In a 1624 devotion, the English poet John Donne argued, “No man is an island, entire of itself; every man is a piece of the continent, a part of the main.” 

This sentiment still rings true in modern-day counseling. Behaviors exhibited by other people in clients’ lives — often the people they love most — can affect them acutely. When these patterns are codependent, manipulative or unhealthy, it can cause clients’ presenting issues to worsen, stall their progress in counseling or otherwise negatively affect their mental health.

Examples run the gamut from an adult client whose parent deals with anxious feelings by being critical of or over-involved in the client’s life to a client whose spouse has experienced past trauma and is prone to angry outbursts.

These types of scenarios are not uncommon, and they often surface as counselors and clients begin to unpack the issue(s) that brought them into therapy, says Jen Ohlund, a licensed associate counselor (LAC) who counsels adolescents and adults at a practice in Mesa, Arizona. One indicator that a client is not getting the support they need from the people in their life can be failure to make progress in counseling, despite hard work on the part of both the client and counselor.

In counseling, a practitioner might hear clients make statements such as “I feel like I’m getting better, but I go home and I keep being told the same [unhealthy] things over and over again” or “I am doing everything I can and nothing is changing,” Ohlund says.

“Any progress they’re making is being shot down by the other individual,” she explains. “That’s when we introduce boundaries. We talk about what a healthy boundary is and equip them with [psychoeducation] that we can’t control how other people react. We can’t always walk on eggshells. Sometimes other people have to work through their triggers, and if they’re not going to do that, we have to set boundaries.”

Seeing the whole picture

Empathic listening and validation from a counselor can serve as important first steps with clients who are wrestling with guilt, aggravation, sadness or other feelings spurred by the behavior of loved ones, Ohlund says. Simply talking through what has and hasn’t been working can be powerful, as can receiving assurance from a counselor that many people struggle with similar challenges and the client is not alone in feeling those same emotions.

“A lot of times, they don’t want to feel this way. They care and love this person,” says Ohlund, a member of the American Counseling Association. “They might feel overwhelmed [or] frustrated with their loved one or turn inward and beat themselves up, feeling like they’re not doing something right [or] not doing enough to meet [the other person’s] needs.”

Counselors can also listen for indicators that clients are struggling with isolation, a lack of boundaries (such as receiving an extremely high number of text messages from a family member) or feelings that they can “never say no” to their loved one. In these cases, clients might not have other people in their life who can act as a sounding board to give them a clear perspective. One way counselors can help clients temper the unhealthy messages they receive from a loved one is to support them in finding connection with other people who offer positivity and a voice of clarity. This will help clients self-regulate, Ohlund notes.

Michelle Fowler, an LAC at the Arizona Center for Marriage and Family Therapy, urges counselors to help these clients through an attachment lens. “We are wired to need one another and respond to one another. Doing therapy in a bubble is very unrealistic,” Fowler says. “The relationships around the client have the greatest influence on their well-being. It’s neglectful of us to ignore those contacts or not address them when they are a source of [a client’s] distress or, potentially, a resource to help in recovery.”

Asking targeted questions during the intake process is a good way for clinicians to get a picture of the supportive factors in a client’s life, says Breanna Lucci, a licensed mental health counselor at a group practice in the North Shore of Massachusetts. These questions can include:

• Who is in your support system? Who can you turn to for support?
• Who makes you happy?
• What are your standards in a relationship, and how do you know a relationship is a healthy one?
• Does your family know that you’re going to therapy, and are they supportive of that decision?
• Describe your living environment. Is it supportive?
• Who (other than your counselor) are you comfortable talking to about topics related to mental health?

Lucci also finds that discussions about a client’s self-talk can uncover outside factors affecting their mental health. She uses motivational interviewing with clients to delve deeper into these external influences.

For example, if a client says, “I’m anxious, but I just need to get over it,” then Lucci, an ACA member, asks, “Why do you feel that way? Where have you heard that?” Or if they say, “I’ve been told I’m stupid,” then she breaks down what “stupid” means to the client and asks, “Who said that? How did it affect you?” Talking through a client’s language choices in this way helps them to recognize patterns and realize how things they have heard from others and internalized have become part of their self-talk and self-belief. The goal of this work, Lucci stresses, is always for the client to get to these realizations on their own.

Carrie E. Collier, a licensed professional counselor who specializes in Bowen family systems theory at her Washington, D.C., practice, agrees that the language clients use in session about their relationships can relay valuable information about the client’s context and how they respond to others.

“An individual is not in a vacuum — there’s always reciprocity in relationships,” says Collier, director of the Bowen Center for the Study of the Family in Washington. “Anxiety is contagious; if a person is living with other people, there are a lot of shared emotions that are going on. I try and help a person get really clear about what’s theirs and what’s the other person’s, and what he or she is putting into it and what [others] are putting into it. … As a counselor, it’s important to see the [client’s] entire context and the landscape. It’s not just one person sitting in the office with me. It’s not a cause and effect. It’s relationships and people reacting to one another, and that is what the counselor and the client are up against.”

Fostering understanding

With those who are surrounded by unhealthy patterns, it is vital for counselors to be aware of resources (both in their local area and online) that can help clients better understand what their loved one is going through and support the client outside of counseling sessions, Lucci says.

As a licensed drug and alcohol counselor, Lucci is knowledgeable about numerous addiction resources in her area, including a recovery center that offers interventions and free family workshops. She often recommends Johann Hari’s TED Talk, titled “Everything you think you
know about addiction is wrong” (see bit.ly/3aqbpV4), to clients whose family members struggle with addiction. She also has a ready list of organizations that offer support groups and other resources to help those whose loved ones live with mental illness or who struggle with parenting issues, caregiving roles, work stress, an incarcerated loved one and a range of other challenges. The support groups and educational materials from the Depression and Bipolar Support Alliance (dbsalliance.org) and the National Alliance on Mental Illness (nami.org) can be particularly helpful, she adds.

Finding avenues of safe support outside of counseling equips this client population to “be healthy in spite of their circumstances, and some of that is [learning] acceptance,” says Fowler, who counsels adolescents, individual adults and couples. Understanding the big picture that frames a loved one’s behavior (including, in some cases, mental illness) empowers clients and can help them “gain empathy or understanding so it doesn’t feel like a personal attack,” Fowler explains. 

Roughly one-third of Fowler’s caseload is adolescents, and for these clients, questions about the adults in their life can reveal important information about the support they are — or aren’t — receiving at home, she says.

“One place that I always start, especially with the adolescents I see, is the assumption that if they could go to the adults in their circle to deal with their [presenting] problem in a supportive way, they probably wouldn’t be in my office,” says Fowler, an ACA member. “Sometimes it turns out the parents have mental health issues and the client is doing as best as can be expected. It is definitely not happening in a vacuum. … If somebody else really is why, or part of why, they are struggling, is that a person who could be involved in therapy? Is this a person who could potentially help, or does the client need coping skills to deal with [this person]? If it’s a parent and child, I definitely want the parent to come in as much as possible. But if that parent isn’t going to be a safe person because they have their own struggles or are not willing to adjust, be open and see [the] child’s perspective, then how do I shore up [the client] with coping strategies?”

One example Fowler has seen among her caseload is clients who identify as LGBTQ and “have gotten very clear messages from their family that they’re not open to talk about it.” These clients are left to work through their identity and mental health issues on their own — an experience she describes as a “personal journey of how to make peace with themselves while staying in their current environment.” 

For couples and individual clients, a dose of honesty from a counselor about how much their situation could improve may be called for, Ohlund notes. “We [counselors] don’t necessarily give advice to clients, but I also think it’s important to be clear that in some situations, if you continue to stay in this relationship, this is what it will look like. If you learn all of these coping skills and boundaries and nothing else changes, the relationship won’t be better. You can maintain the relationship and be stable, but thriving is a completely different thing,” Ohlund says. “It’s important not to be vague. Be very clear [about] what it would look like if they chose different options so they can weigh it appropriately.” 

Even as clients grow through counseling, the other person in the relationship may not change. This concept is so important, Ohlund points out, that it is written into the informed consent forms at the practice where she works.

“This is one of the most difficult parts of therapy: When you grow and develop, the people around you may not,” Ohlund says. “Once [clients] learn coping mechanisms, communication skills and begin to feel more confident … they may find that the relationships around them change, or they may not even want [those relationships] in their life” any longer.

Counselors can serve as vital resources to help these clients work through self-judgment, anger and other feelings, while equipping them with coping mechanisms such as mindfulness, self-care and self-compassion exercises, Ohlund says. She acknowledges that helping clients learn to see things through a new, healthier lens takes time. Along the way, it is important to help clients focus on the things in their life that are going well, she says.

Rewriting unhealthy patterns 

Fowler once worked with a teenage client whose presenting issues were depression, self-harm and suicidal ideation. The client’s parents had gone through a tumultuous divorce seven years prior, and her father had since remarried. The parents had 50-50 custody of the teen and continued to squabble, sometimes in front of her.

The environments at her mother’s and father’s homes were opposite. The only communication she received from her father involved correction or discipline. His home had much stricter expectations around behaviors and schedules than her mother’s home did, and the client also had stepsibling relationships to navigate at her father’s home. Because the client’s friends lived closer to her mother’s home, she had more opportunity and freedom to connect with her peers when staying with her mother.

The teen was “upside down” on whom she could trust, Fowler recalls. She was exhibiting attention-seeking behaviors online and had been hospitalized for suicidal ideation before Fowler’s work with her. 

Fowler took a different approach from the teen’s previous therapist, who had not involved the parents in the counseling sessions. Fowler focused on rewriting the parent-child and parent-to-parent communication and response patterns that had become unhealthy. She also invited the client’s mother, father and stepmother into counseling, first in a group session without the client and later with one of the adults in sessions with the client.

Fowler used emotionally focused therapy with the teen to help her learn to explain what she was feeling to her parents. The method focuses on exploring primary emotions and practicing communication of those emotions in a way that the client’s attachment figure can receive, Fowler explains. By helping the client share — and the parents truly hear what she was saying — the mother and father were better able to understand the seriousness of their daughter’s depression and the impact their discord was having on her. This experience also tapped into her father’s empathy and allowed him to put his anger aside, Fowler recalls.

Fowler also worked with the adults on how to respond to their daughter in helpful and supportive ways. “I explained that [she] is looking for support and safety and is not feeling loved or feeling approved, so she’s looking for it elsewhere,” Fowler says.

The parents agreed to stop arguing in front of the teen, and the father had a change of heart and began to plan activities to be able to spend time with his daughter in a positive way. Within months, the teen was feeling much better, and her self-harm behaviors and suicidal ideation dissipated, Fowler says. Although her parents still have to monitor her cell phone use, the client’s situation has greatly improved.

“All of that contention, seemingly overnight, went away,” Fowler says. “I know that the changes that the parents made were a huge factor in helping the child.”

It “took some convincing” for the father to change, Fowler recalls. His frustration toward his daughter stemmed from feeling that she was being unsafe online and making herself available to strange men. Ultimately, Fowler used those feelings as leverage to explain that he had a chance to be the safe man in his daughter’s life.

“That was the window that helped him see … [and] understand how he had the opportunity [to make] his daughter feel loved,” Fowler says. 

Setting boundaries

Boundary setting is one of the most important coping mechanisms a counselor can provide to clients who are surrounded by unhealthy patterns. Even though clients cannot control a loved one’s behavior, they can control the boundaries they choose to establish in the relationship, Ohlund notes. This work must be client led and will look different for each person, based on their preferences and needs.

Exploration of boundaries is best done in session when the environment is calm — before the client needs to confront a loved one in the heat of the moment. Clients should not set a boundary until they are comfortable enforcing it, Ohlund stresses. The counselor and client should also talk through what it will feel like to enforce the boundary, including understanding and preparing for the possibility that it may make the other person feel worse, including triggering anxiety or feelings of abandonment.

Sometimes people may not understand these new boundaries. “Those who benefit from not having boundaries won’t want to deal with what’s going on with them and are going to fight it a lot,” Ohlund points out.

Ohlund often works with clients to establish boundaries that have stages that are customizable if or when a situation arises. For example, if a client has a spouse or family member who is prone to critical or angry outbursts, the first step might be for the client to leave the room or go to another part of the house. If the behavior continues, the client could leave the house for a brief time. Similarly, they could choose to temporarily block the phone number of a family member who is prone to sending a barrage of text messages when that person is upset.

“This is much better than just asking them to stop. What will you do when [the behavior] doesn’t stop? We have to set a boundary that we have control over so we don’t get sucked in or pulled in,” she says. 

Ohlund once had a client whose mother did not approve of some of the ways he and his partner chose to parent their children. She would repeatedly overstep her bounds and impose her opinions on the children. The situation pitted the client’s children against him, Ohlund says.

The mother continued the behavior even though her son spoke with her about it multiple times. Eventually, with Ohlund’s support, he set a boundary that if his mother continued to disparage his parenting style to his children, he would cut off his family’s contact with her for one month.

The mother did not stop her behavior, so the client followed through and cut off contact. During that time, his mother criticized him to other members of their extended family. “He knew it was the right decision, even though it was tough,” Ohlund says. “Eventually, the mom did come around, although it took a considerable amount of time to come to that point.”

This client’s decision to hold firm to his boundary resulted in a positive outcome, but that isn’t always the case. Sometimes people don’t agree with the boundary, which can create a disconnect or distance in the relationship, Ohlund says. “The reality is that [people] don’t have control over whether someone else is going to respond or not respond. It can be very disheartening and something to grieve and think of as a loss. It’s something you are working very hard on, but it’s out of your control,” she notes.

Collier stresses that the goal of boundary setting should be to guide clients to find what’s best for their own mental health, based on their principles. It also involves reflecting on what has and hasn’t worked in the past.

“The goal is not to get the [other] person to change. That’s very important [to understand]. If you are doing something out of your own principle, then it doesn’t matter how the other person responds. You want to say it to them not because it will help them or prompt change but because it’s your principle. It will only work when the [client] has done their own principled thinking,” Collier says. She advises counselors to ask good questions and stay out of the client’s emotional process: “Don’t jump in and become involved in [a client’s] emotions. Just get them thinking about ways to do things differently.”

Lucci agrees that effective boundaries must be rooted in a client’s values. Part of this process may involve having a wider conversation on what the client’s relationship standards are, including what they want out of the relationship and what they feel is required to continue the relationship.

“Setting boundaries can be extremely uncomfortable for people, and that’s why I emphasize that [boundaries] continually change and can be adjusted,” Lucci says. “[This process] is not one session. It’s a very slow process, and it’s adjust, adjust, adjust.”

Clients who are working to establish boundaries may find it helpful to practice the necessary conversations with a counselor before initiating them with loved ones. For example, what might it feel like not to respond to a text from that person? Collier notes that a counselor can talk this scenario through with a client, acknowledge how hard it will be and assess whether it feels like the right thing to do. “Know that there is going to be an uncomfortableness; saying no is going to be hard,” Collier acknowledges. 

It may also be helpful to focus on communication techniques with these clients, including how to bring up sensitive or triggering topics with a loved one in a nondefensive way, Lucci adds. Counselors and clients can practice taking in comments and information from loved ones and then expressing themselves without spurring debate or becoming defensive. In this vein, Lucci sometimes encourages clients to write a dialogue down and read it back to her in session.

“It’s natural to get really anxious about these conversations, and a counselor can help alleviate some of that anxiety by preparing [with the client],” Lucci explains. She asks clients what the goal of the conversation is and how they want to approach it. “It’s really important to listen to what the client wants,” she says. “I want the client to feel empowered and have knowledge, but ultimately it’s their own decision” regarding how to handle the situation.

The counselor’s role

Counselors play an important role in helping clients whose mental health is negatively affected by the toxic patterns of others in their lives. These patterns may indicate that the other person needs counseling themselves, but first and foremost, the counselor’s ethical duty is to help their client, regardless of whether it is appropriate or possible to involve family members or others in their counseling sessions. (An important caveat is when counselors take measures to protect clients from “serious and foreseeable harm.” See Standard B.2.a. of the 2014 ACA Code of Ethics.)

“It’s not ever my job to diagnose someone I don’t know and those who aren’t a client of mine,” Lucci says. “But I can listen and hear the behaviors described by the client and how it’s affecting them. Then, we focus on how [the client] can deal with those behaviors. I don’t ever want to assume how someone is feeling or what’s going on. … Most of all, I want people to feel connected and come to decisions about change on their own.”

Counselors can also equip clients in these situations with resources and serve as support while they decide what they want the relationship to look like, Ohlund adds. But this work will take patience on the part of the counselor, she notes.

“As a counselor, sometimes we can see really far ahead. We can see really clearly what needs to be done in a situation, but it may take a client a very long time to get there,” Ohlund says. “Sometimes it’s easy to feel frustrated: Why can’t they see [it]? Why do they keep these patterns?” 

She advises counselors to be patient and not feel like they are doing things wrong. Instead, “be assured that you’re doing all you can to support a client, and that’s what they need — they may have never had that in their life,” she says.

Similarly, Collier feels her role is to sit with clients and ask questions to help them explore emotions and come to realizations about their situation. Her focus is on the process rather than the symptoms that bring clients into counseling. “I’m interested in how the person is thinking about the problem and the challenge, what has worked and what hasn’t worked, what they’ve tried and how they understand it,” Collier says.

Counselors also need to work through relationship struggles in their own lives to better support clients who are seeking help for similar issues, Collier stresses.

“The client’s ability to change and really think about their situation is only going to be as good as that person who is sitting in the room with them and their ability to see and think about situations,” Collier says. “Our level of maturity lends itself to what will really help a person, and that comes from really examining relationships and patterns in our own lives. That is above and beyond any technique or anything that I can do with a client. We all have problems in our own lives and our relationships, and we need to work on those so we can help clients and think objectively.”

 

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

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