Monthly Archives: February 2013

Who are you? Who, who, who, who?

Bradley T. Erford February 28, 2013

Bradley-TThe Who, performing “Who Are You?,” was playing in my head this morning. The song was released in 1978 but easily could have been inspired by the events of 1964, when the band transformed its identity and went through four name changes in a single year: from The Detours to The Who to The High Numbers before finally returning to and etching the identity of The Who in history.

We are all familiar with Erik Erikson’s fifth stage: identity vs. role confusion. Normally in adolescence, people develop a personal identity and cogent sense of self, usually after much experimentation with different roles, behaviors and activities, and no small amount of soul searching. We all strive to gain direction in life and fit somehow into society, even if we find that “fit” by acting against society. We are told that if we receive encouragement and reinforcement throughout our exploration, we are likely to emerge with a strong identity; confusion and insecurity await those unsure of their beliefs and mission. What is sometimes lost in the discussion is that identity — knowing who you are — is a critical precursor to the future tasks of intimacy, generativity and integrity. Thus, a strong identity is critical to a meaningful and productive life and career.

This month’s Counseling Today cover story focuses on professional identity — a topic I believe is perhaps THE critical professional issue of our time. Who we are as professional counselors today is very different than who we were 35 years ago (before licensure), 65 years ago (before ACA) and 100 years ago (when the counseling profession was born).

We all come from diverse cultural and experiential backgrounds, and we draw strength from this diversity, both singly as individual counselors and collectively as a profession. How each of us got here is like a confluence of small streams flowing into what is now a major river of the counseling profession. Our past shapes our future and how we make sense of the present.

I majored in biology as an undergraduate. Yes, my mother got a deathbed promise that I would become a doctor (she just didn’t say what kind of doctor). I still remember the class discussions concerning how biological systems are defined and operate. A viable system must establish and maintain a clear boundary to protect itself from harm. But the system’s boundary must also remain permeable to outside influences so that it can exchange substances needed for growth and survival. If the system becomes rigid and impermeable, it will atrophy and eventually die. The counseling profession is a system, and we need to remain permeable to outside influences to thrive, even while protecting ourselves from harm.

At the core of our professional identity are specialized educational standards, knowledge and training in a number of essential areas. Our core principles are focused on wellness and strengths so that our clients and students not only become “not sick,” but also actually become healthy and thrive. These core principles, among others, form our identity as professional counselors.

Growing pains inevitably will occur, but there is a reason why they are called growing pains — we are growing and developing, becoming different and better than we were. In just the past few years, we have wrestled with and are still in the process of overcoming a number of developmental challenges, including requiring all core faculty in CACREP-accredited counseling programs to have degrees in counselor education, standardizing counseling degree programs by moving to 60 credits for all CACREP-accredited master’s degree programs, viewing school counselors as counselors who practice in educational settings rather than educators who have specialized counselor training, and requiring supervision of counselors-in-training by professional counselors (credentialed supervisors). Years from now, these practices will have become so woven into the fabric of our professional identity that we will question what took us so long to adopt them. And 35 years from now, after facing many more challenges and growing pains, we will be in a very different place and share a more unified identity and advocacy voice.

Given our professional focus on human development, I have recently wondered why we do not have an overriding stage theory or task model of professional counselor identity — a theory or model to help us explain how to promote and attain a unified identity, and perhaps stave off “multiple professional identity disorder.” Certainly such a theory would espouse a common core of educational and training standards, attainment of appropriate licensure and certification, and participation in professional counseling associations. Although these components all exist today and are paving the road to a more unified profession in the future, a great number of challenges still exist, and some backsliding is sure to occur.

For example, I recently wrote a letter to the 2016 CACREP Standards Revision Committee. Among other issues, I asked the committee to reinsert what seems like a minor clause, but one with vast implications for professional identity. The revised standard requires that “faculty must identify with the counseling profession through sustained memberships in professional counseling organizations.” The previous standard inserted the parenthetical phrase “… through memberships in professional organizations (i.e., ACA and/or its divisions).” Removal of that phrase would certainly lead back to “multiple professional identity disorder.”

But if we really want to have an impact on future generations of professional counselors and build a unified profession, accrediting bodies and universities must require counselors-in-training to participate in professional counseling associations. In a recent “round” at an ACA Governing Council meeting, a question was posed: How did you become involved with ACA? No less than 90 percent of us responded that we were “told” to join ACA by our graduate faculty. We had a firm professional counselor identity because our faculty and mentors had firm professional counselor identities. So, I also requested that CACREP establish a standard requiring graduate counseling students to identify with the counseling profession through sustained memberships in professional counseling organizations (i.e., ACA and/or its divisions). Exposing all of our counselors-in-training to the world of the professional counselor would be a giant step toward a unified professional counselor identity. The current reality is that most counselors-in-training do not belong to a professional counseling association. That is troubling.

A larger question is how we develop and maintain an appropriate professional identity (boundary) while still benefiting from the input and strengths of our interprofessional colleagues (permeability). After all, we share the same literature, have similar training standards and often receive similar supervision. But will we, as a counseling profession, mirror the mistakes of other mental health professions that seek to create impermeable barriers between professional groups? That seek to restrict counselor practice through legislation and regulations?

No one knows for sure what the future holds, but just as our appreciation for classic rock has matured, so will the counseling profession mature … over the next 35, 65 and even 100 years. But for now, enjoy reading this month’s feature articles and answer this question: Who are you?

The counseling profession really wants to know!

Sample article 3

Knowledge Share

By Rebecca Heselmeyer & Eric W. Cowan

Understanding bulimic dissociation to create new pathways for change

Given the extensive research on eating disorders, motivated clients and a gold standard treatment — cognitive behavior therapy — it is perplexing that recidivism rates remain so high for bulimia. It behooves us as counselors to investigate possible hindrances to effective treatment and adjust our approach accordingly for those clients with bulimia who have not achieved long-term resolution. It is notable that, despite the substantial evidence linking dissociation and bulimia, many counselors remain unaware of this connection. Further, the nature of the relationship has not been sufficiently explored. In this article, we apply principles from self-psychology to bulimic dissociation and use this new understanding to inform clinical practice.

When I (Rebecca) first met Sonya, she sat across from me tearfully expressing the shame she felt about her binging and purging and the feeling of defeat she experienced from failed efforts: to stop thinking about food, to stop scrutinizing her body, to stop mindlessly gorging on food and then rushing to vomit. Sonya presented as many clients with bulimia do — she expressed a desire to change and a willingness to try whatever therapeutic assignments I may assign to her. Rather than engage with her in familiar and expected territory by focusing on food (nutrition, food journals and so on), I turned my attention to a different part of Sonya’s experience, inviting into our conversation the part of her identity that up until then had likely been unacknowledged and invalidated repeatedly. We have labeled this the dissociated bulimia identity (DBI). To explain our reasoning for yet another coined term with a nifty initialism, let’s shift gears and look at the underlining theory.

Self-psychology and the vertical split

Heinz Kohut proposed that children need specific interactions and feedback from caregivers to formulate cohesive, integrated selves. An important part of this process involves mirroring, in which caregivers demonstrate accurate, empathic affective attunement with the child. For example, a child may cry out upon seeing shadows in a dark bedroom at night. An attuned care provider might respond by giving language to what the child is experiencing (“You are afraid”) and comforting the child. Through such interactions, the child not only learns language for his or her affective state, but also learns that he or she can be afraid and still be loved. Gradually, with additional interactions in which the caregiver reflects the child’s fear in a nurturing manner, this affective state becomes identified and integrated into the child’s sense of self.

Assuming the care provider responds to the multitude of emotional experiences with validating, reflective attunement, the self then develops into a cohesive being where all affective states — love, joy, fear, grief, discouragement, excitement, loneliness and so on — have an identified and accepted place. The child has been welcomed into the world of shared meanings and connections and has formed a cohesive sense of self composed of, to use Harry Stack Sullivan’s language, “reflected appraisals.” Further, the process that enables identification and integration also teaches the child about self-care; the nurturing and soothing interactions with the caregiver over time become internalized so that the child develops the ability to self-soothe and manage emotional experiences without relying on the caregiver’s presence.

Now imagine the same child in the frightening, dark bedroom, crying out at the lurking shadows. In this house, the caregiver responds with taunts, calling the child a scaredy-cat and snapping at her to go back to sleep “or else.” Continued interactions of this nature also identify the affective state while invalidating the experience of it. The child is taught that fear is not allowed and is shamed for experiencing it. There is no comforting hug or lullaby to internalize; there is only the message of rejection. There is a disconnect between the child and others, which results in a parallel disconnect from internal thoughts and feelings. Dependence on the caregiver is crucial for survival, so anything that might threaten this relationship is sacrificed. Consequently, affective states met with invalidation become disavowed and denied integration into the “socially acceptable self.” But where do these affective states go?

Kohut proposed that lack of adequate and empathic mirroring results in a “vertical split” — a metaphor for the partition between self-experiences integrated into the “normal” self and disavowed affects and frustrated developmental needs. Repression can be understood as a horizontal split, with unconscious desires tucked away deep in the psyche and blocked from the rest of the aware mind and body. The vertical split, on the other hand, designates a chasm between selves: the integrated affects and being states that were met with empathic mirroring and those that were sacrificed in an attempt to maintain the essential relationship with primary caregivers.

Therefore, validated affective states become integrated into the normal, socially acceptable self, while invalidated affective states are sequestered on the other side of the split, forming the unacknowledged, rogue DBI. Acknowledging this part of the self-experience has been deemed threatening and forbidden. Perhaps more important, the child never learns to effectively acknowledge, self-soothe and manage this part of self-experience. Needless to say, mere ignoring cannot relieve the emotional demands of loneliness, lust, anger, guilt, despair and other feelings. When the DBI demands attention, the now-adult client may address it in the one way she or he knows how — with food.

Media teach us time and again that food is a source of comfort, pleasure and love. The absurdity of media campaigns goes so far as to sexualize food. Jean Kilbourne, in her “Killing Us Softly” lectures, observes the potency of a variety of media messages, including ones that offer food as a substitute for relationships. Food is also culturally anchored in our experiences: family gatherings, celebrations and times of mourning. Our bodies respond physically and physiologically to eating. In the most basic sense, food literally fills a void within us. Binging provides momentary relief and escape, and the process at work is twofold.

Dissociative symptoms are present throughout the binge-purge cycle, with peaks occurring during the binge and immediately after the binge. Dissociation is commonly thought of as an escape from painful psychological experiences. Dissociative symptoms are on a continuum ranging from minor alterations in perceptual functioning to significant disruptions, such as a dissociative fugue. The dissociation associated with bulimia is primarily categorized as mild to moderate. Clients may feel out of control or have a detached experience of watching themselves binge.

Let’s explore the dual process at play, using Sonya as an example.

Dissociation, revisited

Sonya would often report the quick onset of the urge to binge. As she began, her feelings of disconnectedness and lack of control grew, enabling her to eat beyond capacity by blunting both the physical and emotional discomfort she would otherwise experience. Psychologically, the dissociative symptoms she experienced also provided temporary relief from the triggering affective state. At the same time, the dissociative experience allowed Sonya to “jump” the vertical split and access the very region housing the unmet need that was triggering the binge — in her case, a deep sense of helplessness. This dis-integrated part of her self-experience that was reproached during her development has shown up in her adult life, but she lacks the ability to effectively identify, manage and attend to it.

The binge-purge behavior brings with it dissociative processes that temporarily provide Sonya with both an escape from pain and access to the region where she can acknowledge and soothe that otherwise denied self-aspect. The function of dissociation is to “escape” to a very specific and important place: her DBI. In other words, while Sonya is desperately (and ineffectively) seeking physical comforts, her psychological self is likewise seeking to self-soothe the neglected and needy DBI. She is momentarily allowed access to this outlawed part of the self and can attend to the very real need for nurturing and validation.

With the conclusion of the binge also comes the conclusion of dissociative symptoms. Sonya becomes more aware of her physical self — and simultaneously is returning to her socially acceptable, normal psychological self — and is swept by feelings of shame and guilt. Physically she feels great discomfort and embarrassment at the quantity of food she has consumed, while psychologically she has trespassed to visit and comfort the forbidden DBI. She has broken the rules — physically by food consumption and psychologically by traversing the vertical split. Guilt reigns supreme, and she purges to expunge herself of the harm done.

Through this lens, the functionality of the binge-purge behavior and dissociation can be seen as the client’s best effort to attend to a disorganized self-experience. For many clients, including Sonya, bulimia is a clinical presentation that, at its core, is a disorder of self rather than being fundamentally rooted in body image concerns. The clients’ repeated attempts at self-care through the use of food fail because the core unmet developmental needs are never brought out of exile and given their rightful place in the integrated “normal” self. Symptom-focused counseling that serves largely as behavior management — food journals, nutritionists, love-my-body activities — prove ineffective for these clients because there is no room for the underlying disorder of self to emerge in the therapeutic dialogue. For this to happen, there needs to be a shift in the counseling mindset and conversation.

Clinical applications

If I had partnered solely with Sonya’s desire to extinguish her bulimic behaviors, I would also have partnered solely with her “socially acceptable” self  — that part of her that genuinely does want to stop binging and purging. Concurrently, I would have communicated to her that her DBI was not welcome.

The DBI relies on the function of her behaviors for much-needed psychological care, so there is likely a very substantial part of Sonya that wants to binge and purge and has no intention of giving this up. Focusing the counseling conversation on ways to extinguish and change behavior, without also addressing the purpose of the behavior and offering an alternate way of accomplishing the function, invalidates the part of the client’s experience that appreciates and needs the behavior. If approached in this manner, the client’s DBI is likely to “go into hiding” for fear that successful counseling will result in its extinction (rather than integration). In effect, this guarantees an unsuccessful long-term counseling outcome.

Instead, I invited Sonya to tell me about the part of her that wants to binge and purge. This is a potentially shame-laden and socially ostracized part of Sonya’s being, so it is important for me to seek it out and welcome it rather than assume it will enter the therapeutic dialogue without active and sometimes repeated invitation. Counselors need to provide an experience in which all parts of the client’s experience — both the desire to cease behavior and the desire to maintain it — are welcomed and validated. We encourage counselors to address the DBI directly (“Tell me about the part of you that needs to keep doing this”) or by using third-person language (“Tell me about her — the part of you that defies your attempts to control her”). In addition, use language that demonstrates an appreciation for the adaptive function of bulimia that is, in a sense, trying to help.

Occasionally it may serve as a powerful paradoxical intervention for the counselor to urge the client not to give up the binge-purge behavior too quickly. Clearly this intervention is not appropriate when working with clients who have significant health risks. But for clients in relative physical good health, and especially for those who have had extensive counseling, an intervention of this sort likely will be unexpected and get beyond psychological resistance by “siding” with the DBI against the socially conforming self. You can observe to clients how cruel they are to their bulimic selves when they use disparaging language (“I’m such a fatso loser when I binge”).

Once it is established in the therapeutic dialogue that all parts of the client’s experience are welcomed and validated, new pathways for healing can emerge because the client, with the counselor’s support, can begin to acknowledge and express the frustrated developmental needs that are the driving force behind the bulimic behavior. An important part of this approach is keeping the therapeutic conversation focused on the client’s inner world of needs, feelings and thoughts, particularly those that are outside the client’s normal experience, so the client can expand self-reflective awareness.

Once clients gain insight into the role their bulimia has served in managing emotions and needs, a powerful experiential process unfolds as the counselor provides the empathic mirroring response that was previously withheld during the client’s childhood development. Counseling provides the repeated, accurate, empathic attunement that the client’s caregivers failed to supply. Just as over time the child internalizes the caregiver’s ability to soothe and comfort, the client’s new awareness of emotional triggers, coupled with the empathic, attuned response from the counselor, allows the client an opportunity to begin addressing and meeting her or his needs in a new, direct way. The ongoing process of welcoming the formerly forbidden self-experiences into the counseling relationship gradually breaks through the wall of the vertical split, allowing a merging of selves into a now fully integrated self. As this happens, the need for bulimic behaviors diminishes and, without a purpose, the behaviors eventually cease.

Similar to the experiences of other clients, the turning point for Sonya came when she felt at liberty to speak about the part of her that could not imagine life without binging and purging. Gradually, Sonya’s sense of inner connectedness and connection with others grew, and she became skillful at recognizing her emotional needs and attending to them in healthy ways. Her binging and purging has subsequently tapered.

We hope you will find this conceptualization and the suggested techniques enriching to your counseling practice.

 

“Knowledge Share” articles are based on sessions presented at American Counseling Association Conferences.

Rebecca Heselmeyer is a staff counselor in residence at the James Madison University (JMU) Counseling and Student Development Center, adjunct instructor for the JMU Counseling Programs and a member of the Rockingham Memorial Hospital Psychiatric Emergency Team. Contact her at heselmrj@jmu.edu.

Eric W. Cowan is a professor in the Department of Counseling and Graduate Psychology at James Madison University and the author of Ariadne’s Thread: Case Studies in the Therapeutic Relationship. Contact him at cowanwe@jmu.edu.

Letters to the editor: ct@counseling.org

Sample article 2

Reader Viewpoint

By Kim Johancen-Walt

The initial interview with the self-harming and suicidal client

Deidre, age 24, had agreed to see me after confiding to a close friend that she was thinking about killing herself. During our first session, she discussed how self-mutilation and an eating disorder had allowed her brief moments of relief from isolation and self-hatred. Diedre had been self-harming for more than 10 years and, although her behaviors had helped her survive unbearable emotional pain, she had become increasingly hopeless, desperate and suicidal.

As a licensed professional counselor and therapist working with clients who are suicidal, self-harming or engaged in both behaviors simultaneously, I have learned the importance of the initial interview. So many of our clients, like Diedre, have been doing the best they can, yet still feel caught in a landslide with suicide rolling toward them. During this first critical meeting, counselors need to create an environment that will become a therapeutic foundation communicating hope and connectedness to a caring other and nurturing a commitment to treatment.

Counselors working with this population must assess lethality (throughout treatment) while also targeting the painful thoughts and feelings fueling the client’s potentially life-threatening behavior. Through my research, experience and constant search for more effective treatment, I have created a model that allows the counselor a vehicle to accomplish these tasks effectively from the very first interaction. It blends strategies with assessment tools to create a therapeutic space in which change can happen for even the most difficult of clients. Here, I offer an overview of the three stages that have guided treatment for my clients, helping them achieve success in their efforts to create lives worth living.

Stage 1: Creating safety

One of my clients recently likened counseling to a living, breathing diary, with the added benefit that a counselor can offer support and sound advice. We have to embody that kind of safe container for the vulnerable individuals we are treating. As my clients begin telling me their stories of self-harm and survival, I offer my belief that people do not engage in these behaviors without reason. Our clients are hurting themselves or wanting to kill themselves because they are desperate to end their emotional suffering. Through understanding and accepting their behavior, we can directly target feelings of shame and isolation that may be keeping our clients chained and silent. Regardless of their behaviors, it is important to remind our clients that they are doing the best they can and that their lives are worth saving.

Many therapists focus on behavior instead of asking questions about the painful feelings fueling that behavior. It is of utmost importance, of course, to find out if clients’ actions are putting their lives at risk, but if we are interested solely in the behavior, we will find ourselves only treating symptoms. In our efforts to help clients feel safe and understood, it is important to ask them why they are self-harming or suicidal. Many of my clients have had their self-esteem and sense of self-worth shredded through a variety of traumas. In these instances, the need to punish themselves for their perceived flaws may be fueling their self-harming and suicidal behavior.

Samantha, age 18, had become suicidal after experiencing sustained trauma while growing up with an emotionally and physically abusive mother. These experiences led Samantha down a road lined with isolation, rage and self-hatred. In a desperate attempt to end her emotional pain, she found herself with a knife in her hand and a desire to slit her own throat. Thankfully, Samantha did not kill herself, but she was obviously drowning in unbearable emotional pain. By focusing on what had fed this suicidal gesture, she was able to resolve many of her issues and was no longer suicidal. She left therapy soon after with her prevention strategy plan firmly in place.

As the story of my client’s unique and painful journey unfolds, I am diligent about checking in repeatedly during the interview to ensure that the client is feeling safe and accepted. Furthermore, I request that the client correct me if at any point I miss or misinterpret any part of the story. This type of questioning creates a collaborative environment in which the client feels like her/his input is an important part of the process. Matthew Selekman, a respected therapist and internationally published author, discusses how this approach can be richly therapeutic because it makes clients an active participant in their treatment and takes the therapist out of the “expert” role.

Stage 2: Assessing risk of suicide

After a sense of safety has been established and the counselor has communicated the critical role that the client plays in her/his own treatment, it is imperative to assess the client’s level of risk for life-threatening behavior. Jack Klott, a therapist with more than 40 years of experience working with this population, explains that clients who are talking about suicide are ambivalent. This ambivalence leads them to talk about the part of them that wants to live and the part of them that wants to die.

These discussions offer the counselor a wealth of information about what is keeping the client alive while also supplying details about the irrational belief systems that may be leading the client toward attempting suicide. Cognitive restructuring techniques can be extremely effective in these situations, allowing the counselor an opportunity to challenge the client’s irrational thoughts and beliefs.

Victoria, 19, was in my office describing an incident in which she had contemplated hanging herself. A survivor of child sexual abuse and incest, she discussed what led her to this moment of crisis, including the irrational belief that her life would be “better” if she were dead. Through flowing tears and rapid speech that conveyed her need to release the story and the pain attached to it, she recounted how she had tied the sheet around her neck but decided not to commit suicide at the final moment. When I asked her about this life-saving decision, she shared how thoughts of her nieces and nephews had kept her from completing her suicide attempt.

While discussing what was keeping Victoria alive, I was also able to challenge the belief that her life would be better if she killed herself. We talked about the skills Victoria had used to stand up to suicide since this incident. She explained that, at times, focusing on a future career as a doctor helped her stand up to suicidal urges; other times, it was the memory of that day with the bedsheet that reminded her of her strength to survive.

Throughout my career, I have compiled a list of the factors that most commonly heighten clients’ risk level for suicide. For example, although it is a myth that all clients who are self-harming or suicidal have been sexually abused, it is important to note that 12 out of the 14 suicidal high school students I worked with last year reported previous sexual trauma. Other common risk factors include overwhelming feelings of rage, isolation and hopelessness. Clients who have not resolved issues surrounding previous suicide attempts are also at risk of completion. Obviously, the more red flags our clients present to us in treatment, the more at risk they are for life-threatening behavior. According to Anne Marie Albano, director of the Columbia University Clinic for Anxiety and Related Disorders, adolescents who have an untreated anxiety disorder at age 13 are also more at risk for depression by age 15. Add to that a substance abuse disorder, and you have a client who is at a heightened risk for suicide.

Stage 3: Identify strengths and resiliencies

One of the purposes of the assessment interview is to gather information about the level of risk facing our clients. It can also be a valuable therapeutic experience that immediately targets feelings of hopelessness and isolation. By offering our clients a belief that they have the answers and solutions to their problems, we are encouraging them to focus on their ability to overcome and survive.

Tess, 21, had previous success standing up to the shame and isolation associated with an eating disorder. In therapy, we explored how she had “pulled this off” in the past by focusing on her long-term goals (graduating from college) and through her daily practice of mindfulness techniques. We also discussed ways Tess could transfer her previous successes to new crises as they arose.

By encouraging our clients to look at themselves through this solution-driven lens, we communicate faith in their ability to stand up to self-harm and suicide. It is critical that we begin this process at the beginning of treatment because so many of them are coming to our offices feeling isolated and hopeless and in some cases, have had several failed treatment attempts. Many of these clients are becoming increasingly suicidal.

Lisa, 18, came to therapy feeling gradually more suicidal. She had a history of significant substance abuse, bulimia and cutting, and she had walked up to the edge of a busy highway in Denver one hopeless night with thoughts of stepping out into traffic. Lisa was quickly spiraling downward and had become increasingly depressed and withdrawn. During our initial meeting, we talked about how in spite of incredible suffering, Lisa had successfully stood up to many of these behaviors. We talked about her inherent strength and her determination to find meaningful connection with others. Subsequent treatment included validating pain associated with previous trauma, tending seeds of change and identifying the skills and strengths Lisa had used to confront so many challenges in her 18 years of life.

By offering our clients a powerful experience during the initial interview, we can help them uncover the path to hope and recovery. Counselors can use the assessment model discussed in this article in many ways, because that is the dance of therapy. But if the counselor keeps the elements of this model in mind from the very first interview, then therapy can be a collaborative experience that allows us a deeper look into the client’s world. It can also become a protected space for clients to explore and find the ground beneath their feet as they continue their journey toward a life worth living.

 

Kim Johancen-Walt is an ACA-member licensed professional counselor and consultant living in Durango, Colo. In addition to maintaining a private practice, she is a counselor and assistant training director at Fort Lewis College, where she helps train therapists working with high-risk young adults. Contact her at johancenwaltks@gmail.com.

Letters to the editor: ct@counseling.org

Sample article 1

Helping clients find happiness

By Mike Hovancsek

Back when I was in my 20s, I knew a guy named Roger who hung wallpaper for a living. The one thing I remember about Roger is that he was always happy. I would often see him on worksites, zipping around with a bounce in his step, singing gleefully under his breath and generally annoying everyone around him with his positive outlook.

I felt puzzled by Roger. I knew that if I had to hang wallpaper six days a week, I would be pretty miserable. I couldn’t imagine how anyone could possibly get any joy from working at such a mind-numbing job.

Eventually, I decided I was going to figure out what made Roger tick. So I asked him, “If you could do anything in the world, what would you do?”

Without any hesitation Roger answered, “I would go to Hawaii … and hang wallpaper!”

“But how would you even know you were in Hawaii?” I protested. “You would be stuck inside looking at wallpaper all day.”

“But I would be in Hawaii,” Roger said with a tone that fell somewhere between pity and disbelief. In that moment, I realized Roger was as confused by my ignorance as I was by his happiness.

My conversation with Roger reminded me that I shouldn’t judge other people’s happiness according to the things that make me happy. This was when I began to realize that happiness is a complex and highly personal issue.

As Americans, we spend a lot of time worrying about whether we are happy and whether we are happy enough. There are reasons to be wary of this pursuit. As the 19th century philosopher John Stewart Mill once said, “Ask yourself whether you are happy, and you cease to be so.”

Certainly, as counselors, we can think of examples of people who harmed their lives by recklessly seeking happiness. Our waiting rooms are full of people who have tangled themselves into addiction, debt and unhealthy relationships in the search for happiness.

The reality is that as human beings, we are blessed with a wide range of emotions that serve us in many ways. We need to experience a variety of emotions to efficiently store information, retrieve information and respond properly to our environment. In fact, discontent is a wonderful motivator. Would we seek out food if we didn’t get hungry? Would we seek out more knowledge if we were content with the knowledge we already had? The truth is, if we were happy all the time, we would stop growing, learning and striving for our own self-preservation.

In his Communist Manifesto, Karl Marx warns that in a capitalist society, people can become willingly enslaved by the pursuit of material comforts. He hypothesized that people would work long hours to make money so they could pay off all their material goods, effectively becoming slaves to their own debts. In a day and age when the average American works more hours than previous generations while also carrying thousands of dollars in credit card debt, it is hard to ignore Marx’s point.

In Brave New World, Aldous Huxley imagines a world in which perfect happiness is maintained through a regimen of behavioral control, genetic engineering, intense training and a synthetic drug called Soma. While Huxley’s book is fiction, it bears an uncomfortable resemblance to modern life, in which the news is loaded with celebrity scandals and we are encouraged to pursue pharmaceutical answers to our common problems.

Americans have certainly sought out their own version of Huxley’s Soma. In his 2008 book, Comfortably Numb: How Psychiatry Is Medicating a Nation, Charles Barber reminds us that in 2006, the United States made up 66 percent of the global antidepressant market.

Why study happiness?

With all of those arguments in mind, why should we bother to study happiness? One reason is because its opposite, depression, is taking an increasingly heavy toll on society. As Martin Seligman points out in his book Authentic Happiness, “Depression is now 10 times as prevalent as it was in 1960, and it strikes at a much younger age.”

A 2001 report in Health and Medicine Week concluded that depression affects an estimated 17 million people in the United States each year. According to a 1996 report by the Centers for Disease Control and Prevention, the death rate from suicide remains higher than for Alzheimer’s, chronic liver disease, homicide, arteriosclerosis or hypertension.

Depression also has a significant economic impact. Consider the following.

• According to a 2004 World Health Organization study, major depressive disorder is the leading cause of disability in the United States for people between the ages of 15 and 44.

• A 2001 article in The Wall Street Journal concluded that depression among workers in the United States costs businesses about $70 billion annually in medical expenditures, lost productivity and related costs.

• A 1999 National Institute of Mental Health report concluded that $11 billion a year is lost as a result of workers who were less productive or made mistakes due to depression.

Recognizing the need for the study of happiness and healthy adjustment, Seligman pushed for the development of positive psychology. This is a massive shift in thinking. The field of psychology had spent much of the previous 100 years focusing on the things that were wrong with people. Sigmund Freud, for example, once stated that the best that can be hoped for in life is “the transformation of hysteric misery into common unhappiness.” For those who want more than “common unhappiness,” there is positive psychology.

People are surprisingly inaccurate at predicting their own happiness. In his 2007 book Stumbling on Happiness, Daniel Gilbert reports that we tend to make judgments about the future based on our current feelings and that we fail to take into account our ability to adjust. For example, we may predict that life would no longer be worth living if we were to become quadriplegic. Research suggests this conclusion is quite inaccurate. According to Seligman, “Of people with extreme quadriplegia, 84 percent consider their life to be average or above average.”

We also tend to assume that various things will make us happy even though research suggests that, in reality, they do not. For example, we may think we would be happy if we had more money. But Seligman reminds us, “Mounting over the last 40 years in every wealthy country on the globe, there has been a startling increase in depression.” He also cites studies which found that people who win the lottery tend to have a brief burst of happiness for an average of three months before returning to the baseline of happiness they experienced before winning the lottery.

Indeed, research has failed to show a significant correlation between happiness and material wealth once individuals reach a point where they have a place to live and a little something to eat. Similarly, research has been unable to find a correlation between happiness and attractiveness, happiness and health or happiness and popularity.

One important finding in positive psychology research: We often neglect the things in life that truly make us happy in the quest for things that we think will make us happy. We may, for example, neglect our family and friends to focus on getting a promotion at work. Soon after receiving the promotion, however, we return to the emotions we had prior to the promotion.

Everyday happiness

So, what actually makes people happy? Clients can use several different practices to find happiness in their everyday lives.

Have a sense of control

Daniel Nettle points out that people who have a strong sense of control in their lives report a significantly higher level of happiness than people who have a poor sense of control. As a result, clients are likely to benefit from shifting their focus away from the things they cannot control (for example, the behavior of other people or things that happened in the past) and toward things they can control (for example, changing their own behavior in a way that is likely to improve a bad situation). I often describe this to clients as shifting from a “victim” role to a “survivor” role.

Savor the small pleasures in everyday life

As Gilbert reminds us, “We are served more by frequency of happy events than by intensity of happy events.” This suggests that we don’t need to win the lottery to be happy; we just need to enjoy a lot of small pleasures in everyday life. Counselors might challenge their clients to write a list of simple, healthy pleasures in their lives and encourage them to commit to spending time being mindful with a few of those pleasures every day.

Practice positive cognitions

In Hamlet, Shakespeare writes, “There is nothing either good or bad, but thinking makes it so.” Indeed, anyone who has even a passing familiarity with cognitive therapy knows that the cognitions we choose to interpret our world have a profound effect on how we feel and act.

“Optimistic people tend to interpret their troubles as transient, controllable and specific to one situation,” according to Seligman. “Pessimistic people, in contrast, believe that their troubles last forever, undermine everything they do and are uncontrollable.” So encourage your clients to focus on the transient, controllable and situation-specific elements of their problems.

Recognize problems as opportunities for growth

Tal Ben-Shahar encourages his students to “Learn to fail or fail to learn.” I find myself using this phrase with clients on a regular basis. It challenges them to think about each problem as a learning tool rather than as proof that the world is a terrible place. When prompted, clients can almost always cite examples of past difficulties that have helped them to learn and grow. Recognizing this, they can view their current problems as one more opportunity for learning and growth.

Focus on gratitude

I often encourage clients to create a gratitude journal. I challenge them to spend a few evenings each week documenting things for which they are grateful in their lives. Once there is a journal to fill, clients will often go through their lives looking for things they can include. This exercise can change their perspective significantly.

Have a sense of attachment to others

In The American Paradox, David Myers states, “There are few stronger predictors of happiness than a close, nurturing, equitable, intimate, lifelong companionship with one’s best friend.” Clients can commit to spending more time with the people who are important to them. When clients report that they are not close to anyone, I suggest they write down a list of their interests. Then we look for the social manifestations of those interests. For example, if a person likes to read, he may want to join a book club. If a person likes animals, she can volunteer at the local animal shelter.

This principle extends to the larger community as well. In their 1998 article “Social Well-being,” Corey Lee M. Keyes and Shane Lopez reported that the degree to which a person is engaged in society is positively correlated with measures of happiness, generativity, optimism, life satisfaction and a sense of safety in one’s environment.

Have a sense of attachment to the universe

People tend to report more happiness when they have a sense of meaning and connection in their lives, whether it is their spirituality or through a secular sense of connection to humanity. As a result, clients are likely to benefit from redirecting their focus toward their own spiritual or humanist values.

Be altruistic

Research suggests that altruistic people are more likely to be happy, and happier people are more likely to be altruistic. Challenge clients to find charitable activities that are meaningful to them. This can get them engaged in their communities, give them a sense of purpose and shift their focus away from dwelling on their problems.

It is actually a lot of fun to help clients explore their own positive psychology. Most clients will have good results in a relatively short period of time by working these techniques into their daily lives. These skills are also a great form of self-care for professionals in the mental health field. Have fun!

 

Mike Hovancsek is an American Counseling Association member who runs a private practice in Stow, Ohio. He also offers presentations and workshops on a variety of subjects. Contact him at therapy@ohio.net.

Letters to the editor: ct@counseling.org

Writing guidelines for Counseling Today

 

The mission of Counseling Today is to serve individuals active in professional counseling — in schools, in universities, in the workplace and in the marketplace — as well as other citizens, community leaders and policymakers who appreciate the importance of the role of professional counselors in today’s society.

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