Monthly Archives: November 2017

Understanding adult ADHD

By Donna Mac November 20, 2017

Many people ask, “Isn’t ADHD something that kids grow out of?” When people think of attention-deficit/hyperactivity disorder (ADHD), they usually picture a child “bouncing off the walls” and then being unable to follow directions to stop that behavior.

In mainstream society, we don’t see adults bouncing off the walls, so it makes sense that people wonder if ADHD is something that is “grown out of.” In addition, ADHD usually isn’t diagnosed for the very first time during adulthood. Because the onset of ADHD typically is prior to age 4, it is usually first diagnosed in childhood. Therefore, people don’t tend to think of ADHD as an “adult condition.” Rather, they might assume that it’s isolated as a childhood condition.

It is important to remember that ADHD is actually a genetic condition. It affects the brain’s neurotransmitter system of dopamine and norepinephrine, brain waves and connections, and the actual structure of the brain, specifically the frontal lobe and prefrontal cortex, cerebral volume, caudate nucleus and gray matter/white matter. In addition, certain environmental factors can further exacerbate a person’s symptomology. Regardless, ADHD is actually a “brain condition,” which means that it can also affect adults.

Going back to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, there was a chapter that included mental health diagnoses that were all first diagnosed in “infancy, childhood or adolescence.” ADHD was one of the diagnoses included in that chapter. Therefore, some people figured those disorders were not likely found in adults. However, the chapter’s title didn’t specify that those disorders weren’t found in adults; rather, it indicated that they were typically first noticed in childhood.

When the fifth edition of the DSM (DSM-5) was written, the task force offered more clarification for those disorders, so that the entire chapter was actually eliminated and the diagnoses in that chapter displaced. Due to the revision, ADHD was moved to the new “Neurodevelopmental Disorders” chapter, to more accurately reflect that the disorder is related to the biology of the brain.

In writing the DSM-5’s revisions for ADHD, there was also a symptom threshold change for the adult qualifiers. The purpose of the change was to reflect the substantial evidence of clinically significant ADHD impairment in adults within social, occupational and educational settings, in addition to difficulties with maintaining daily living responsibilities. To qualify for an ADHD diagnosis according to the DSM-5, an adult needs to meet only five symptoms, instead of the six required for children, in either of the two presentations (hyperactive/impulsive and inattentive/disorganized).

 

Growing out of ADHD?

At this point, it has been well-established that adults can have ADHD, so the question now becomes: Is it possible for a child with ADHD to experience symptom reduction (or elimination) as he or she transitions to adulthood? The answer is tertiary: yes, no and sometimes!

As children with ADHD grow into adolescence, research does show that up to two-thirds will experience a noticeable reduction in motoric restlessness or hyperactivity. Because of the manner in which the brain develops during this period, there can be an opportunity for rewiring in which the neurons proliferate and then are pruned back to complete the development of the frontal lobes.

With this particular symptomology of hyperactivity and motoric restlessness being reduced or eliminated, however, it is still possible that the person’s other ADHD symptoms may remain. The remaining symptoms are likely the ADHD core symptoms of impulsivity, impaired attention and lack of intrinsic motivation. Research shows that these symptoms will likely continue to some degree — possibly still to a clinically significant degree — but they might also be less impairing than they were for the person during childhood.

So, to answer the question of whether adults can experience ADHD symptom reduction or elimination, here is a recap:

  • Some symptoms in adults will dissipate completely.
  • Some symptoms will lessen.
  • Some symptoms will remain the same.
  • Some symptoms will change by being expressed differently than they were in childhood.
  • Sometimes, the symptoms will remain, but they will appear less impairing because the adult has developed strategies to manage the symptoms.

As we examine how adult ADHD symptoms can be expressed, think about ADHD as a brain disorder stemming from an inability to self-regulate and executive functioning deficits. These functions allow us to plan, change flexibly from one course of action to another, inhibit actions (impulse control) and modulate affect. Executive functioning also includes organizational skills, emotional control, working memory and short-term memory, time estimation and time management, focus and attention, problem-solving, verbal reasoning, intrinsic motivation, task initiation and shifting gears. If a deficit is present in any of these areas, think about how much more difficult an already stressful job would be, in addition to how one might struggle with maintaining relationships, raising a family, completing daily living responsibilities and remaining connected in the community.

 

Childhood vs. adulthood scenarios

With all of the possible ADHD deficits stemming from its different presentations and with different degrees of impairment, these symptoms can be expressed in adults in a variety of ways. The scenarios below showcase how ADHD symptoms might remain similar in adulthood as in childhood, or how the symptoms’ expressions can also change over time.

  • Think about a child with ADHD constantly getting out of her seat at school. That can be the same adult tapping her pen or shaking her leg at her desk at work.
  • Think about a child with ADHD constantly talking to her “neighbor” in school while the teacher is talking. That might be the same adult unintentionally getting her co-workers off-task during a meeting.
  • Think about a child with ADHD impulsively pulling a toy out of another kid’s hand, struggling to take turns and share. That sounds like the same adult struggling to “take turns” while he is talking and expressing ideas with his co-workers.
  • Think about a child with ADHD refusing to shut off her video game. That might be the same adult finding it difficult to get off of her social media accounts.
  • Think about a child with ADHD unwilling to compromise with friends, always wanting his own way instead. That sounds like the same adult insisting his wife watch “his show” or listen to “his radio station.”
  • Think about a child with ADHD carelessly rushing through her trumpet scales (a dreaded, nonpreferred task) in an attempt to get to the preferred part of her trumpet practice sooner, which is playing the actual song. That could be the same adult at work, carelessly rushing through writing a report, to more quickly get to the things she actually enjoys doing at her job.
  • Think about a child with ADHD always trying to get away with doing less at school (maybe by not “showing” his required math work). That might be the same adult also trying to get away with doing less at his job.
  • Think about a child with ADHD being dragged out of bed and taking “forever” to get dressed, eat breakfast and groom herself. That may be the same adult constantly being late for work or other appointments.
  • Think about the bedroom of a child with ADHD looking like a tornado hit it. That could be the same adult whose wife is nagging him because his dirty laundry is all over the bedroom floor, or whose boss is upset with him because he presents poorly at work with a disorganized, messy desk.
  • Think about a child with ADHD incessantly begging her parents for something to obtain immediate gratification for herself: “Take me to the pool. Take me to the pool! Puh-Lease!” That sounds like the same adult refusing to take “no” for an answer in other social relationships.
  • Think about a child with ADHD disregarding minor details with his schoolwork. That could be the same adult overlooking “minor details” in other areas of life, such as neglecting to wear his identification badge at work, forgetting to check the “change oil on this date” sticker in his car or, worse, forgetting to check the gas tank.
  • Think about a child with ADHD struggling to get started with her chores at home. That can be the same adult struggling to initiate, sustain or complete daily living responsibilities at home. For example, she may buy groceries, get them home and put the items away in the kitchen. However, the items needing to be placed elsewhere in the house (shampoo, body wash, etc.) remain in the grocery bags on the kitchen counter. After her husband nags her for a day to put the rest of the items away, she eventually moves the grocery bags upstairs to the bathroom and places the bags on the bathroom counter. After her husband nags her another day, she eventually takes the items out of the bag and puts them under the bathroom cabinet.
  • Think about a child with ADHD climbing the drapes in a banquet hall at a wedding. That could be the same adult craving a dopamine rush as she is darting in and out of traffic at high rates of speed. Remember, when it comes to dopamine, people with ADHD either don’t produce enough, retain enough or transport it efficiently. Dopamine is a “feel good” neurotransmitter (in addition to being the main “focus” neurotransmitter), so when individuals are recklessly impulsive, they are likely feeling understimulated and attempting to stimulate their dopamine level to “feel good.”

However, people with ADHD can be notoriously impatient. In the driving scenario above, it may not be about stimulation; it might be about her impatience. In a third scenario, this person could also be darting in and out of traffic because she is late for something because people with ADHD can also be notoriously late.

  • Think about a child with ADHD hyperfocusing on something — likely a preferred activity that seems irrelevant to others. Many times, this is because of norepinephrine. We require this neurotransmitter to help us pay attention to things that are either boring or challenging. When this neurotransmitter is not produced enough, retained enough or transported efficiently, as in people with ADHD, it can be a struggle to pay attention in boring and challenging situations. However, when people with ADHD really enjoy something, norepinephrine can actually be stimulated, and then they can hyperfocus.

Now think of the adult hyperfocusing at home on something that appears irrelevant. This person also then has a propensity toward becoming overwhelmed with all of the other dreaded, nonpreferred tasks on her “list of things to do.” She may use the hyperfocus ability with something that she enjoys as a misguided coping strategy to avoid the nonpreferred tasks. This further perpetuates her feelings of being overwhelmed with everything that she’s supposed to be doing and not getting accomplished.

  • Think about a child with ADHD struggling to pay attention to his teacher. That sounds like the same adult struggling to remain focused as he and his wife have a conversation at the dinner table. Then, the next morning, when he doesn’t get out of bed when he’s supposed to, she wonders why he didn’t get up early to take the dog to the vet. It’s possible that he wasn’t focusing on their conversation the previous night, so he didn’t actually know he was responsible for this. Or, he did know, but he struggled with time management. Or, he struggled with intrinsic motivation to get out of bed to get things accomplished for the day. Or, he was paying attention to the conversation, remembered it and was actually motivated to take the dog to the vet, but he forgot to set his alarm clock.

With this type of situation, it can be unclear why he didn’t get up that morning because it could have been from any number of ADHD symptoms — or a combination of some of them.

 

Other experiences

According to the Centers for Disease Control and Prevention, people with ADHD also experience other situations that I didn’t necessarily address specifically in the scenarios above. People with ADHD can experience:

  • More unplanned pregnancies and sexually transmitted diseases
  • Higher arrest rates and propensity for repeating offenses
  • More aggressive behavior (This does not mean that all adults with ADHD are aggressive. In fact, most are not. But the rates of aggression among those with ADHD are higher when compared with those in the general population.)
  • More speeding tickets
  • More shoplifting convictions
  • More money management issues, impulsive spending habits and credit card debt
  • More substance abuse (higher in unmedicated ADHD patients than in the general population)
  • More risk-taking behaviors
  • Higher rates of smoking (in unmedicated ADHD patients)
  • Higher rates of depression (especially among males) and anxiety
  • Comorbid diagnoses (more than half of those with ADHD have a dual diagnosis)
  • Low self-esteem due to perceived failures at school or work and due to struggles in relationships

In looking at all of the different issues and scenarios related to ADHD and presented in this article, it is important to note that all adults will be late to an appointment once in awhile, lose something important, become overwhelmed with their “list of things to do,” interrupt during a conversation or even get a speeding ticket. These situations are all within normal limits as human beings. It becomes clinically significant only when a variety of these instances occur chronically and intensely and also interfere with the person’s functioning.

Adults with noticeable ADHD symptoms can sometimes manage these symptoms. This can be done in a number of ways:

  • An ADHD medication regimen
  • Psychotherapy to learn strategies to self-regulate
  • Neurofeedback to help strengthen connections in the brain
  • Holistic practices of consuming nutrients that promote proper brain functioning, including zinc, vitamin C, omega 3 fatty acids and protein
  • Exercise to increase blood flow in the brain, specifically in the neocortex where it’s needed to increase focus and decrease impulsivity

A combination of treatment modalities may be most effective so that adults with ADHD can continue to function well in their respective environments.

Because of the multifaceted origin of this disorder and the external variables each person experiences, ADHD symptoms can come across differently, so each person with ADHD (child or adult) will not present the same, even among the same presentation. Some individuals will have overtly noticeable symptoms. In the case of other individuals, outsiders may not even notice their symptomology, especially if they have learned to cope with their ADHD and self-regulate.

 

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Donna Mac is a licensed clinical professional counselor treating adolescents in psychotherapy who are transitioning to adulthood. She is also the author of the book Toddlers & ADHD, which can actually be applied across the life span. Find out more via her website, toddlersandadhd.com or email donnamac0211@gmail.com.

 

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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.

Behind the book: Cognitive Behavioral Therapies: A Guidebook for Practitioners

By Bethany Bray November 16, 2017

What makes cognitive behavioral therapy (CBT) such a tried-and-true, “go-to” method for professional counselors?

Ann Vernon and Kristene Doyle put it simply in the preface to their book, Cognitive Behavior Therapies: A Guidebook for Practitioners: “CBT readily lends itself to a broad array of interventions that are practical in nature and have been proven to effect change.”

Their book, recently published by the American Counseling Association, explores CBT and its many branches, from acceptance and commitment therapy to mindfulness.

Both Vernon and Doyle  trained and worked with Albert Ellis, the father of what was a groundbreaking method when he introduced it in the 1950s. Ellis is considered the originator of cognitive behavioral therapy, although he used the term rational emotive therapy, and later, rational emotive behavior therapy (REBT).

Doyle is director of the Albert Ellis Institute in New York City, and Vernon is president of the institute’s board of trustees.

 

 

Q+A: Cognitive behavioral therapy

Counseling Today sent Vernon and Doyle some questions, via email, to find out more. Responses are co-written, except where noted.

 

In your opinion, what makes cognitive behavioral therapy a “good fit,” particularly, for professional counselors?

CBT is a good fit for professional counselors as it is evidence-based and supported by empirical research. CBT has been shown to be effective for a variety of clinical problems individuals face and work on in counseling, including anxiety, depression, eating disorders, post-traumatic stress disorder (PTSD), obsessive-compulsive and related disorders.

Many insurance companies are requiring short-term, evidence-based therapy in order for individuals to be reimbursed. Given the nature of today’s society, with individuals wanting results at a fast pace, CBT affords that opportunity.

 

In the preface, you mention that one of the goals of your book is to dispel myths and misconceptions about CBT. Can you elaborate on that – what are some common misconceptions counselors might have about CBT?

Without a doubt, the major misconception is that there is only one CBT theory, when in reality there are many different theories under the cognitive behavioral “umbrella,” as described in this book. Rational-emotive behavior therapy (REBT) was the first theory, developed by Albert Ellis in 1955 when he revolutionized the profession by being the first to break from psychoanalysis. Shortly thereafter Aaron Beck developed cognitive therapy (CT), known as cognitive behavioral therapy, which adds to the confusion about what CBT actually is!

Another myth is that the emphasis is on cognitions with very little focus on feelings. In reality, CBT theories stress that thoughts, feelings and behaviors are interconnected in that feelings and behaviors emanate from beliefs. There is a major focus on helping clients see how their thoughts impact their feelings and helping them change their thoughts in order to develop more healthy and adaptive behaviors as opposed to unhealthy, negative emotions.

Yet another myth, which relates more to REBT in particular, is that there is very little importance placed on the relationship. This myth can be traced back to Albert Ellis, who did not place as much importance on the relationship as current REBT practitioners do, in part because he did not believe that a good client-therapist relationship was sufficient [on its own] to bring about change. REBT practitioners still believe this,  however, Ellis’ style was often more abrasive and confrontational.  Current REBT practitioners are less confrontational, more empathic and believe strongly in the importance of a good therapeutic alliance – which they consider an integral part of this theory.

 

What inspired you to collaborate and create this book? What new aspects of CBT did you hope to highlight?

We were inspired to create this book because upon review of available counseling-related materials, a book solely dedicated to the different CBT approaches [written] specifically for counselors was lacking. We saw a need for a solid understanding of how similar and different the CBT approaches are, as well as how they are applied in the counseling setting.

To demonstrate the unique aspects and nuances of each of the CBT approaches, we had the authors submit a transcript of a session that brought to life the theory that was addressed in the chapter. In addition, in Chapter 9, we had all the authors address the same client, highlighting how their particular approach would be utilized in counseling. It was our intention to provide readers a crystallized perspective of each of the various CBT approaches. Finally, each chapter includes sidebars to allow readers to apply what they learned in the chapter.

 

Do you feel that CBT is growing in popularity, or remaining steady as a “go to” method for counselors?

CBT, in our opinion, is growing in popularity amongst counselors. At The Albert Ellis Institute, we have noticed a trend in our professional continuing education courses of mostly counselors attending with the desire of learning specific theory and applications. Given that counselors are often on the “front lines” of treatment, they are realizing CBT is not simply a series of techniques that can be applied to various problems, but rather a generic term that encompasses a variety of different approaches that all have a common theoretical foundation. As more and more counselors acquire specialized training in CBT, the conclusion is that it will continue to grow in popularity with graduate programs requiring their students to be exposed to the theory and application.

 

What suggestions would you have for a practitioner who has been using CBT with clients for decades? What should they keep in mind?

Counseling practitioners who have used CBT for decades must be convinced that CBT theories are empowering because while clients may not be able to change certain life circumstances, they can change the way they think and feel about them, which is the essence of CBT. They should continue to read about and employ new techniques and practices to enhance their work with clients. They should keep in mind that under the CBT umbrella there are slightly different approaches to helping clients change. This is especially true for the “third wave” of CBT theories — acceptance and commitment therapy (ACT), dialectical behavioral therapy (DBT) and mindfulness. Experienced practitioners may want to explore these theories and utilize them with clients who might be a good fit for a particular approach, thus expanding their CBT toolbox.

 

What suggestions would you have for a practitioner who is just starting out and is interested in using CBT with clients? What should they keep in mind?

New practitioners who are just beginning and are interested in CBT should, of course, familiarize themselves with the particular CBT theory they are most interested in learning about and practicing, understanding that CBT is the “treatment of choice” for many disorders and has wide applicability cross-culturally, as well as with children and adolescents, couples and families. In addition, practitioners in private practice or mental health settings should be aware that managed care companies are huge CBT fans because it is generally a shorter-term therapy and the focus is on goal achievement and concrete markers for change and accountability.

Another factor that both seasoned and practitioners new to CBT should consider is that while CBT is generally individualistic, practitioners need to also see clients in the context of their environment and their culture. The goal of CBT is to help clients function in their world more effectively, which may often result in social advocacy. CBT practitioners can work with clients to reduce the intensity of their negative emotions that may prevent them from being appropriately assertive in confronting injustices.

This last statement actually reflects another myth about CBT, which is that CBT therapists only focus on changing the way clients think about their circumstances, which can imply passive acceptance of the status quo. In fact, from a CBT perspective, a counselor working with an abused woman would work with her to challenge the belief that she isn’t worthy and therefore deserves the abusive treatment – and then help empower her, so she is able to effectively confront a pervasive problem that affects far too many women.

 

What draws you, personally, to CBT? What do you like about the method? What led you to specialize in it – and also become involved with the Albert Ellis Institute?

I (Ann Vernon) began my counseling career as an elementary school counselor who was trained in client-centered therapy. I rather quickly became disillusioned with this approach when working with young clients, because despite the fact that I listened well and the clients seemed to feel better, they really didn’t get better. So when I heard Albert Ellis speak at an ACA conference in New York [in the 1970s] and read about the training at his institute, I decided to pursue [it]. During the primary practicum I was so excited to hear Virginia Waters talk about how REBT could be adapted for children, and after her lecture I asked if she would provide feedback on a social-emotional education program I had written but wanted to adapt in order to incorporate REBT principles. With her helpful feedback, I wrote Help Yourself to a Healthier You, followed by Thinking, Feeling, and Behaving and the Passport Program.

So that really started my love affair with this theory because it was educative and skill-oriented and comprehensive – addressing feeling, thinking and behaving. I was also drawn to this method because of the emphasis on problem prevention, which was something that I readily endorsed as a school counselor. After becoming a mental health counselor working with adults as well as with young clients, I continued to find that REBT was the best “fit” for me as well as my clients.

I have been so fortunate to be a part of the Albert Ellis Institute for so many years, first as a trainee, then as a board member and now president of the Albert Ellis Institute [Board of Trustees]. It has been extremely rewarding to do training in various parts of the world and to see firsthand how influential this theory is and how it has had an incredibly positive impact on so many people, including myself!

 

I (Kristene Doyle) was drawn to CBT when I learned about it in undergraduate psychology classes at McGill University. The theory made sense, and I appreciated the evidence-based nature of it. When I entered my doctoral program, it had a heavy emphasis on CBT orientation. There was a close relationship between Hofstra University and The Albert Ellis Institute (AEI), and AEI was one of the internship sites available for fourth-year students.

Having the honor of the founder of CBT,  Albert Ellis, be my mentor and train me has contributed to my passion of practicing a theory that has empirical support. I began my career at AEI as a doctoral student and have worked in various capacities for the past 20 years, and now serve as its director. I laugh at the letter of recommendation Dr. Ellis wrote for me when I was preparing for job applications upon graduation. Little did I know I would end up as the director [of his institute]! Furthermore, I believe in and carry out the mission of AEI, which is to promote emotional and behavioral health through research, practice, and training of mental health professionals in the use of REBT and CBT.

 

 

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Cognitive Behavior Therapies: A Guidebook for Practitioners is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-347-6647 x222

 

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

 

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

 

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

 

@TechCounselor: There’s no escaping technology

By Adria S. Dunbar and Beth A. Vincent November 13, 2017

Do you pay for your drive-through latte with your iPhone app while streaming Spotify through your Bluetooth speakers and double-checking your GPS for traffic notifications? Or are you the stalwart who prefers to park and go inside to order your coffee because drive-throughs seem so impersonal and face-to-face communication is an endangered art? Whether you’re the early adopter who embraces technology usage in every aspect of your life or the skeptical laggard who argues that we would all be better off if we were less plugged in, you can’t escape the question of whether (or how) to integrate technology into your life and work.

For those of us who are counselors, our technology habits in our personal lives likely influence how we use technology in our professional lives, including in our relationships with colleagues and clients. Yet it can be difficult to remain self-aware about our habits and choices surrounding technology use. Constant advances in new technologies ensure that as soon as we have a solid grasp on current technology, a new innovation bursts onto the market and changes everything. This is lifelong learning to the extreme.

Why does it matter which technologies we use and how? If technology is a means to an end — be it increased efficiency, convenience, communication, transparency or organization — then it matters whether those ends are achieved. Email enables us to communicate from the convenience of our smartphones, but not when the messages pile up too fast for us to read and reply to them. Cell phones make us accessible 24/7 from any location, but only until our signal gets dropped. PowerPoint helps us stay on track in meetings, but not when the presenter falls back on reading slide after slide of black bullet point text from a plain white background. When technology fails — when it does not get us to the desired end — we can end up feeling lost, frustrated or even betrayed.

The downsides of technology can arise from our own abuse of technology or be inherent in the technology itself. We see the human tendency to abuse technology every time a co-worker consistently replies to all when they think they are replying to one. Or when we sit in a meeting that is filled with the incessant tapping of keyboard keys as colleagues refuse to unplug long enough to attend a one-hour meeting. Or, perhaps worst of all, when we sit silently while a lunch companion stares at a screen rather than paying attention to the human being seated directly across from them. At times, we may catch ourselves being less present in the company of others, distracted by social media, email or notifications. Some of the ways people use software may even be categorized as addictive or criminal.

In addition to these human failings, other pitfalls are inherent to the technologies themselves. Important emails wind up in spam folders, text messages never make it to their intended audience, and software crashes a moment before we hit save, just as we are entering the final case note of the day. Just as we all benefit from technology, we also struggle to navigate its challenges.

As counselors, our choices around technology use are laden with our professional responsibilities. Federal laws dictate what we can do and say in online and digital formats. Our social media must be monitored carefully to avoid the creation of dual relationships or unintentional self-disclosure to clients. Our behaviors must be models of healthy boundaries in front of those we serve. Ethical standards exist to help guide our professional behaviors, but as counselors, we are confronted with an ever-changing technology landscape that affects our personal and professional lives and the lives of our clients.

In this shifting landscape, how do counselors make decisions about which products to use and which to avoid? How can we leverage technology to make us more efficient and effective without allowing technology to steal the spotlight away from the real work we are doing with clients? We must keep returning to the question: “What is the end goal, and how can technology help us get there?”

Each column in this new monthly series for CT Online will explore this question in the context of a different type of mobile and online software technology that counselors use.

Future column topics will include:

  • Email
  • Productivity software
  • Communication software
  • Site blocking software
  • Record-keeping software
  • Online counseling platforms
  • Chat and texting
  • Mobile devices

 

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Adria S. Dunbar is an assistant professor in the Department of Educational Leadership, Policy and Human Development at North Carolina State University in Raleigh. She has more than 15 years of experience with both efficient and inefficient technology in school settings, private practice and counselor education. Contact her at adria.dunbar@ncsu.edu.

 

Beth A. Vincent is an assistant professor at Campbell University in Buies Creek, North Carolina, in counselor education. She is a counselor educator, licensed school counselor and former career counselor who is driven to learn everything there is to know about innovative productivity software to help counselors be their most present selves. Contact her at evincent@campbell.edu.

 

Our Instagram is @techncounselor.

 

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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.

 

Bringing Syrian hospitality into your counseling practice

By Shadin Atiyeh November 8, 2017

In a small village resting in a valley watched over by a medieval castle, the women made their morning rounds. At each house, they were met by the same ritual. A warm greeting with a kiss on each cheek, an invitation to sit and at least three rounds of offerings: sweets, coffee and fruit. This is an obligation, to express hospitality to guests, but the host treats it as an honor and a joy.

Between each offering, conversation flows about family members, friends and occurrences in the village. The host asks intentionally about each person in the guest’s life. Silences are reserved to hold sadness, grief or political sentiments better left unsaid. These silences are broken with “May God help,” or “baseeta,” translating literally to “simple,” but used to acknowledge the futility of talking about a topic and moving on to the next one.

The Arabic language is vast but vague. One word can carry many meanings, but translated without context, it can lose all meaning. Another example is “Yalla,” which the women will use to indicate that they are ready to leave and move on to the next visit. It can mean “let’s go,” and “hurry up” or “come on.” The goodbyes are drawn out, with invitations to stay longer, kisses and hugs. The guests invite the host to visit them next time.

These morning visits serve multiple purposes. There is no one in the village who will not have a visit from a neighbor, a friend or a family member each day. There is no household task that won’t have a helping hand. There is no meal that anyone in the village will eat alone. There is no newcomer who is not welcomed with multiple visits from each neighbor offering food and conversation. There is also no misstep, family argument or fashion mistake that does not get aired out with the dirty laundry in rooftop conversations. In English, there are many words for aloneness, and each word can have either positive or negative connotations (e.g., solitude and loneliness). In Arabic, “wahida” has a mostly negative connotation: sadness, loneliness, pity.

The values of hospitality, community and honor are central to Syrian and many Middle Eastern cultures. Growing up as an American of Syrian Arab descent, my father told us one story to teach us true hospitality. This story did not involve a fellow Arab but rather a Jewish man who helped my father when he arrived in the United States from Syria at the age of 18. This Jewish business owner gave my father his first job in the United States and supported him in his first years.

When I visited Syria for the first time with my father, I experienced the hospitality and community that he knew. These values can be hard to find in the United States — a primarily individualistic culture where privacy is paramount and the belief that we must make it on our own is prominent. I can imagine the culture shock when my father came to the United States and possibly went a few days without a knock on the door from a neighbor. I felt a similar shock in Syria. I remember craving some privacy or solitude in which to think and read, some freedom from feeling scrutinized.

 

Bridging cultural boundaries

As a licensed professional counselor and approved clinical supervisor working with refugee populations, I try to hold on to an empathy for how culture shock feels and to encourage that empathy among my supervisees. I have an appreciation for my father’s story because I currently work at a Jewish agency expressing Jewish values by resettling Middle Eastern refugees. I have a firsthand experience of the power of this work to bridge cultural boundaries.

As the Syrian refugee crisis continues, refugees are forced to flee their communities and are placed in third countries for resettlement when there is no opportunity to return home. In the United States, a network of nonprofit agencies is responsible for meeting families at the airport, securing housing and providing basic services and cultural orientation. I have learned that we can accomplish these steps either by checking off the boxes or by approaching these refugee families with the same spirit of hospitality and welcoming that they most likely would afford to us. Doing so demonstrates respect and honor and eases the culture shock of being in a new country.

How could you incorporate hospitality into your counseling practice to make it more welcoming for those of Middle Eastern descent? You can follow some rituals that might help to evoke a sense of respect and suggest that your practice is a place to sit and talk.

Many therapists in the United States put effort and thought into how the room is set up. This traditionally involves a private and quiet setting, dim lighting, plants and the therapist’s chair facing a couch. You might have a table with drinks available, but it is important to insist that these clients partake because they would not think it appropriate to take a drink on their own or accept a drink on the first offer. Going through the ritual of making and pouring coffee for your client further demonstrates care and respect. Having a candy dish or sweets tray can also be useful, but it is important to hold the dish and offer it to these clients.

Giving gifts acknowledges the value of relationships to these clients, so you might consider giving small gifts at the first and last sessions. These gifts might be cards, representational items, journals, bookmarks or books. These gifts can serve a therapeutic purpose.

Artwork on the walls can include Arabic writing, such as the words “Ahlwan wa Sahlan,” meaning “Welcome and Health.” Some therapists have their name in Arabic next to the English writing on their doors. If your client speaks English as a second language, make an effort to learn some words that can communicate empathy for the difficulty of learning a new language and having an accent. One of my favorite moments with a client was when my position as the all-knowing authority was shattered by my broken attempts to speak French.

Be careful not to assume what language your clients speak. Instead, ask. Iran, Afghanistan and Somalia, for example, are not Arab countries and speak languages other than Arabic. There are also different ethnic groups such as the Kurds, Armenians, Jews and Chaldeans within Arab countries who may not speak Arabic as their first language.

Don’t expect your client to teach you about their culture. Obtain supervision and consultation and read from credible sources. Hisham Matar’s In the Country of Men is a novel that offers raw insight into the experience of a child growing up in Libya and being forced to leave. Bint Arab: Arab and Arab American Women in the United States, by Evelyn Shakir, portrays the diversity of Arab American cultures and the dissonance women of Arab descent experience living in the United States.

Poetry is another window into cultures and is a highly revered art in Arab traditions. Some famous Arab and Arab American poets include Nizar Qabbani, Adonis, Khalil Gibran and Maram al-Massri. These poems might also be therapeutic tools.

The Arabic language is also ornate, formal and elaborate. It is not enough to say, “Welcome”; you should say “Two welcomes.” When someone says, “Good morning,” the response should be more extravagant, such as “Morning of light.”

There are many sayings and poems that could hold the extreme sadness, loss and loneliness attached to leaving one’s country, home and community. Qabbani wrote: “My son lays down his pens, his crayon box in front of me and asks me to draw a homeland for him. The brush trembles in my hands and I sink, weeping.” My clients might spend a lot of time talking about how loss of homeland has affected their children, parents and other family members. I honor my clients’ positions in their families and allow them to discuss these other people in session because these family members might be extensions of self.

Your clients are the experts on their experiences of their culture and their perspectives on it. Many clients from racial or ethnic minorities might be walking into your office with the same questions: Will the therapist understand my culture? Will the therapist respect my culture?

As the counselor, you have the power to initiate a conversation about these unspoken questions, make these concerns explicit and address them. Respect and acknowledge differences while also connecting on commonalities such as the feelings of loss, guilt and shame.

Counselors working with this population must also acknowledge the political and social climate in which these refugees are entering the United States. Experiences and fears of discrimination and prejudice have contributed to increased anxiety, depression and traumatic stress among Arab Americans in the United States. Adding clients’ past traumatic experiences to these experiences can lead many to isolate themselves further.

Therapists in the United States inundated with negative images of the Middle East might be at risk of holding unexamined negative stereotypes and beliefs about Middle Eastern people and their cultures. The therapeutic space can become a place of risk for further harming vulnerable clients, or it can provide an opportunity to give clients a chance to experience understanding and support.

In bringing a spirit of Syrian hospitality into my work as a counselor, I am able to communicate a warmth and welcoming to my clients. As my clients walk a tightrope over an ocean — behind them loss and in front of them both danger and opportunity — I hope the therapeutic space offers rest and reflection. A good host is usually invited as a guest. I attempt to be invited as a guest into my clients’ lives so that I can work with them to build bridges over those oceans.

 

“Light is more important than the lantern. The poem more important than the notebook.” — Nizar Qabbani

 

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Shadin Atiyeh is a master’s-level licensed professional counselor in Michigan, national certified counselor and approved clinical supervisor. She is currently a doctoral student in counselor education and supervision and a department manager within a refugee resettlement and social services agency. She has five years of experience providing clinical services, case management and employment services with vulnerable populations, including refugees and other immigrants, survivors of domestic violence and sexual assault, and families experiencing homelessness. She also serves as a clinical supervision for counseling interns and prelicensure counselors. Contact her at shadin.atiyeh@waldenu.edu.

 

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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.

Technology Tutor: Revisiting the ethics of discussing clients online

By Rob Reinhardt November 7, 2017

If you have given even a cursory observation to the advertisements that appear on Facebook, during Google searches or on many of the websites that you visit, you will have noticed that these advertisements are targeted at you. The ads might be related to web searches you have performed, the area you live in or something that is generally popular with your age group.

This is how companies such as Facebook and Google make almost all of their money. They gather information about you (and everyone else) and sell advertising to companies that want to target you. They make a lot of money doing this because they are very good at letting those companies get very specific with their targeting. (Google reported revenues of $26 billion in the fourth quarter of 2016 alone.) For a glimpse into the kinds of details that Facebook collects about people, check out the great infographic at bit.ly/FBTargetOptions. That list keeps growing and getting more refined. It is especially important to note this passage from Facebook’s overview of how to target ads: “Behaviors are constructed from both someone’s activity on Facebook and offline activity provided by data from Facebook’s trusted third-party partners.”

In other words, to target advertising to their users, Facebook is collecting data from many different sources about both online and offline activity. So, this is not restricted only to the activity on Facebook.

What does this have to do with our clients (and potential clients)?

I continue to witness counselors engaging in referrals and case consultation in online forums such as Listservs and Facebook groups. This is despite my previous article on this topic last year in Counseling Today (see bit.ly/discussingclients) in which I discussed the difficulty of maintaining confidentiality for clients and the PIT principle (permanence, identity, transferability), and even with American Counseling Association Chief Professional Officer David Kaplan clearly stating that discussing clients online is an ethics no-no. The existence of marketing databases curated by entities such as Facebook and Google adds yet another reason that we need to consider other ways of addressing client needs.

Take this example of a completely fictional situation that could quite easily refer to a real situation:

Johnny Client contacts Susie Counselor about an appointment. He provides some background, and Susie recognizes that she is not a great fit for him. She decides to reach out to her local mailing list or Facebook group of therapists to see if she can provide Johnny with a solid referral. She writes: “Looking for referral for 30-something male dealing with depression. Needs counselor in network with ABC Insurance.”

Although this may seem innocuous at first, it is likely more than enough information for Johnny to be identified. In my previous article, I pointed out the human reasons this is an issue. (For instance, what if someone who knows Johnny or even Johnny himself is in the group? What if someone copies and pastes or screenshots the information?)

Now let’s look at it from a targeted marketing standpoint. Johnny’s call to Susie didn’t happen in a vacuum. Prior to calling her, Johnny did a search for “Counselor MyTown” and visited Susie’s website. These are traceable behaviors tied directly to Johnny, and they likely will end up in the databases used by entities such as Google and Facebook to target advertising. Based on these behaviors, Johnny is likely to start seeing ads on his computer for mental health treatments, counselors in the area and self-help books.

It is important to note that Susie Counselor is now probably connected to Johnny in these databases because he visited her website and placed a call to her. So, when she posts about the 30-something male with depression shortly after receiving Johnny’s call, it’s not a huge leap for database algorithms to figure out that this is the same Johnny Client who recently visited her website and called her — the same Johnny Client whose address, birthday and many other pieces of information already exist in the databases. Except now, thanks to Susie, those databases have learned that Johnny is dealing with depression. They may well have already known what insurance Johnny has, but if not, that’s another bonus that Susie provided for them.

What you can do

I’d like to highlight one of my suggestions from the previous article as well as provide a couple of other suggestions:

  • Make it counselor-centric: When seeking someone to refer to, focus on the counselor’s skills, not the client’s issues. For example, you might say, “I’m looking for a counselor who helps clients dealing with depression.”
  • Keep it offline: Go old school! Keep your own notebook or database of people you can refer to. Note their strengths, location, the insurance they accept, etc. Network and get to know them to elevate the quality of your referrals.
  • Raise awareness: Sometimes, counselors need to be reminded of things that we often tell our clients. For instance, just because others are engaging in a behavior doesn’t make it OK. Make others in your online forums aware of the privacy issues surrounding discussing referrals and cases online. Point them to this article and to my previous article that I referenced earlier. Point them to the pertinent passages in the ACA Code of Ethics (noted below). Even if they aren’t counselors, the ethics codes for social workers, psychologists, marriage and family therapists and psychiatrists contain similar passages, so their concern for client privacy and confidentiality should be just as great. Above all, be kind and compassionate in your approach.

Pertinent standards in the ACA Code of Ethics

B.1.c. Respect for Confidentiality

“Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification.”

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Note the inclusion of “prospective” clients. Do you have the person’s consent before disclosing anything about them online? Can you accomplish your goal without disclosing information about them online? If so, what is your legal or ethical justification for disclosing?

B.2.e. Minimal Disclosure

“To the extent possible, clients are informed before confidential information is disclosed and are involved in the disclosure decision-making process. When circumstances require the disclosure of confidential information, only essential information is revealed.”

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Do clients (or prospective clients) fully understand the ramifications of you disclosing information about them online? Do they understand how few details it might take for computer algorithms to identify them? Are they aware of all the options for accomplishing the goal, and do they approve of online disclosure?

B.3.c. Confidential Settings

“Counselors discuss confidential information only in settings in which they can reasonably ensure client privacy.”

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Is there any way that this standard doesn’t completely rule out using online forums for any disclosure? Based on my experience and expertise, there simply is no way that counselors can reasonably ensure client privacy if they share any details about clients in most online forums.

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For an interesting discussion of this topic, including an interview with social media policy expert Keely Kolmes, check out Episode 104 of the TherapyTech with Rob and Roy podcast.

 

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

Letters to the editor: ct@counseling.org

 

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