Tag Archives: women

New maternal mental health certification available to counselors

By Bethany Bray April 25, 2019

It’s estimated that 1 in 9 American mothers experience peripartum depression.

Because maternal mental health issues are so prevalent, many counselors’ caseloads include clients who are struggling during the first weeks and months of motherhood. However, few practitioners are well-trained enough to fully understand the unique needs and risks this population presents, says Birdie Meyer, the director of certification for Postpartum Support International (PSI), a Portland, Oregon-based nonprofit established to raise awareness of and connect people to resources for maternal mental health issues.

“There are a lot of nuances to this stage of life,” says Meyer, a registered nurse with a master’s degree in counseling. “You can really do damage if you send someone to a therapist who doesn’t know perinatal mental health … [And] There aren’t enough providers out there.”

Worse yet, a practitioner who treats perinatal clients but hasn’t completed comprehensive coursework or trainings in this area can risk doing harm to mothers at a vulnerable time of life. In her decades working in perinatal mental health, Meyer says she’s witnessed horror stories of women being reported to their local department of social services by a practitioner who mis-read the symptoms of peripartum distress – which can include feeling ambivalent toward a new baby or, in severe cases, thoughts of harming the baby or themselves.

“The despair that comes with [peripartum depression] feels like life will never be better, never be the same again. Many times, women seek help but don’t get someone [a practitioner] who understood, or the woman didn’t know where to turn,” says Meyer, who recently retired as coordinator of the perinatal mood disorders program at Indiana University Health, a large hospital system based in Indianapolis.

For this very reason, PSI has begun to offer a certification for helping professionals in perinatal mental health. It’s a project that has been three years in coming, and Meyer was closely involved in the certification’s development and launch.

PSI’s new Certification in Perinatal Mental Health became available in August to counselors, social workers and other mental health practitioners, as well as prescribers (medical doctors, psychiatrists), doulas, midwifes, lactation consultants and other affiliated professions. So far, 130 practitioners have become certified but hundreds more have begun collecting the hours of coursework required to qualify to take the certification exam, Meyer says.

Before a practitioner can list PMH-C after their name, they must pass a rigorous exam and have at least two years of experience in their field. They must also show proof of completion for 14 hours of continuing education in a subject related to maternal mental health. Finally, applicants must participate in an intensive, six-hour training that PSI offers in locations across the U.S., or a pre-approved course equivalent.

PSI has partnered with Pearson VUE, a company with testing centers across the U.S., to proctor the certification exam. The cost to sit for the exam, a test of 125 multiple choice questions, is $500.

PSI developed and refined the certification exam with several teams of subject-matter experts, including professional counselors, Meyer says.

“The test is rigorous,” says Meyer, “but if you’ve had the training that is required you should be able to pass.”

In order to keep up the PMH-C certification, a practitioner will have to complete at least six hours of continuing education each year, she adds.

Meyer believes that the PMH certification will ensure that more and more practitioners are qualified and available to give parents get the help they need in a most critical and vulnerable time of life.

The certification came to fruition after the family of Robyn Cohen, a woman who passed away as a result of a maternal mental health issues, donated to PSI to fund the project in her memory.

 

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Find out more about PSI and the Certification in Perinatal Mental Health at postpartum.net

 

Email questions about the PMH-C to certification@postpartum.net

 

Listen to an extended interview with Birdie Meyer on the Mom & Mind podcast (episode 104): drkaeni.com/podcast/

 

 

 

Related reading: For more on the unique mental health needs of peripartum clients, see the feature article “Bundle of joy?” in the April issue of Counseling Today.

 

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

 

 

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

 

 

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

 

 

Bundle of joy?

By Bethany Bray March 28, 2019

What day of the week is it?” “Why can’t I get my baby to stop crying?” “Did I take a shower this morning, or was that yesterday … or the day before?” These are the types of questions that parents — and especially mothers — often find themselves asking in the foggy, exhausting and often-overwhelming months that follow the birth of a new baby.

“The first three months [of motherhood] are a twilight zone,” says Susannah Baldwin, a licensed professional counselor (LPC) who is the founder and director of a Greenville, South Carolina, counseling practice that specializes in maternal mental health. “Some people call it the fourth trimester, but I call it the twilight zone phase. … They go from working to, boom, they have a baby and don’t leave the house for two weeks.”

Regardless of whether the child is the woman’s first or fifth, the postpartum period can be characterized by the presence of unique mental health needs and challenges. In addition to learning (or reacclimating to) the ropes of parenting and bonding with a new baby, mothers must adjust to changes in their identity and to different pressures on their relationship with a partner and the family system as a whole. Navigating this major life change is made more difficult by sleep deprivation and by bodies that are undergoing the biological and hormonal shifts associated with not being pregnant anymore.

Counselors can play a vital role in preparing clients for this “twilight zone” and normalizing the often anxiety-provoking challenges that accompany the postpartum period. One of the most important things counselors can do for postpartum clients, Baldwin says, is to create a welcoming space and foster a therapeutic bond so that these mothers are comfortable talking through the good, the bad and the ugly of their experience. This includes bringing to light the irrational, fearful and sometimes shame-inducing thoughts that can be part of new motherhood.

These challenges are amplified for mothers who have a pre-existing mental illness, who don’t have a stable partner or strong family supports, or who are part of various at-risk populations, including those living in poverty. Clients who already struggle with self-doubt, negative thought patterns, unprocessed trauma or other issues related to mental illness may find it overwhelming to assume the role of caregiver for themselves and for an infant, says Baldwin, whose practice serves clients going through issues related to infertility, pregnancy, traumatic childbirth or postpartum distress.

Postpartum “is such a critical time,” says Baldwin, a practitioner certified in perinatal mental health. “If existing issues are left untreated, it will affect their attachment and entire [parenting] experience. Do not underestimate that this is a time of gravity in a new parent’s life. Really attend to that and keep it in mind.”

Baby blues

It is normal for new mothers to experience periods of worry or sadness in the days and weeks following the birth of a baby. If these feelings intensify or last longer than a few weeks, however, it may be a sign of postpartum depression.

The Centers for Disease Control and Prevention reports that 1 in 9 mothers nationwide experience depression either in postpartum or peripartum, which includes the period of pregnancy through and after the birth of a baby. Peripartum depression is the more accurate term to use because symptoms can begin during pregnancy itself, not just after the birth, notes Isabel A. Thompson, a licensed mental health counselor in Florida who is writing a book for mental health practitioners on strength-based approaches for working with clients with peripartum depression.

Counselors working with clients who are pregnant or are new mothers should listen carefully for potential indicators of peripartum depression. According to the organization Postpartum Support International, these red flags can include:

  • Crying and having persistent feelings of sadness
  • Feeling ambivalent toward the baby
  • Feeling numb, angry, irritable, guilty, restless or hopeless
  • Worrying about or having thoughts of harming the baby or oneself

Thompson, a member of the American Counseling Association, recommends that counselors conduct periodic wellness check-ins with all peripartum clients. This action helps screen for peripartum depression and mood disorders but can also identify other areas in which these clients are struggling. Check-in questions can include:

  • How is the client feeling in her relationship with a partner (if applicable)?
  • How much is the client socializing?
  • How is the client’s physical health? Is she eating regularly and sleeping when she is able?
  • Is the client feeling connected to her religion or spirituality (if applicable)?

“Also ask about her sense of meaning and purpose,” suggests Thompson, an assistant professor in the counseling department at Nova Southeastern University. “Sometimes in the day-to-day slog of caring for an infant, it’s easy to lose your sense of meaning. Bring her back to why she wanted to be a parent in the first place.”

Isolation can also come into play for new mothers. “Before,” Thompson says, “they were working and having social contact, and now they’re home alone. Help her find ways she can reintegrate with previous friendships and find support with other parents.”

Tools for the journey

The estimated prevalence of peripartum depression in the United States ranges from 8.9 percent of women during pregnancy to as much as 37 percent of mothers during the first year after birth of a baby. These statistics were included in a February 2019 JAMA article that recommended counseling — specifically cognitive behavior therapy (CBT) and interpersonal therapy — as an effective means of preventing perinatal depression.

The journal study, conducted by a government task force, compared the effectiveness of CBT and interpersonal therapy versus the effectiveness of physical activity, the use of antidepressants, omega-3 fatty acids, and other supportive and behavioral interventions such as infant sleep training and expressive writing. Researchers found the two therapy methods to be most effective in preventing perinatal depression, especially for mothers with a history of depression or “certain socioeconomic risk factors” such as poverty or single parenthood. Women who received either CBT or interpersonal therapy during the study were 39 percent less likely to develop perinatal depression than those who did not receive counseling.

The anxious and fearful thoughts that often come in pregnancy and postpartum can generate a barrage of new cognitive distortions, says Quinn K. Smelser, an ACA member and LPC in Washington, D.C., who is working on a doctoral dissertation about parent-child attachment and the Marschak Interaction Method. Teaching clients to challenge these distortions — such as through the help of CBT — can greatly enhance their ability to cope and persevere through the challenges of peripartum.

Smelser, who presented a session on attachment and maternal mental illness at the ACA 2018 Conference & Expo in Atlanta, says that person-centered approaches, mind-body interventions, breathing techniques and mindfulness can also be helpful with this population. Likewise, grounding techniques can be beneficial, but Smelser cautions counselors to remember that a woman’s body will process sensations differently as she progresses through pregnancy and postpartum. For example, Smelser had a client who found that pressing her feet into her shoes helped her to center herself — until she was about six months pregnant and the exercise just became painful.

Thompson notes that narrative therapy can also be helpful for new mothers. Each woman’s experience of conception, pregnancy, birth and postpartum will be different — and can range from easy to miserable. Having the client tell her story, whether it involved an unplanned cesarean section or was a long-awaited miracle after struggling with infertility, can help her process the experience, Thompson says.

Remember also that the childbirth experience itself can be traumatic and might require processing with a counselor. Thompson suggests having clients talk through or write (if they prefer) how the entire pregnancy, birth and postpartum period went for them and what they wished had been different.

A population at risk

When it comes to clients who are pregnant or new mothers, counselors’ first instinct may be to screen for signs of peripartum depression. That’s wise, given how common it is. But this population is also at risk for a number of other issues, from social isolation and burnout connected to exhaustion, to guilt and other emotions related to wanting — or not wanting — to return to work after maternity leave.

Baldwin, a co-author of the ACA Practice Brief on peripartum and postpartum anxiety, separates the issues that these clients are at risk for into three categories: perinatal distress, interpersonal distress and relationship distress.

Perinatal distress includes the classic symptoms associated with peripartum depression or anxiety, such as crying and sadness, but it extends to anything that is interfering with aspects of everyday life such as eating, sleeping, relationships or home life, Baldwin explains. For example, a mother with perinatal distress may be so worried that her baby is going to stop breathing that she stays up all night watching the child sleep. Or she stops checking the mail because there is a steep hill leading to her mailbox, and she’s afraid the baby might somehow fall out of the stroller.

Risk of isolation also falls under this category. An example is a mother who fears taking her baby out in public because it’s flu season, Baldwin says. “In American culture, we are driven to be independent and individualistic, and that drives parents to feel like they have to do everything alone. If they ask for help, it’s seen as a shortcoming,” Baldwin says. “The biggest threat [that can lead to isolation] is the cultural belief that you’re supposed to do this without anyone’s help.”

Interpersonal distress involves issues related to a woman’s changing identity and her transition to motherhood. Similar to what people experience during a midlife crisis, new mothers may feel generally unsettled in life. They may wrestle with difficult thoughts such as “I love my kid, but I don’t love this role” or “This isn’t what I thought it would be,” Baldwin says. This sense of unease can arrive with a first baby or a later birth.

“These crises come from subconscious places. [Mothers] don’t realize why they’re upset or unsettled,” Baldwin says. “They may find themselves making rash decisions. All the sudden, they have an awareness of a gap or hole that must be filled, and they don’t know what to do but try and fill it in.”

Relationship distress involves the new pressures that come when baby makes three (or four or five). Couples often assume that having a baby will make them stronger and create the family that they always wanted, Baldwin says. “But it can be the opposite if we’re not attentive to it. It’s so often underestimated, the huge impact that adding a child or dependent to a family will have,” she says.

Babies often provide lots of joy, but the simple reality is that they also exert a substantial drain on a couple’s finances, time and personal energy — all of which can affect the relationship dynamic. Clients may report feeling distant from their partner or struggling with a lack of intimacy after having a baby, Baldwin says. She adds that those struggles don’t revolve just around sex but also around finding time alone or experiencing a loving connection.

“Couples often put themselves on the back burner” when a new baby arrives, Baldwin says. “They haven’t been on a date in six months. Or perhaps they’re not fighting but only talk about bottles and play dates and not about other things. … Resentment and bickering over tasks — that’s what often brings people to therapy.”

Smelser, a trauma and play therapist at the Gil Institute for Trauma Recovery and Education in Fairfax, Virginia, notes that peripartum clients and their partners are at risk for developing unhealthy patterns in their relationships. Examples include not making time for each other, having vastly different parenting styles, not dividing up responsibilities in an equitable manner, and getting so ingrained in certain roles and patterns that all flexibility is lost. If not addressed, these issues can create tension and grow into larger problems later in the relationship, Smelser says.

Counselors can broach the subject by asking questions about a client’s dynamic with her partner, Smelser says. Prior to having a baby, the client may never have seen her partner with a child or in a caregiving role. How she perceives her partner now may need some therapeutic attention, Smelser says. In cases of a pre-existing mental illness, counselors should stress the importance of these clients getting the support they need so that they can focus on themselves and engage in self-care.

“There’s so much opportunity to psychoeducate a pregnant client or new mom,” Smelser says. “They just need help adjusting. Really deep dive into that rather than glossing over how stressful new motherhood is. Don’t dismiss it [as a clinician]. Really talk about it and validate those feelings.”

How counselors can help

Do you know the difference between a doula and a midwife? How about what organizations offer postpartum support groups in your community? Are you comfortable conferring with a client’s OB-GYN if she has questions about taking antidepressants while breastfeeding?

Counselors don’t have to be parents themselves to offer empathy and a listening ear to peripartum clients. Becoming familiar with and sensitive to the unique needs of this population can make a major difference to mothers who are struggling.

> Make a plan: During pregnancy, help these clients create a safety plan to ensure that both they and their babies get the support they need in the months ahead. This is important for any mother, but it is vital for those with pre-existing mental illnesses, Smelser says. Counselors should discuss what steps the client would take to keep herself and her child safe were she to find herself in crisis and unable to manage. Identify the supports that she can rely on ahead of time. Also talk through what her therapy plan will look like with an infant at home. What might her needs be, and what should she focus on in counseling?

“Stopping therapy for a few months because of the demands of motherhood is the absolute last thing we want to happen,” Smelser says. “Plan on how and when she will give herself breathers. Will it be a neighbor taking the baby for 30 minutes while she goes for a walk? What does she do now to regulate [her mental health], and how can we ensure that it still happens? Make sure the mother has lots of support so she can take a break if she needs to, to help her better regulate to return to caring for the child. Even an hour a day for self-care, that can be vitally important.”

> Identify supports: Counselors should familiarize themselves with the parenting and maternal support groups — especially those geared for participants with a particular mental health diagnosis such as depression — in their local areas. If one doesn’t exist, Smelser suggests counselors consider starting a group themselves.

Thompson advises counselors to also be aware of lactation consultants, breastfeeding support groups, and pelvic floor and other women’s/maternal health specialists in their communities. In addition to birth doulas, there are also postpartum doulas who can support mothers in the weeks after a birth, she notes. Also, counselors can help connect clients who are struggling financially with programs that provide food and other assistance to new mothers, including the federal Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

Some mothers may not feel comfortable sharing their struggles in a support group format, Baldwin notes. She suggests that play groups and other child-focused activities can offer an alternative that helps these mothers find social support and meet parents who are facing similar stressors. Counselors should also be aware of parenting classes, moms groups and exercise classes for mothers at local houses of worship, community centers or medical centers.

Baldwin also encourages counselors to become familiar with Postpartum Support International (postpartum.net), an organization that provides various resources and maintains local networks across the country.

> Focus on strengths: A new mother may experience feelings of inadequacy when a new baby arrives and she struggles with seemingly simple tasks such as figuring out her baby’s sleep schedule. First-time mothers especially may have thoughts such as “Why can’t I do this?” or “I have a Ph.D., but I don’t know how to help my baby stop crying,” Thompson says. These assumed inadequacies can spur feelings of guilt, shame or anxiety.

Counselors can help by normalizing clients’ experiences, Thompson says. Explain that it’s routine to struggle, and there are nuances to learning a baby’s needs and preferences. In addition, counselors can highlight clients’ strengths and focus on what they are doing well, she says.

“Help her identify her strengths, even if she’s not feeling them currently. How did she feel strong before she had the baby? How can she reconnect with that?” Thompson says. “Ask questions in a way that can help [her] identify the differences between caring for an infant and succeeding at work. Explain that it’s a totally new role, and validate that it will be hard: ‘You are used to being able to accomplish things easily, but now even taking a shower requires you to wait for your husband to get home from work.’ Normalize those challenges.”

Smelser tells clients that it’s normal for all parents — including those without pre-existing mental health issues — to feel like they’ve reached their wits’ end at times. “Recognize those moments as just thoughts. It’s just a moment and will pass,” Smelser says. “There are so many shoulds, such as ‘I should be able to handle this.’ Identify that as a cognitive distortion and equip the client with tools to handle it.”

> Ask the right questions: Baldwin suggests that counselors start by asking peripartum clients general, broad questions and then “follow the trail” to identify areas where they are struggling and need more therapeutic work or support outside of counseling. Have them discuss life “before” and “after” the baby: How are they sleeping? How often do they get time to themselves? How is their relationship with their partner?

“Depending on how open they are,” Baldwin says, “ask more specific questions, such as ‘When was the last time you talked [with your partner] about something other than the baby, chores or errands? Do you have a ritual in place for spending time together and connecting?’ Depending on their answer, go down the trail and ask more: ‘How often do you bicker? How often do you feel you’re parenting solo?’ One of the biggest challenges is that prioritization. The baby and the bills and the stuff gets prioritized.”

Follow up with more leading questions, Baldwin suggests, such as “Tell me how much of your energy goes into worry. Who in your life helps you out emotionally, practically and socially? Do you have people who can help you in all three areas?”

One of the most important questions counselors can ask, Baldwin adds, is whether a client has a family history of postpartum depression.

> Explore expectations versus reality: Exploratory questions can also help clients work through expectations they might be harboring (either consciously or unconsciously) about parenthood, Baldwin says. She suggests asking, “Where did you imagine you’d be at this point, and how does it compare to where you are?”

“Perhaps they always imagined loving staying home [with a baby], and it turns out they hate it. … Expectations can get people in trouble,” Baldwin says.

Control issues can stem from creating an expectation — such as planning to breastfeed or have a natural birth — that goes unmet due to factors outside of a client’s control, Baldwin says. Clients who have perfectionist or Type A tendencies may struggle in this area. Counselors may need to help these clients understand that having a baby is simply not a controllable experience, she says. It’s not as simple as making a plan and sticking to it.

> Discuss returning to work: Counselors can play a key supportive role as clients navigate emotions surrounding the decision of whether to return to work. Remind clients that there is no right or wrong decision and that nothing is permanent: If they return to work and find themselves overwhelmed, they have the power to make changes, Baldwin says.

“The whole point of questions on this subject is to empower them to realize that they choose their job, their lifestyle,” Baldwin says. “Ask them, ‘What are your plans for returning to a job?’ I don’t even say your job. If they express hesitation or distress, then I’ll focus on it and ask more questions: ‘How did you imagine it would be? How did you imagine it would feel to drop your child off at day care?’”

Counselors can help clients who have made the decision to return to work prepare both mentally and practically. Baldwin suggests that clients do a “dry run” long before their first day back. This includes waking up early and getting themselves and their child ready as if they needed to leave by a certain time to make the drop-off at child care. “Going back to work doesn’t have to be this big ominous day,” Baldwin notes.

> Work on your vocabulary: Do you know what a nipple shield is? When was the last time you walked down the baby aisle at Target? Unless a counselor is familiar with a new mother’s world, that mother isn’t going to feel comfortable disclosing feelings that are intense, personal and sometimes scary in therapy sessions, Baldwin says. Counselors who don’t specialize in maternal mental health should bring themselves up to speed on current birth and parenting practices to connect with peripartum clients. Postpartum Support International has a page of resources for practitioners on its website and offers a certification in perinatal mental health.

Counselors should also be aware of the different options for childbirth, adds Thompson, who presented a session on breastfeeding and peripartum depression at the ACA 2017 Conference in San Francisco. Babies are born today in hospitals, at home or at birth centers with a range of support professionals, from midwives to nurses, all of which have different philosophies.

> Focus on attachment: Counselors who are working with postpartum clients should be mindful of the importance of the mother-infant bond and provide support for mothers who are struggling in this area. Research suggests that the bond formed through breastfeeding can be protective for mothers and reduce symptoms of peripartum depression, Thompson notes. However, many mothers are unable to breastfeed for various reasons, so counselors should frame questions on this topic carefully to avoid inducing guilty feelings. In addition to breastfeeding, mothers and infants can bond through skin-to-skin contact, by making eye contact while bottle feeding and in other ways, Thompson says.

Maternal mental illness — and untreated mental illness in particular — has the potential to affect the attachment bond, which can have negative implications for a child’s cognitive development and relationship patterns later in life, Smelser says. Counselors can ask questions to get indications of how well mothers are connecting with their babies. “How does she react when her child cries? Are there moments in the day when it’s harder?” Smelser says. “If she has a baby with colic, she may need a space where she can simply be honest and say, ‘It’s awful.’ Can she soothe her baby? What’s working and not working? Is she figuring [her child] out?”

Counselors can also normalize these struggles and stress to these clients that it is OK to ask for help whenever they need it, Smelser adds.

> Talk about medication: Many psychiatric medications have different risks and side effects when taken during pregnancy, breastfeeding and postpartum. Counselors must make sure that their clients are communicating with their prescribers, Smelser emphasizes. Counselors should also check in regularly during counseling sessions about clients’ medication management and how medications are affecting their mood. If granted permission by the client, counselors can also check in with the client’s OB-GYN and other medical professionals.

“Make sure everyone is talking to one another and that the mother is getting all the information she needs from her prescriber. Help and empower her to advocate and ask questions,” Smelser says. “Connections between practitioners — a client’s OB-GYN, prescriber and counselor — are not always that great. Medical professionals don’t always ask [patients] about mood or mental wellness. In an ideal world, all these people would be housed in the same space, but we are not there.”

Thompson also stresses the need for regular check-ins with clients about medication usage. Clients should discuss any changes in dosage with their prescribers, weighing the possible risks of taking the medication during pregnancy or breastfeeding against the risks to their own wellness if medication is reduced or not taken, she adds.

> Be baby friendly: Allowing and even inviting mothers to bring their newborns into counseling sessions can go a long way toward helping them feel supported and understood, Thompson notes. Finding child care can often be a barrier to treatment. When it comes to referrals, counselors should look for inpatient programs that allow new mothers to attend with their child, she adds.

> View mother and baby as one unit: In the United States, medical professionals often place greater focus on an infant’s health in the first few months of life. In reality, Thompson asserts, the mother’s and baby’s health are intertwined, and counselors should keep this in mind.

“During pregnancy, they were literally one unit, and only recently have become two. Emotionally, they’re still so bonded. That connection needs to be honored,” she says. “Addressing any mental health needs the mother has will automatically help her connect with her baby. If she is struggling with mental health, she will be less responsive to her baby’s facial cues and expressions. Healthier moms mean healthier babies.”

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Contact the counselors interviewed in this article:

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

ACA Practice Briefs (counseling.org/knowledge-center/practice-briefs)

Use your ACA member login to access practice briefs on postpartum posttraumatic stress disorder, peripartum and postpartum anxiety, and peripartum and postpartum depression.

Counseling Today (ct.counseling.org)

ACA Interest Networks (counseling.org/aca-community/aca-groups/interest-networks)

  • Women’s Interest Network

 

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

Letters to the editor: ct@counseling.org

 

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

Talking about menopause

By Laurie Meyers January 7, 2019

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

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

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

Understanding the process

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

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

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

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

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

Is it hot in here?

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

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

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

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

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

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

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

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

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

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

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

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

Depression risk

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

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

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

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

Sense of self and sexuality

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

Letters to the editor: ct@counseling.org

 

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

 

Talking about #MeToo

By Laurie Meyers August 31, 2018

In 2006, activist Tarana Burke founded the “me too” movement — a grassroots campaign to help survivors of sexual violence, particularly young women of color from low-wealth communities. Over time, the movement with a simple message — you are not alone — built a community of survivors from all walks of life.

In fall 2017, in the wake of allegations of sexual assault and harassment by film producer and entertainment mogul Harvey Weinstein and other powerful men, “me too” went viral — and global — with a single hashtag. Social media feeds were suddenly flooded with #MeToo, sometimes accompanied by personal stories or alternately issued as a statement in itself.

In the year that has followed this mass call for awareness, stories of sexual harassment and assault have continued to come to light. The discussions about how to achieve safety and equality show no signs of flagging. Some of these conversations are happening in counseling practices as counselors help clients process their own #MeToo stories.

For licensed professional counselor (LPC) Sarah Kate Valatka, a private practitioner in Blacksburg, Virginia, the most striking element of #MeToo has been the sense of community — albeit an unchosen one — the movement has created for survivors. That feeling of community not only helps clients feel less isolated but also engenders hope as they see other survivors navigating their own trauma, says Valatka, an American Counseling Association member whose practice specialties include addressing gender-based violence.

Other counselors say the movement is encouraging women who previously chose to remain silent about their experiences to seek help. “I absolutely believe this has empowered more women to come forward,” says Brooke Bagley, an LPC at the Sexual Assault Center of East Tennessee in Knoxville. “I have heard the narrative repeatedly — that many have been scared, isolated or unsure of the legitimacy of their own traumas, and this movement has given these individuals a voice.”

Indeed, Bagley says although the practice where she works has not seen a substantial increase in new clients, a number of people who had not previously thought of themselves as survivors have come in looking for help to process their experiences.

Charity Hagains, a licensed professional counselor supervisor who specializes in sexual trauma, says she and other counselors at the Noyau Wellness Center in Dallas have seen many new clients seeking help not for assault but for experiences they are just now realizing had crossed the line into sexual harassment. Hagains says she has commonly heard statements from clients such as, “It never occurred to me that this [behavior] wasn’t OK. Every boss I have ever had commented on my body.”

Hagains says the #MeToo movement has also caused many adult women to reconsider their younger experiences. Typical incidents these women have shared in session with Hagains include being pressured to show their bodies in a chatroom when they were preteens or being coerced into having sex as teenagers. At the time, they didn’t consider it coercion because they thought they were old enough to consent or had been drinking and thus excused the other person’s actions.

“It always made me feel awful,” clients have told Hagains. “I was ashamed, but I didn’t realize that it was something that other people would see as not my fault.”

Conversations such as these — both inside and outside of counselors’ offices — are long overdue, asserts Laura Morse, an LPC who specializes in relationship and sexual issues, including assault and trauma. Telling these stories has served to highlight how often sexual assault occurs, but clients are grappling with what comes next, she says.

“So much of the counseling journey with sexual assault survivors is figuring out the ‘and’ after identifying with #MeToo,” says Morse, a private practitioner in Lancaster, Pennsylvania. “Empowering individuals after assault to write their narrative, decide their legal choices and how or if they want to share their story, that’s the part of the conversation that #MeToo leaves us grappling with as a community.”

Moving on from #MeToo

The journey to healing from sexual trauma often begins with defining what has happened to the client, Bagley says. Using psychoeducation, she talks to clients about what constitutes sexual assault or harassment. She also explains common reactions and responses to sexual trauma. Once clients have a better understanding of what they have experienced, Bagley says she can delve into how their trauma is manifesting and work toward the management of symptoms.

Shame and guilt often accompany sexual assault and can be difficult to move past, says Trish McCoy Kessler, an LPC and owner of Empower Counseling, a practice in Lynchburg, Virginia, that focuses on the needs of women and girls. She starts by normalizing what clients are feeling and emphasizing that the sexual violence or harassment they have experienced is not their fault.

Kessler, a member of ACA, uses cognitive behavior therapy to help clients note when they experience a negative emotion and identify the thoughts that are evoking that feeling. She then challenges those thoughts, asking clients to consider whether any evidence exists to support their negative self-talk. Simply instilling hope in clients that their feelings of shame and guilt will lessen over time can help reduce their anxiety and stress, Kessler adds.

Kessler also focuses on coping skills with clients, she says, because many people who have experienced trauma use maladaptive coping skills such as substance abuse and emotional eating. Kessler teaches clients to instead use positive skills such as meditation, reaching out to friends (to avoid isolation), listening to music and writing or journaling. She has found it especially helpful to suggest that clients (and particularly teen clients) keep a list of effective coping skills on their phones to refer to when they are feeling overwhelmed. Kessler also emphasizes the importance of self-care, including getting adequate sleep, getting the proper nutrition and engaging in regular exercise.

Hagains notes that many of her clients lack compassion for themselves. She encourages them to identify as survivors rather than victims and attempts to teach self-compassion by holding a mirror up to the compassion that her clients show to others. For example, Hagains asks clients to consider what they would say to a friend going through the same experiences. “It’s usually not something like, ‘You’re awful,’” she notes wryly. “If you would give your friend a hug, give yourself a hug,” she urges.

Hagains also asks clients to identify the shame statements that they tell themselves. Then she helps them create positive, affirming messages to replace the negative self-talk.

Over time, Bagley has created a five-phase model that she uses for clients who have experienced sexual trauma. In the first phase, she assesses and identifies the client’s level of trauma through a symptom-based checklist. She then explores the emotional, cognitive, physiological and behavioral responses the client is experiencing.

Phase 2 focuses on building rapport and establishing the therapeutic relationship. Because clients who have experienced trauma are very vulnerable, it is imperative to provide a nurturing and safe environment, Bagley emphasizes. Once she has established a bond with the client and a sense of safety, Bagley focuses on the person’s present strengths and explores how the client can use those strengths to cope with the trauma.

Bagley begins cognitive-based interventions in Phase 3. Together, she and the client identify thought distortions attached to the trauma and start practicing ways of reframing negative beliefs.

In the fourth phase, Bagley focuses on identifying specific emotions. She teaches clients to practice mindfulness by noting where on their bodies they feel certain emotions and what is happening around them when they experience these feelings. Bagley says this helps clients identify triggers and also aids in bridging the mind-body disconnect that can occur with recent sexual trauma.

In the fifth and final phase, clients build a narrative surrounding their trauma. “At this stage in the therapeutic process, clients should be displaying more stability and management of symptoms,” Bagley says. “This is often apparent through changes in the language clients use to describe their trauma experience, as well as a shift in self-view.”

At this point, Bagley has clients retell their trauma to desensitize their trauma response and to empower them to feel more in control of their story.

It takes a village

Morse often works with other professionals, including law enforcement, to help survivors of sexual violence. She tells clients there are different paths they can take as part of their treatment and asks them what makes sense or seems helpful to them. Some clients are empowered by learning about their legal rights, and the possibility of pursuing justice gives them a sense of agency. For other survivors, gaining strategies to manage anxiety is critical to their daily functioning, Morse says.

When clients choose to seek justice through the legal system, Morse offers to go to the police station with them and sit in on a meeting with detectives. Beforehand, she prepares clients by explaining that they will be asked numerous questions about what happened to them. She also educates them about how lengthy the legal process can be and the emotional toll it may take.

Many of Morse’s clients have experienced harassment at work, and in these cases, they often choose to file a complaint through their employer’s human resources department. To prepare these clients, Morse goes through their employee handbook so they fully understand the company’s harassment policies.

Morse also strives to help survivors of sexual violence feel safe again, which often requires connecting them with outside resources. She frequently recommends self-defense classes, noting that in many cities, there are now free classes offered for survivors of assault. In some cases, reestablishing a client’s sense of safety may require a change in phone number or residence.

For those who struggle with overwhelming anxiety, Morse is a big proponent of eye movement desensitization and reprocessing (EMDR), and she refers these clients to a certified EMDR practitioner. If anxiety and depression are impeding her clients’ daily functioning, she has them meet with a psychiatrist to explore the need for short-term medication management of symptoms.

Morse says group therapy can also be a crucial therapeutic tool because it provides a way for survivors to share their stories with others who have experienced sexual trauma. Many community agencies and YWCAs offer free groups, she notes.

Morse also emphasizes the power of just being there for clients. “Many survivors of assault reflect that the most helpful part of the therapeutic process is simply having someone to listen and believe them on their journey,” she says. “Oftentimes, we’ll spend several sessions talking through the details and allowing a woman to rewrite her narrative as an assault survivor.”

When #MeToo is painful

Although counselors generally say that the #MeToo movement is socially necessary and can be personally empowering, they also note that for some survivors, the constant reminders of sexual trauma can have an unintended adverse effect.

“The movement can often feel like a double-edged sword in terms of awareness for survivors,” Bagley says. Although many survivors are grateful that the truth of the widespread nature of sexual violence is being made evident, the sheer volume of stories can be overwhelming. “It floods social media, news outlets [and] radio programs, leaving little escape for survivors,” Bagley explains. “Additionally, the backlash and negative media response to the movement has … a triggering and negative impact.”

Valatka agrees. “You [a survivor] may be on social media, and it’s just a normal day. Then someone shares, and it’s bringing it into your day — bringing it to survivors when they weren’t planning for it.”

Shaina Ali, an LPC and owner of Integrated Counseling Solutions in Orlando, Florida, says that when clients who are survivors of sexual assault or harassment bring up #MeToo, she uses an existential approach. “How does this affect your story? What does this mean for you?” Ali asks clients.

Her intent is to help clients focus on how hearing these stories affects their progress. In some cases, clients realize that they have handled potentially retraumatizing information better than they thought they might, says Ali, who specializes in trauma work. For others, their reactions are an indication that they have more trauma work to do. Ali notes that some of her clients who had come to her for issues unrelated to trauma realized that the #MeToo stories mirrored their own experiences — experiences they previously hadn’t recognized they needed to talk about.

Because #MeToo and other news stories related to mental health — such as the recent suicides of Kate Spade and Anthony Bourdain — can potentially have an effect on any client, Ali always raises such topics in session. She says this serves two purposes: to check in and head off trouble before it starts and to give clients an opportunity to bring up experiences they haven’t previously been ready to share.

Sometimes the triggering comes from the casual conversation of people clients are close to, Hagains points out. As people talk about #MeToo, sexual assault and harassment survivors hear a lot of opinions being shared, some of which are full of blame. It is not uncommon to hear people say things such as, “Well, she went to his apartment, so she deserved it,” Hagains notes.

Hagains tells clients that in these cases, they need to set boundaries by telling friends or family members that they do not wish to discuss the topic and that they will have to agree to disagree. In certain cases, such as with casual Facebook friends, Hagains urges clients to decide how important it is for them to stay in contact. It may be in a client’s best interests to mute those who are making hurtful statements. Sometimes setting boundaries means limiting contact; other times it may become necessary to cease contact altogether. 

What are men learning?

The larger goal of #MeToo is to change the way that men and society as a whole see — and treat — women. Is it working?

Hagains says the topic is definitely coming up in sessions with male clients. She says that about 90 percent of the men she counsels have asked her about behavior — as in what is OK and what isn’t.

“I think a lot of men are reexamining their roles,” she says. Many of them are realizing that what they thought was appropriate or complimentary to women can actually be offensive.

A familiar refrain that Hagains hears in session from male clients who are grappling with the implications of #MeToo: “I thought women liked to be complimented on their bodies.” She responds by telling them that it might be OK to say in a bar but definitely not at work.

Ali, an adjunct professor at both Central Florida University and the Chicago School of Psychology, has also heard increased discussion from men about the topic of sexual assault and harassment, both in her practice and in the classroom. Ali teaches clients and students about harassment, setting boundaries and establishing healthy relationships.

“The way I see it,” says Kessler, “is that #MeToo is not just for women. I want men to see, this is how you treat women.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Adult Child Sexual Abuse Survivors” by Rachel M. Hoffman and Chelsey Zoldan
  • “Intimate Partner Violence — Treating Victims” by Christine E. Murray

 

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

Letters to the editor: ct@counseling.org

 

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

When post-abortion emotions need unpacking

By Bethany Bray April 3, 2018

Catherine Beckett, an American Counseling Association member with a private practice in Portland, Oregon, has made it a habit to avoid using “must” phrases with clients. “It sends a message to the client about what they’ve experienced,” says Beckett, who specializes in grief counseling. “I don’t ever want to say, ‘Oh, you must feel so guilty,’ or ‘You must feel so isolated,’ because that may not be the case at all.”

A case in point: when clients reveal in counseling that they have had an abortion at some point in their past. Some clients consider that experience to be just another piece of their life story, free of any negative associations. For others, the experience can evoke a range of issues, from spiritual and familial turmoil to attachment difficulties and feelings of loss. When dealing with such a highly charged topic, counselors must be prepared to put their own personal views aside to support clients who fall into either camp — and those who present a range of emotions in between.

Research cited by an American Psychological Association task force found that the majority of women who elect to have an abortion will not experience mental health difficulties afterward (see apa.org/pi/women/programs/abortion/). In February 2017, JAMA Psychiatry published a study titled “Women’s mental health and well-being 5 years after receiving or being denied an abortion.” The study observed 956 women over the course of five years, including 231 who initially were turned away from abortion facilities. Among the authors’ conclusions: “In this study, compared with having an abortion, being denied an abortion may be associated with greater risk of initially experiencing adverse psychological outcomes. Psychological well-being improved over time so that both groups of women eventually converged. These findings do not support policies that restrict women’s access to abortion on the basis that abortion harms women’s mental health.”

Even though most women will not experience long-term mental health problems after an abortion, some may still endure feelings of loss or encounter other negative emotions caused by external factors such as culture or family. For certain clients, a past abortion experience, whether it took place one month ago or decades ago, can be at the root of a range of issues — low self-esteem, relationship problems, disenfranchised grief — that surface during counseling sessions.

Beckett notes that most of the women she works with aren’t questioning their decision to have an abortion but rather “struggling to process it and place it in the narrative of their own lives in a way that feels comfortable.”

“As a practitioner, you should know about [abortion] and understand that within the population you’re seeing, it’s probably in their story,” says Jennie Brightup, a licensed clinical marriage and family therapist in private practice outside of Wichita, Kansas. “You need to be prepared to know how to work with it.”

Counselors should approach the revelation of an abortion just like any other experience or issue that clients may have in their histories, Brightup says. “Have an open mind. Allow it to be something that can be a problem for your client. See that it could be an issue … [and] have some knowledge about how to treat it.”

‘You think you’re alone’

The Guttmacher Institute, a reproductive health research organization, estimates that in 2014 (the most recent data available), 926,200 abortions were performed among women between the ages of 15 and 44 in the United States. This comes out to a rate of 14.6 abortions per 1,000 women.

The institute notes that this marks America’s lowest abortion rate since the process was legalized nationwide by the Roe v. Wade Supreme Court decision in 1973. The U.S. abortion rate has seen a steady decline after peaking in 1980 and 1981 at close to 30 abortions per 1,000 women. Using the 2014 data, the Guttmacher Institute extrapolates that 5 percent of U.S. women will have an abortion by age 20; 19 percent will have an abortion by age 30; and 24 percent will have an abortion by age 45.

Abortion is more common than many people, including mental health practitioners, think, says Trudy Johnson, a licensed marriage and family therapist who presented on “Choice Processing and Resolution: Bringing Abortion After-Care Into the 21st Century at ACA’s 2012 Conference & Expo in San Francisco. Johnson, who had an abortion in college, says that for many people, processing the abortion experience is “a slow burn. It doesn’t affect you until later on. [Many] women have had an abortion, but you think you’re alone. You don’t feel you get to grieve it. … It’s a gut-level thing, a tender place. Many have never told a soul,” says Johnson, who specializes in trauma resolution, including abortion-related issues.

Connecting issues

For clients who have yet to process and place a past abortion into their self-narrative, it can feel like a sadness that they can’t quite pinpoint or define. “It’s kind of like a phantom pain. It’s there, but you don’t know why,” Johnson says.

Clients with a variety of presenting issues may have unprocessed emotions surrounding a past abortion that could be compounding their struggles, Johnson says. These issues can include:

  • Depression and anxiety
  • Complicated grief
  • Anger
  • Shame and guilt (especially shame that is undefined or has no apparent cause)
  • Self-loathing and self-esteem issues
  • Relationship issues (including destructive relationships)
  • Destructive behaviors (including substance abuse)

For certain clients, their unprocessed emotions can feel like a weight they have carried and buried deep within themselves for a long time without sharing it with anyone, Johnson says.

Johnson recalls one client who initially came for couples counseling with her husband but eventually started seeing Johnson for individual counseling. During a session, Johnson recognized that the woman was becoming upset, so she handed her a blanket and pillow for comfort. The client put the blanket over her head, obscuring her face, and disclosed that she had had an abortion 18 years prior. Her family had shamed her for the decision, and her feelings of shame were still so overwhelming that putting the blanket over her head was the only way she could bring herself to talk about the experience, Johnson recounts.

“You just can’t imagine the shame that [some of] these clients carry,” says Johnson, a private practitioner who splits her time between Arizona and Tennessee. “They just have to talk about it. We, as professionals, can be that safe place.”

Clients who have had abortions sometimes question whether they have the right to grieve because there was a choice involved to terminate their pregnancies, says Beckett, who is an adjunct faculty member in the doctoral counseling program at Oregon State University. The concept of the experience of disenfranchised grief — those who are not supported in their grief because it is not culturally recognized or validated — applies in these instances, Beckett says. In fact, the disenfranchisement can be both external (a loss not recognized by the client’s culture) and internal (a loss that the client, individually, does not recognize).

“People do not have the same kind of support and validation [to grieve a loss] when they’re disenfranchised, and that is a huge part of abortion grief,” Beckett says. “The emotional aftermath is so impacted by spiritual, political and ethical values and beliefs. That will really color how they process it and how much they’re able to reach out and get support. This all needs to go into our assessment of a client. What was their experience, but also how are they talking to themselves about it? All of that should inform how we offer support.”

Broaching the subject

Practitioners might want to consider asking clients (female and male) about pregnancy loss, including abortion, on intake forms. Brightup asks clients about past pregnancy loss in a genogram exercise she does in the first few sessions of counseling. If the client mentions an abortion, she simply makes a note and keeps going. It is not a topic she feels a need to jump on immediately, she says, and she doesn’t want to risk retraumatizing clients or prompting them to talk about it if they are not ready. Some clients may not mention an abortion on an intake form or genogram because they don’t consider it a loss or associate it with trauma, Brightup says. Others have buried the issue so deep that they don’t think about it or feel that it is worth mentioning, she adds.

“When you’re hearing their story, you can find places to check in and ask questions. Most of the time, I allow them to come around and tell me. It’s a core secret. If you feel [judgmental] to them, they’ll never tell you and they’ll run [stop coming to therapy],” says Brightup, a certified eye movement desensitization and reprocessing (EMDR) therapist.

Practitioner language is also important, Beckett notes. “For some people, asking [if they have an abortion in their past] is giving them permission to talk about it. And the way we ask about it may give them clues about whether or not it is safe to talk to us about it,” she says. “For example, there’s a difference between, ‘Is this something you have experience with?’ and ‘Well, you haven’t had an abortion, have you?’”

Even the word “abortion” can provoke an intense reaction for some clients, Johnson says. In some cases, she will use the phrase “pregnancy termination” or even “the A word” with clients who feel triggered and begin to close themselves off.

“You might need to say it differently,” Johnson advises. “Abortion immediately turns it into a political, socially charged [issue]. Changing the terminology helps it to be safer.”

The key is to foster a safe, trusted bond so that clients will feel free to bring the topic up themselves when they are ready, Johnson says. “The most important thing is building a relationship of safety,” she emphasizes.

Different points on a path

Clients who disclose having an abortion in their past may vary widely on how they feel about the procedure and how much they have processed those feelings.

“There are clients who will come in and do not report having any mental health issues related to their abortion experience. Understand that they’re out there. But the other side is out there too,” Brightup says. Practitioners must be prepared to work with clients who express either sentiment — or a range of feelings in between.

Counselors should watch their clients’ body language and other cues, especially in cases in which a client is emphatic or even defensive when talking about an abortion. It is wise to unpack the client’s experience and associated feelings over time, Brightup says.

If counselors disagree with a client’s assertions concerning how she feels about the procedure, “you can lose the client because they won’t come back [to therapy],” she says. “Agree with their narrative. In little pieces, once they trust you, you can come back to the story and probe a little, ask a few questions as gently and carefully as you can.”

Some clients will have fit the abortion into their self-narrative and moved on, whereas others won’t be as far along in the journey. Still others will have worked through their feelings surrounding the procedure in a healthy way previously but may find themselves struggling with it again as they move into another life stage such as pregnancy or motherhood, Beckett says.

This was the case for one of Beckett’s clients who sought counseling because she was struggling with powerful emotions that had resurfaced. The client had undergone an abortion when she was 17. Later in her life, she had a daughter, and that daughter was now turning 17 herself. Even though her daughter wasn’t facing any type of decision regarding pregnancy or abortion, her age triggered feelings in the client that needed more therapeutic attention.

The client’s abortion had been illegal at the time where she lived, so she had felt compelled to keep it a secret, Beckett explains. The client realized her daughter was now the age she had been when she had an abortion. “The mother saw, for the first time, how young she [had been] and how desperately she had needed love and support at the time, and she didn’t get it,” Beckett says. The realization was “exquisitely painful” for the client, but at the same time, it brought “a new level of compassion for her 17-year-old self,” Beckett recounts.

“She took a great deal of comfort in knowing that if her daughter were to get pregnant, it would be an entirely different experience. Her daughter would have the support of her family and better care,” Beckett says.

The hard work of unpacking

Just as clients will differ in the work they have done — or haven’t done — to process the emotions surrounding an abortion, the support and interventions they might need from a counselor will also vary.

“People grieve very differently, and we need to be ready to support people however they are doing it,” Beckett says. “Some people are going to want to take action or give back somehow. Others will respond to more creative processes or ritual creation. Others will want a quiet, safe place to process.”

Normalizing a client’s experience can be a much-needed first step. Beckett says that talking about how common abortion is, and the fact that many people feel a need to process their feelings afterward, can bring relief to clients. Practitioners can also help clients reframe their thoughts to realize that feelings of relief after the procedure are common, as is a fear of judgment and a sense of isolation that can accompany that fear.

“Figure out what this particular client’s experience is and then, if appropriate, offer normalization of that,” Beckett says. “Support them to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

In Brightup’s experience, post-abortion work with clients often falls into four quadrants:

  • Reconciling how clients feel about themselves
  • Engaging in grief work around how clients perceive and feel about the loss (if they do indeed view it as a loss)
  • Working through clients’ spiritual issues or any inner tensions related to “rules” that were broken
  • Working on clients’ relationships and how they relate to people: Are there areas that need healing?

From there, practitioners should tailor their approaches to meet each client’s individual needs and pacing, Brightup says. She often uses sand tray therapy as a tool to help clients talk about post-abortion loss and find closure. Journaling, writing letters or poems, creating art and engaging in other creative outlets can also be helpful, she says. Certain clients may respond to creating some kind of physical memorial or taking time out of a counseling session to do a remembrance with just the two of you, Brightup adds.

Beckett agrees that counselors should collaborate with clients to find a ritual or activity that works for them. Although many clients will make progress through talk therapy or by connecting in group work to those who have had similar experiences, others will feel a need to take some kind of action, Beckett says. Creating memorials and rituals, writing letters or participating in other creative interventions can help these clients to process their emotions and experiences.

For one of Beckett’s clients, healing involved creating a special ritual on what would have been her child’s due date. Each year, the client would be intentional about spending time with a child — whether a niece or a nephew or the child of a friend — who was the same age that her child would have been.

“She came in pretty soon after her abortion, and she knew she needed help to process it,” Beckett says. “She wasn’t questioning the decision, but she was having trouble [with the fact] that her life would move forward but the life of the baby she had not had wouldn’t move forward. She wrote a letter to that baby expressing her caring and regret and explaining why she felt she couldn’t bring him or her into the world. Every year on her due date, she would find a way to connect with a child she knew that would be that age. She would spend time with that child and make it a good day for them.”

Whereas this intervention helped this particular client to find peace, “for other clients, the thought of that would seem hellish,” Beckett stresses. “There’s no prescription for this. It’s a process of figuring out what is still remaining and needs to be released. Talk with the
client to find creative ways to be able to do that.”

Counselors can help clients navigate areas in which they feel emotionally stuck, Beckett explains. For example, one of her clients was struggling even though she had worked through many of the emotions she had experienced after an abortion. The client had three children, and when she became pregnant with a fourth, she and her partner made the decision to terminate the pregnancy.

“There was one part that she couldn’t get OK with: ‘I see myself as someone who takes care of others,’” Beckett says. “That’s where we focused: How did she define ‘taking care’? How did this decision threaten her self-concept? We dove into that area and she eventually realized that terminating the pregnancy was taking care of her fourth child. That was the best way to take care of that child, instead of bringing the child into an already-overwhelmed system that wouldn’t have been able to provide what the child needed.”

Johnson finds narrative therapy a useful approach when focusing on post-abortion issues with clients. Giving them the freedom to tell the story of their abortion — how old they were, how it happened, who came with them that day — can be powerful, she says. Sometimes clients won’t remember the details about their abortion because they’ve blocked them out, Johnson says, but as they open up and talk about the experience in therapy, they often start to recall things.

“This has been in their head for years. When they finally start talking about it, they go on and on because that’s [often] what they need,” Johnson says. “You can see the layers coming off as they’re processing it verbally, the whole story. … Letting them talk about the details and tell their story is a starting point.”

When relevant, Johnson also helps clients identify all the points of grief connected to the abortion beyond the loss of a pregnancy. For example, clients might have experienced a breakup with their romantic partners or the breakdown of a relationship with their parents or other family members either leading up to or after the abortion. Giving clients permission to grieve and accept the loss of these things is an important step, Johnson says.

There are “so many layers to this. The main thing [for counselors] is being a safe place. The impact of a hidden abortion could really be affecting the outcome of your therapy if it’s not addressed. Be aware that there could be this issue under all of the other stuff [the presenting issues],” Johnson says.

“Treat this as a disenfranchised and complicated grief situation, and take out all the political mess and pros and cons,” she continues. “The client has already made a choice. Let’s forget about that and just work on the grief. They’re not the same person that they were when they made the choice. They’re a different person now, so they need to have permission to revisit that time in their life and be free of it. The therapist is kind of a vessel of freedom for that, and it’s a wonderful place. … You’re helping them overcome the bondage, pain and grief that’s been with them for so long.”

Putting personal feelings aside

Abortion remains one of the most politically and socially polarizing issues in modern-day America. Despite this — or, in some cases, because of this — certain clients are going to need to work through issues related to abortion in the counseling office. A practitioner’s role is to be a support through it all, regardless of his or her own personal views on the topic.

Brightup urges counselors to rely on their training, which includes setting personal opinions aside and being what the client needs.

Creating a neutral and welcoming space for clients to talk about such a sensitive topic is paramount, Johnson agrees. “If you don’t have any experience working in this area, you can do more damage without meaning to,” she says. “Or, for some people, there’s a hidden implication that if you help a client through feelings related to an abortion, you’re condoning abortion.” That is simply not true, she stresses.

Beckett agrees. “Clients need a safe and nonjudgmental space to share [about their abortion experience], and that’s hard for some counselors based on their own belief system. It’s not going to be easy for all counselors — that affirmation of [the client’s] right to grieve. [But] a client needs support to determine what is needed to move them toward greater comfort and peace. Offer them ideas and support around getting those things that they need.”

 

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Disclosing an innermost secret

As clients process post-abortion emotions, they may struggle with the decision to tell others, including a current or former partner. What should a counselor’s role be in that process? Read more in our online-exclusive article: wp.me/p2BxKN-54z

 

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Bethany Bray is a staff 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.