic stress, a condition caused by pervasive, systemic external forces, can result in physiological, psychological and behavioral symptoms that negatively affect everyday functioning.

Symptoms of traumatic stress can include hyperarousal or hypoarousal, avoidance and re-experiencing. Hyperarousal in early childhood is often observed through displays of inconsolable crying, flailing about, arching the back and biting. Hypoarousal involves emotional numbing that may be observed as a child who sleeps excessively, displays a dazed expression or averts his or her eyes. Avoidance is characterized by withdrawal, which is often demonstrated as displaying less affection, consistently looking away or avoiding facial contact. Other observable features of avoidance include a fear of being separated from caregivers, refusal to follow directions, disorientation and extreme sadness.

Re-experiencing is often the most subtle of the three symptoms, but it can be observed through the presence of rigid and repetitive patterns. These patterns can include common play leading to outbursts or withdrawal if the pattern is changed or interrupted. The play or reenactments have a noticeable anxious quality to them, or the child appears to space out when engaged in these patterns. One of the most consistent observations of re-experiencing is the presence of nightmares.

Neurological responses to traumatic stress include:

  • Increased levels of adrenaline (activation of the sympathetic nervous system)
  • Decreased levels of cortisol and serotonin (a reduced ability to moderate the sympathetic nervous system or emotional reactivity)
  • Increased levels of endogenous opioids (which result in pain reduction, emotional blunting and memory impairment)

In addition, chronic stress can interrupt cognitive functions such as planning, working memory and mental flexibility. Hence, it is important to systematically assess how children use relationships, interact with others and interact with their environment. Furthermore, when traumatic stressors deplete the coping resources of caregivers, they can become neglectful or show signs of chronic danger, leading to the potential disruption of the attachment system for young children.

Attachment issues

Attachment research describes children’s behaviors along a wellness spectrum from secure attachment (most well) to insecure attachment (where children are at highest risk). With secure attachments, caregivers display relaxed, warm and positive interactions involving some form of direct expression of feelings or desires and the ability to negotiate conflict or disagreement. In this manner, caregivers are encouraging, sensitive, consistent and responsive. With insecure attachments, the child loses confidence to varying degrees in the caregiving system, believing that the caregiver lacks responsiveness and availability during times of distress or trauma.

Securely attached children typically display the following healthy behaviors during the different phases of growth:

  • Phase I (0 to 3 months): Newborns often seek out connection (eye contact and touch) and respond to familiar smells, sights and sounds.
  • Phase II (3 to 6 months): Infants begin to orient to familiar people (preferring those who are familiar to them while avoiding those who are not familiar) and are emotionally expressive, responding to others’ emotional signals.
  • Phase III (6 months on): Infants become wary of strangers and actively seek out familiar caregivers. Additionally, they begin practicing verbal and nonverbal displays of happiness, sadness, anger and fear.
  • Phase IV (from the second to third year on): These young children notably gain increased abilities to negotiate with caregivers (sometimes resulting in short-lived tantrums), are better able to coordinate goals with others (showing adaptable and responsive goals), display increasingly empathic responses to others, and progressively develop greater walking and complex verbal communication skills.

Insecure attachments styles are divided into three categories: avoidant, resistant and disorganized-disoriented. Avoidant attachment styles often can be associated with caregivers who minimize the perceptions of young children, are emotionally unavailable, and assign care of the child to others. This results in young children becoming indifferent to the presence of the caregiver, displaying detached/neutral responses to others, and minimizing opportunities for interaction with others.

Resistant attachment styles are associated with caregivers who resist distress (showing avoidance verbally or physically) and often wait for the child to get highly upset before attempting to sooth. This conditions young children to maximize distress, to resist or display difficultly in being soothed, and to under-regulate their emotions (e.g., responding dramatically to change and acting out dramatically when expectations are not met). Additionally, these children readily perceive experiences as threatening, get frustrated easily, and often approach life anxiously or as if helpless. These children initiate their interactions with others through their distress.

The third and most unhealthy attachment style is disorganized-disoriented. It is associated with caregivers who are often confrontational, helpless, frightened or disengaged (avoidant). These caregivers often passively place children at risk due to the caregivers’ lack of involvement or preventive parenting skills. Their children respond by attempting to adapt to the caregivers’ emotional needs — either caretaking or avoiding. These adaptive behaviors are often observed as consistent displays of confusion, hostility, freezing responses or caregiving responses (e.g., reassuring, pleasing, cheering up).

Counselors’ role: As counselors, we are uniquely trained to meet the needs of young children because of our emphasis on human development, prevention, ecosystems and wellness. Counselors can use three main restorative skills to intervene with young children experiencing attachment issues related to traumatic stress. We can:

  • Set up a safe and warm environment in our clinical settings
  • Display trust through culturally sensitive gestures, tone of voice and facial expressions
  • Nurture a nonjudgmental understanding of young clients while focusing on exploration, empowerment and acceptance

By engaging in these three practices, professional counselors should be able to aid young children in working through a variety of social, emotional, behavioral and learning challenges. Counselors can foster warmth and vitality by employing mutuality and relational socio-dramatic play experiences. Additionally, counselors can create mediated learning so that young children can develop the ability to self-define, contextualize and transform their reality into healthy developmental journeys. This gentle, nonthreatening rebalancing of the energy can create restorative opportunities.

Ten evidence-based interventions

In 2000, Cirecie A. West-Olatunji (one of the co-authors of this article) and a colleague created a program called the Children’s Crisis Unit, in partnership with a local YWCA rape crisis unit, to provide clinical services to young children in a five-county area when referred for allegations of child sexual abuse. Over a four-year period, the Children’s Crisis Unit provided assessment and intervention for children and provided consultation to clinicians, law enforcement, medical professionals and legal professionals, both locally and nationally. During this time, training was provided for counseling, psychology and social work graduate students who learned how to work specifically with clients from birth to age 5.

The following techniques were used systematically with hundreds of clients. Although these interventions may be similar to those used with nonsymptomatic children, in working with young children, there are several unique features, including:

  • Assessment for degree of severity
  • Remediation
  • Involvement of the caregiver
  • Bookmarking for interventions at later developmental periods

1) Popsicle sticks: This intervention can be introduced in the first session with the primary caregiver and the child. One of the appealing things about the use of Popsicle sticks is that they are very inexpensive, meaning nearly any family can afford them. Counselors can use nontoxic crayons or markers and other craft tools such as glitter, buttons, yarn and nontoxic glue. Counselors direct the caregiver-child dyad to use the Popsicle sticks to create individual members of their family as dolls. This activity can be continued at home between sessions. This intervention facilitates bonding and trust, decreases anxiety, is client-centered and culturally appropriate, and allows children to tell their story.

2) Feeling faces: This activity provides easy access for the counselor because various versions can be downloaded from the internet. Use of the feeling faces allows children to identify with other children and their facial expressions. In the exercise, the counselor directs the child to select those faces to which he or she is drawn to determine thematic links between the selected faces. The counselor then hypothesizes and contextualizes the presenting problem. This activity is useful in remediating flattened affect, with the counselor directing the child to mimic faces that match a range of emotions.

3) Storytelling: Narrative activities allow children to tell stories of their own choosing or give a particular recounting as directed by the counselor. Storytelling also allows the caregiver to recount or read the child a story that represents some resolution to the problem. Additionally, this activity permits the counselor to a) read the child a story representing some resolution to the problem and then engage in dialogue about feelings or b) collect pre- and post-observational data regarding the child’s responses.

4) Puppets: This intervention is helpful in allowing children to use dramatic play to express their feelings, recount a story or “restory” prior negative events. It can be particularly useful when the caregiver is actively involved in the puppet intervention. Puppets can be of the caregivers’ own making or ones that are available in the clinical room. Smaller and isomorphic puppets work better with infants and toddlers, whereas 3- and 4-year-old children are more likely to respond to animal-shaped and larger puppets.

5) Anatomically and culturally correct figurines: These figurines can be useful in cases of physical and sexual abuse because children are more likely to provide an accurate accounting when directed to engage in dramatic play. This intervention allows children to reenact situations that they have experienced. Additionally, it offers opportunities for children to point to parts of the body on the figurines as well as on themselves. This activity can provide the counselor with an assessment of the child’s developmentally appropriate knowledge about sexuality.

6) Dollhouse: This intervention offers a physical example of the home that can be used to explain what happens in the home from the child’s perspective. Use of a dollhouse can aid in accessing the child’s memories more easily based on familiarity with household items rather than starting from scratch. This activity allows counselors to be either:

  • Directive with the child, using prompts such as, “Tell me what happens in this room” (while pointing to a specific room in the dollhouse)
  • Nondirective with the child, permitting the child to have free-flowing play with the items in the dollhouse (while making observational notes)

7) Play dough (modeling clay): Modeling clay provides a kinesthetic, moldable medium that children can use to contextualize and express feelings involving sensory experiences. This intervention permits children to create representations of their family members by providing definition to body parts and facial expressions, and thus connecting emotions, experiences and people to the critical event. Play dough activities allow counselors to direct children to mold important people (both family members and nonfamily members) in their lives.

8) Freehand drawing: This activity offers children the opportunity to creatively express what is happening for them in the moment. Tools for this activity are based on the child’s developmental level and might include crayons, markers, pens, pencils or chalk, depending on the child’s age and motor skills. Counselors can use this activity to promote comfort, connection, nurturance and fun for children.

9) Kinetic family/human figure drawing: Kinetic family drawing is a more directive technique that allows children to articulate how they see themselves in relation to other family members. This activity allows for dialogue between the parent and child in terms of perspectives of the family. The counselor offers paper and drawing instruments and directs the child to draw a picture of her or his family. (Note: Try to avoid stick figures, depending on the age of the child.)

10) In vivo parent-child observation and feedback: This intervention permits the counselor to assume an observer role as the parent and child interact. It can be either directive or nondirective. This activity allows for a real-time view of the interaction quality between the parent and child, providing insight into parenting style and skills as well as attachment issues. In vivo observations afford counselors the opportunity to prepare the clinical room with play materials and direct the parent to engage with the child (or, in a nondirective way, allow the parent and child to interact without instructions). Thus, the counselor can step back to observe (either in the clinical room or in an adjoining room with a one-way mirror). If the counselor is in the room, she or he can provide instant feedback and redirection, if necessary.

It should be noted that when working with preverbal children, counselors should rely on nonverbals such as body language, facial expressions, physiological responses and the child’s attention and focus. Also, be aware that children’s comprehension develops earlier than their language abilities. It is important to remember that children understand more than they can communicate.

Extending our reach

The counseling profession is poised to serve as a leading provider of much-needed services to young children. Our focus on prevention, environmental context, development and wellness makes us uniquely trained to assess, intervene with and investigate clinical issues in early childhood. The benefits for us as a profession are numerous and extensive.

First, by incorporating a focus on young children, we can increase our role definition by providing psychological consultation to children, parents, and child care providers in day care centers (such as Head Start) and preschools. Second, we move from the implicit to the explicit. Many practicing counselors are already working with young children in their agencies, schools and private practices. However, without counselor educators and policymakers explicating guidelines for practice, the profession lacks a systematic response to ensure application of evidence-based interventions. Third, we can expand our involvement in addressing the needs of this clinical population by securing grants from federal agencies and private foundations; attending think tanks and conventions where other health professionals are gathering to discuss the needs of young children; and advocating for increased coordination of service providers across all service delivery platforms and agencies. Finally, we can advocate for ourselves by becoming more visible within the larger health care community.

Recommendations: Existing courses in counselor education need to incorporate a paradigm that includes training specifically geared toward clinical populations from birth to age 5. The major challenge within this discipline is how to transform base-level skills into effective techniques and interventions for young clients.

School counselors especially need to have specialized skills and training so they are equipped with tools that acknowledge characteristics and cultural nuances that are specific to child populations. Allowing graduate students to become familiar with the pediatric population early in their training begins the process of conceptualizing young children in the context of a holistic, strength-based and culture-centered approach.

Some professionals have offered a solution to this dilemma by suggesting a framework that incorporates exposure to a variety of populations or the use of various subspecialties. In such a framework, counselor educators systematically incorporate broad content knowledge of specialized populations that is applied throughout the curriculum. Family courses could focus on the specific issues that pediatric members of the family system face and how these issues affect the entire family’s functioning. In addition, family courses could focus on interventions geared toward young children that incorporate the entire family, hence aiding the family to function more effectively. Counseling courses on theory and technique might add discussions on how to incorporate young child development and issues into concepts and interventions that are specific to various counseling theories.

Finally, to further develop our understanding of what practicing counselors actually do when working with young children, it is important to perform additional counseling research. One way of advancing our knowledge in this area might be the use of a Delphi study. This systematic approach, which would gather a panel of experts through a nominations process, could be used to generate ideas, gain consensus and identify opinions of a wide range of counseling professionals without face-to-face interaction. This method could provide a means of bridging research and practice to reach a common understanding of what steps can be taken to explore our conceptualization and assessment of and intervention with young children.

In sum, counselors have the ideal training to work closely with young clients and to provide culturally appropriate interventions to address the unique needs of this client population. Use of developmentally informed and ecosystemic frameworks will allow counselors to be accurate in their conceptualization and treatment of young children.

 

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Cirecie A. West-Olatunji serves as associate professor in counseling at Xavier University of Louisiana (XULA) and as director of the XULA Center for Traumatic Stress Research. She is a past president of the American Counseling Association and the Association for Multicultural Counseling and Development (AMCD). Internationally, she has provided consultation and training in southern Africa, the Pacific Rim and Europe. Contact her at colatunj@xula.edu.

Jeff D. Wolfgang is an assistant professor in the Department of Counseling in the College of Education at North Carolina A&T State University. His research focuses on multigenerational effects of trauma on young children and their families. Contact him at jdwolfgang@ncat.edu.

Kimberly N. Frazier is an associate professor in the Department of Clinical Rehabilitation and Counseling at the Louisiana State University Health Sciences Center-New Orleans. Her research focuses on counseling pediatric populations, cultured-centered counseling interventions and training, systemic oppression and trauma. She is a past president of AMCD and has served as an ACA Governing Council representative. Contact her at kfraz1@lsuhsc.edu.

 

Letters to the editor: ct@counseling.org

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

 

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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.