Tag Archives: women

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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Related resources

  • The upcoming ACA 2018 Conference & Expo in Atlanta includes an education session titled “Compassion and Self-compassion: Therapeutic Approaches to Heal From Grief and Loss” (Saturday, April 28, 7:30 a.m.). See the full conference program at counseling.org/conference.
  • For more on the mandate for counselors to practice competent, nonjudgmental care, refer to the 2014 ACA Code of Ethics at counseling.org/knowledge-center/ethics/code-of-ethics-resources. ACA members with specific questions can schedule a free ethics consultation by calling 800-347-6647 ext. 321 or emailing ethics@counseling.org.
  • Interested in networking with other ACA members on this and other related issues? ACA has interest networks that focus on women’s issues, grief and bereavement, sexual wellness and other topics. Find out more at counseling.org/aca-community/aca-groups/interest-networks.

 

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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 editorct@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.

 

Disclosing an innermost secret

By Bethany Bray March 26, 2018

Should I tell my partner about my abortion?

Fielding questions about sensitive and complicated topics is all in a day’s work for many professional counselors. This question, however, is one that counselors must handle with particular care.

Abortion is among an infinite number of scenarios that clients might want to work through with a counselor so they can fit it into their self-narrative. Telling others about their abortion, whether it occurred one month ago or decades ago, can be an action that some clients consider as they work through the feelings they may have related to the procedure.

Sharing their story — both in therapy and in other outlets — can be one of many potential ways that clients find release and closure, says Catherine Beckett, an American Counseling Association member with a private practice in Portland, Oregon. Counselors can offer support as clients weigh their options and decide whether to disclose an abortion to a former or current romantic partner, family members or friends.

“Help the client assess the potential risks and benefits of sharing, with whom and when, and support them in a decision they feel good about,” says Beckett, an adjunct faculty member in the doctoral counseling program at Oregon State University. “Help them thoughtfully consider and think through what is going to be the most right for them, and perhaps introduce different options [to them as the counselor].”

Trudy Johnson, a licensed marriage and family therapist who splits her time between Arizona and Tennessee, notes that when clients feel ready to tell others about a past abortion, it can be a sign of progress. At the same time, counselors should remind and help prepare clients that their family members and friends may not feel the same way that the client is feeling.

“You can share with others, but you have to be strong enough not to worry about how they are going to respond. Remember, they are not in the same place as you,” says Johnson, who presented on abortion-related issues at ACA’s 2012 Conference & Expo in San Francisco. “You just have to realize that the person you’re telling might not respond the way you’re expecting, and you have to be OK with that. I often get the question, ‘Do I need to tell my children?’ That doesn’t necessarily need to happen. You have to be very careful and make sure that’s what you want to do. Will it serve a purpose? Will it help them to know? Do they need that information?”

It is a delicate “gray area” that has to be considered on a case-by-case basis, Johnson says.

Explore the reasons why the client is feeling a need to share, Beckett agrees. Counselors should help clients find release, whether it is through disclosure or other outlets.

Some clients may ultimately decide that the risks of disclosing their abortion to loved ones outweigh the benefits. Risks include the possibility of difficult feelings regarding the procedure — including grief and shame or stigma from culture or family — resurfacing. Clients who decide not to share might find release instead by posting their story anonymously on an internet message board or by writing a letter they never send, suggests Beckett, who specializes in grief counseling.

For those clients who do decide to disclose their abortion, it might be best to start small, tell just one person whom they trust and then go from there, Beckett says.

“For those who really feel the need to share, determine what is the safest place or who is the safest person to share it with. Then see how that feels: Did it help? Do they want to share further?,” she says. “I think, as counselors, that one of the most valuable ways we can support these women is to serve as someone to talk to about their options, who is not going to pressure or push them in any particular direction.”

 

 

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Although most women will not experience long-term mental health problems after an abortion, some may still endure feelings of loss or other negative emotions caused by external factors such as culture or family. These feelings can surface in counseling sessions.

For more on this topic, see the feature “When post-abortion emotions need unpacking” in the April issue of Counseling Today.

 

 

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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.

 

 

Speaking to the needs of women in counseling

By Bethany Bray January 8, 2018

Rosemarie Scotti Hughes, dean emerita of the School of Psychology and Counseling at Regent University in Virginia, believes that counselor education needs to update the curriculum on the developmental cycle of women and family structure as currently taught in entry-level counseling courses. People are far more diverse in their lifestyle choices than in decades past, she says, but the curriculum hasn’t kept pace.

American women today are getting married and having children much later, on average, than did previous generations. Others are choosing to remain single or raise children on their own or with an unmarried partner. For the first time ever, single adult women outnumber married adult women in the United States.

“The traditional teaching we used to do about life cycles in Counseling 101 or 102 isn’t happening anymore,” Hughes says. “We need to present to students ‘this is what families look like now.’ We need to present a variety of models of what a family can be: same-sex couples, [young adults] living at home after graduating college, couples living together sometimes long years before getting married, having children from multiple partners … single moms who have no intention of marrying.”

Regardless of her life choices, today’s woman is not living in the same world that her mother and grandmothers lived in. In 1960, the median age for a first marriage was 20.3 for women and 22.8 for men in the United States. In 2016, the medians were 27.4 for women and 29.5 for men — roughly a seven-year difference for both genders. In addition, according to the U.S. Centers for Disease Control and Prevention, in recent years, the overall birthrate for American women in their 20s has decreased slightly, whereas the birthrate for women in their 30s has increased.

The social and cultural shifts that Hughes acknowledges are, to use an appropriate pun, married to the issues that female clients bring into the counseling office, from relationships
and family dynamics to career planning and parenting.

These shifts have brought progress in many ways. More and more women are attending college and joining the workforce. At the same time, women continue to struggle with challenges that have plagued the generations before them, such as balancing career and home life and struggling for professional advancement in male-dominated atmospheres.

This reality raises two interrelated questions: What do today’s women need from professional counseling? And how can today’s counselors strive to hit this ever-moving target?

 

 

Diving in

A first step is getting to know the context, culture and full story of the client who is sitting in front of the counselor. Most likely, her experience won’t mirror exactly the U.S. averages for marriage, childbirth, education and other issues.

Recent statistical shifts also differ greatly for women from different backgrounds, especially women of color, notes aretha marbley, an American Counseling Association member and professor of counselor education at Texas Tech University. Women shouldn’t be lumped into one monolithic group, she says, pointing out that the label includes those who are economically disadvantaged, disabled, transgender or otherwise marginalized.

“We need to do a better job of having the voices of all women heard and not just [middle-class female] voices. We’re probably better at that than men, but we’re still not good,” marbley says. “Especially in counseling, don’t make assumptions. Don’t let our voices overshadow those who are marginalized. We really, as counselors, need to do a better job and check our biases at the door — because they’re there.”

Lisa Forbes, an assistant clinical professor in the counseling program at the University of Colorado Denver who also works with clients at an inpatient psychiatric unit at a nearby medical facility, agrees that it is important that counselors not make assumptions. “You can read all the literature on this topic and know everything about women’s rights and equality, but it might not be that way for the woman who is in the room with you. Take each client as their own person,” says Forbes, an ACA member. “First and foremost, take a look at your own beliefs and your own values of stereotypical gender roles. If you’re not constantly trying to challenge those things, you will bring it into the room. … Don’t make assumptions, across the board. Just like any form of multicultural counseling, know the literature, know your personal biases, but get to know your client for who they are and what they need.”

Supporting women clients

Forbes co-presented a session titled “Identity Development of Working Mothers: How to Support Their Mental Health Needs” at ACA’s 2017 Conference & Expo in San Francisco with Margaret Lamar, an assistant professor in the counseling program at Palo Alto University. Women’s issues, especially in the realm of working mothers, is a professional and personal area of interest for Forbes and Lamar, both of who work full time while raising children.

Women frequently can find themselves bumping up against a lose-lose situation, Lamar says. She explains that a woman who works often gets judged as being a bad mother because she doesn’t see her children as much as stay-at-home moms see their kids. At the same time, her workplace supervisors or co-workers might feel she is a liability because she still has to manage the pull of children and family distractions. Pew Research Center data indicate that mothers now spend more hours per week engaged in child care than women did in 1965, Lamar notes.

“There is an expectation that moms should be more present as mothers, but at the same time we’re seeing more and more women in the workforce,” says Lamar, a licensed professional counselor (LPC) and ACA member. “We see women having more anxiety, more depression and feeling overwhelmed. When women are trying to juggle all of these things, the first thing to go is self-care and a focus on relationships. They go into survival mode.”

“These are things that are showing up in our counseling sessions,” she continues, “and we need to be mindful of the language we’re using [and] how we’re pathologizing women. Be aware of that oppressive social context so we are not blaming women. Talk with your clients about [how] they are living in a climate where these expectations are commonplace and it affects mental health.”

Hughes, a recently retired LPC and licensed marriage and family therapist (LMFT) in Virginia, says she often saw female clients who had children later in life and struggled with perfectionism. They often kept their children involved in an endless string of activities, from dance classes and sports to music lessons and Scouts, and then planned extravagant birthday parties and other social activities, Hughes observes.

“They’re adding so much stress to their lives, all of this on top of working,” says Hughes, who wrote the chapter on feminist theory in the ACA Encyclopedia of Counseling. “They keep the kids involved in so many things because they think the kids need all these things for them to be a good mother. I don’t see that they can accept the concept of being a ‘good enough’ mother. … Thinking they can put all of these things into a 24-hour day is fairly unrealistic. You can work and raise your family, but you can’t be supermom. We were never meant to be supermom.”

Hughes says counselors can work with these clients to challenge the irrational thinking that spurs perfectionism and help them focus on what matters most: their relationship with their children.

This “intensive mothering expectation” can lead to self-esteem and identity issues, anxiety, depression and other mental health struggles, Forbes says. The concept, coined in the mid-1990s in the book The Cultural Contradictions of Motherhood by Sharon Hays, an assistant professor of sociology and women’s studies at the University of Virginia, originates with the stereotypical ideal of the 1950s housewife: The woman keeps the household running while bearing responsibility for the majority of household chores and child-rearing tasks.

Decades later, that expectation — whether stated overtly or in more subtle ways — is still going strong, Forbes says. “It puts women in a tough spot, and that’s all wrapped up in our identity development. It’s the idea of a mom who is always involved, takes the kids to their activities and makes kale smoothies every day — being everything for everyone — and it’s really an impossible feat. That’s kind of what we judge women by, and I think it’s unfortunate that we can’t bend a little bit on that.”

Women can even project these expectations onto other women, intentionally or unintentionally, through social media posts and in-person comments, further perpetuating the problem. Forbes has seen this play out in her own life. She is the mother to a 4-year-old and a 2-year-old, and her husband travels often for work.

“I personally struggle a lot with balancing all of these roles and the expectations that moms are put under,” she says. “If I spend an hour away from my kids, I am judged, but if my partner spends an extra hour with the kids, he is patted on the back.”

“If we [practitioners] don’t challenge our own beliefs on this, we will inadvertently bring this into the counseling session,” she adds.

The importance of language

Most of all, counselors must be mindful of the language they use with female clients and check their own assumptions, Lamar says. For example, a counselor working with a female client who is feeling anxious and overwhelmed may initially assume that the woman simply needs to take on less, delegate responsibilities to a partner or ask for help. Although well-meaning, these suggestions carry the implication that the woman is responsible for everything and should be the one to give the responsibility away, Lamar says.

Instead, the counselor might coach the client to negotiate responsibilities with a partner and make a plan, from arranging for childcare to doing the grocery shopping. “It’s really a … shift in our thinking of how to approach that [with a client]. It needs to be both partners coming at this together and negotiating on equal footing,” Lamar says. “It may not be as simple as having trouble setting boundaries. She is under pressure to take on all these pieces in order to feel like she’s a good mom or a good employee. Pay attention to how we acknowledge that instead of placing the responsibility on the woman.”

Similarly, a counselor working with a new mother who is getting ready to return to work should think twice about asking her whether she is ready or if she can handle it, Forbes says. Those kinds of questions assume that it is all up to her. The underlying message is, “You’re the mom. You should stay home,” Forbes observes. Likewise, questions such as, “How are you going to balance everything?” send the message that the client has to balance everything, she
adds. Instead, Forbes suggests that counselors turn their questions to focus on how the mother can advocate for herself to find support and equality at home and at work.

Cassie Owens, an LPC in private practice in Dunwoody, Georgia, cautions that counselors shouldn’t lump their female clients into specific categories — new mother, working professional, single mother — and make related assumptions. “There’s so many different chapters to a woman’s life, and most women wear more than one hat. Be really mindful when asking questions and doing assessments, and don’t make assumptions … based on that first, initial impression or intake session,” says Owens, who specializes in maternal mental health and works exclusively with female clients.

Forbes also focuses on the importance of getting to know the client and her situation. “Listen to a client’s language. Is she wanting help, or is she not sure how to ask? … What changes in her life does she want to make, and what can she advocate for?” counsels Forbes. “Always check in to brainstorm ideas. … Have them make a list and pick one [area to focus on]. What’s the worst-case scenario of an outcome, and what’s the best-case scenario? She knows better than you how things might turn out.”

The same wisdom applies when counseling clients about issues in the workplace, Lamar says. A counselor should not coach a female client to speak up when she is being overlooked professionally without considering her circumstances and professional context. “You should stand up for yourself” is often impractical advice for a number of reasons, including the risk of repercussions, Lamar explains.

“People still underestimate the pressures that women feel in the workplace. I work in academia and mental health, two [professions] that are supposed to be more ‘aware,’ and I have had people take credit for ideas that I’ve had or talk over me in meetings,” Lamar says. “I had a male student explain to me why some [of my] research was wrong. It kind of baffles me. There’s just so many women who experience these kinds of things — microaggressions, victim blaming and, recently, sexual harassment. These are things that women experience all the time to varying degrees.”

The widespread nature of these experiences has made headlines recently as more women have begun coming forward to report cases of sexual harassment involving major figures in
the worlds of politics, entertainment, news media and other professions. We have also repeatedly witnessed examples of why women often choose not to report wrongdoing out of a fear of making waves and the victim blaming that can follow.

Identity and resetting the narrative

It may be useful for counselors to weigh protective factors in female clients’ lives against their risk factors, Forbes says. For instance, counselors might look for areas of life where these clients can strengthen their network of support socially, professionally or therapeutically, such as through local women’s or mothers’ groups, social clubs, nonprofit organizations or church groups.

Finding a “tribe” of people a client can relate to is helpful in combating the feelings of isolation that often accompany many of the issues with which women struggle, especially postpartum depression, Owens says. Online groups can also be a source of support for new mothers or women in different stages of life, says Owens, the vice president of the Georgia chapter of Postpartum Support International. Owens had one client who was a member of a Facebook group for local moms. She invited others to join her for a walk, posting the date, time and location of where to meet. Several women came, allowing her to meet some new people with the shared experience of motherhood.

“That takes a lot of courage, but she really wanted to meet people in her neighborhood,” Owens says. “Also know of support groups that other therapists are running, and know and work with other practitioners in your area. A counselor can help a client navigate them and just [let them] know that these kinds of things exist.”

Counselors can also help support female clients by exploring issues of identity. Often, a woman’s identity is tied to expectations that she has internalized, Forbes says. Counselors can help clients dismantle unhealthy expectations — for example, the mother who does it all — and become aware of how unrealistic they are.

Identity can also be central for women facing transitions, such as a client having a baby in her late 30s after a decade of building a career. This can be a “shock to the system,” Forbes says, because it upsets the equilibrium the client previously felt in her identity.

“Talk the client through her new identity. Being a mother is such a strong identity for a woman, but how can we add that to your existing identity [rather than replacing it]?” asks Forbes. The counselor needs to meet the client where she is. Instead of saying, “This will change everything,” help her to make a plan and rely on a support system, Forbes says.

Owens agrees. “If they’ve had a career and decide to stay home with a baby, it’s a huge change in identity, a loss of self and [can be] a loss of self-worth. Or, it’s the juggling act of going back to work and balancing life. ‘How am I going to be a good mother and employee and [still] take care of myself?’”

In addition to focusing on protective factors, Forbes finds that narrative, feminist and relational-cultural therapies are often helpful when working with female clients. Bibliotherapy can also be used to normalize the expectations and pressures that female clients may be feeling. Forbes recommends anthropologist Solveig Brown’s book All on One Plate: Cultural Expectations on American Mothers to learn more about the intensive mothering concept and its unrealistic expectations.

Helping clients recognize the unrealistic expectations that society often places on women is important, regardless of the theory or method a counselor uses. “There’s so much value in externalizing the problem from the woman. Patterns can be so ingrained that you don’t challenge them, but if you can name them and externalize them, it can be liberating,” Forbes says. “It’s really empowering for women to get to that place that ‘I am not my symptoms; my symptoms are the result of my experience.’”

For example, a female client may be struggling with the decision to take a promotion at work because she feels her children need her more. “Go deeper. Ask the client, ‘What does that mean for you when you have that thought?’ Is it about guilt? If she feels she should be at home with her children, that guilt could turn into low self-worth and feelings of ‘I’m not a good mom,’” Forbes says.

“I would externalize that guilt that she has,” Forbes continues. “She feels like it’s her fault that she has two different roles — mother and employee — and that guilt comes from within. Talk about where that guilt [actually] comes from: greater society. Challenging those societal expectations can help.”

Similarly, Forbes suggests, feelings can be externalized through a version of the empty chair technique typically associated with Gestalt therapy. The client is invited to put her guilt in an empty chair so that she can visualize it, feel it and talk to it. That takes the blame away from the client and helps her realize that “this is not you; it’s your experience of expectations and unfair stereotypes,” Forbes explains.

“Tell [the client], ‘You are not a failure. You live within a context of a culture, within a family, and all of those things affect your self-image and your mental health,’” she says. “They can rewrite their own story on how it works for them, not the way they’ve been told it should be.”

The long road to progress

Although cultural shifts mean that more women are advancing in their careers and living independently, the struggle for progress is far from over. The counselors interviewed for this article agreed that the conversation needs to be ongoing.

Women still shoulder the burden of unpaid maternity leave, child care costs that can be staggering and a pervasive wage gap between them and their male counterparts that is even more pronounced for women of color. There is substantial potential, Lamar notes, for counselors to strengthen their role as client advocates, especially when it comes to policy changes surrounding family leave, child care and other social issues.

“We’re not in a place, as a group of women, to say we’re all done [making progress] now,” says marbley, an LPC supervisor and leader of the ACA Women’s Interest Network. “We need to continue to advocate for those who don’t have the power or ability to do so. We’re not free yet. We’re not ready to say it’s all equal. We can still do better, and if we [women] empower each other, we can help. At the end of the day, it’s not bad. We just have more work to do.”

Hughes was the first female academic dean at Regent before she retired from counselor education in 2009. She notes that throughout her tenure, most of her colleagues and subordinates were male. Likewise, marbley says that in her experience, promotion and tenure remain a struggle for women in counselor education. She also notes that many of the conferences and professional events that young women counselors attend are led by males.

Counseling is a relatively young profession. Perhaps, Hughes says, the work of recognizing the subtleties and needs of women in counseling can be attributed to the profession’s growing pains. “This is all part of counseling’s struggle with identity,” she says. “I’m still not sure if counselors know who we are.”

 

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Statistics snapshot: Women in America

  • On average, women make 80 cents for every dollar earned by a man, a gender wage gap of 20 percent (full-time, year-round employees, as of 2015).

Source: Institute for Women’s Policy Research bit.ly/2leGr6t

  • This past fall, the majority of U.S. college and university students were female — an estimated 11.5 million women compared with 8.9 million men.

Source: National Center for Education Statistics bit.ly/1DLO7Ux

  • Women who are single or living with a nonmarital partner account for 4 out of 10 U.S. births. Less than half of children (46 percent) are living in what has previously been considered a “traditional” household: a family with two married parents in their first marriage.

Source: Pew Research Center pewrsr.ch/1OypOcD

  • It was reported this past year that the mean age at which American women have their first child is 28 years old. In 2014, the mean was 26 years old; in 2000, it was 24; and in 1970, it was 21.

Source: Centers for Disease Control and Prevention bit.ly/2AbMUJQ

  • Between 2007 and 2017, the share of U.S. adults living without a spouse or partner increased from 39 percent to 42 percent.

Source: Pew Research Center pewrsr.ch/2jsZuu5

  • In 2012, 42 million Americans, or 1 out of 5 adults ages 25 and older, had never been married. In 1960, this statistic was roughly 1 in 10.

Source: Pew Research Center pewrsr.ch/1qu8b10

 

 

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To contact the counselors interviewed in this article, email:

 

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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.