Tag Archives: cognitive behavioral therapy

Living with anxiety

By Bethany Bray May 24, 2017

Anxiety disorders are the most common mental illness in the United States, affecting 18 percent of the adult population, or more than 40 million people, according to the National Institutes of Health. Among adolescents the prevalence is even higher: 25 percent of youth ages 13 to 18 live with some type of anxiety disorder.

Anxiety disorders are often coupled with sleeplessness, depression, panic attacks, racing thoughts, headaches or other physical issues. Anxiety can run in families and be a lifelong challenge that spills over into all facets of life, from relationships and parenting to the workplace.

The good news is that anxiety disorders are manageable, and counselors have a plethora of tools to help clients lessen the impact of anxiety. Caitlyn McKinzie Bennett, a licensed mental health counselor, says she regularly talks this through with her clients at her private practice in Orlando, Florida. She often uses an analogy of ocean waves with clients: Anxiety comes in waves, and managing the disorder means learning coping tools and strategies to help surf those waves rather than expecting the waves to disappear entirely.

“Anxiety can be a long-term thing,” says Bennett, who is also a doctoral student in counselor education at the University of Central Florida. “With clients, I try and explain that [anxiety] is the body’s response that something’s not right — based off of what’s happened to you [such as past trauma] or what’s happening currently. Then we can work to accept it, cope and be happier in your life. Some things you can’t necessarily get rid of in their entirety, and that’s OK. It’s learning to be you and have a fulfilling life with anxiety, where you’re able to feel anxious and [still] be productive and be a mother, a student, a partner. I try and normalize that [anxiety is] going to come and go. It’s OK, and it’s human.”

Anxiety doesn’t happen in isolation

Everyone experiences anxiety from time to time, such as worry over an upcoming work responsibility, school exam or first date. Anxiety disorders, however, are marked by worry and racing thoughts that become debilitating and interfere with everyday functioning.

“It’s a normal part of life to experience occasional anxiety,” writes the Anxiety and Depression Association of America on its website (ADAA.org). “But you may experience anxiety that is persistent, seemingly uncontrollable and overwhelming. If it’s an excessive, irrational dread of everyday situations, it can be disabling. When anxiety interferes with daily activities, you may have an anxiety disorder.”

A number of related issues fall under the heading of anxiety disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), including specific phobia, panic disorder, separation anxiety disorder, social anxiety disorder, generalized anxiety disorder and others. According to the DSM-5, anxiety disorders “include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat.”

Racing thoughts, rumination and overthinking possibilities — from social interactions to decision-making — are central to anxiety. In addition, people with anxiety often struggle with insomnia or sleeplessness and physical symptoms such as a racing heart, sweaty palms and headaches, says Bennett, an American Counseling Association member who is currently leading a study for her doctoral dissertation on the effects of neurofeedback training on college students with anxiety. Adolescents sometimes turn to self-harming behaviors such as cutting or hair pulling to cope with anxiety. In adults and adolescents, anxiety can manifest in physiological issues such as stomachaches or irritable bowel syndrome. Although adults may channel their anxiety into physical problems, they’re also generally much more capable than adolescents and children of identifying and articulating the anxious thoughts, ruminations and social struggles that they’re facing, Bennett says.

Bennett worked with a 14-year-old female client whose anxiety had manifested as the behaviors of obsessive-compulsive disorder (OCD), including avoiding the number six, leaving her closet door open a certain way and struggling with crossing thresholds. Bennett worked with the client to identify her triggers and find coping mechanisms, such as connecting with friends and her Christian faith.

“A big part of her improvement was creating the awareness of what was happening,” Bennett says. “Typically there’s a large, irrational fear. With her, she was afraid that her mom was going to die. She would focus on it so much that it would cause her to start the [OCD] behavior. … For her, it felt so real. It was so scary for her that she felt compelled to do these behaviors to keep her mom alive, so to speak.”

Bennett worked with the young client to confront her fears in small doses through exposure therapy, such as listening to a song at volume level six and talking through how she felt afterward. This method allowed Bennett to first address the client’s OCD behaviors and then — once trust was built and the client had progressed — move on to work through the bigger, deeper issue of her fear of her mother’s death.

“It helped her to feel safe enough and have the confidence to work through some smaller things and move on to work on bigger things,” Bennett says. “For her it was talking it out, normalizing that for her and drawing attention to [her anxious behaviors].”

Christopher Pisarik is an associate professor in the Division of Academic Enhancement at the University of Georgia and a licensed professional counselor (LPC) who works with students in need of academic support. He says that stress and irregular sleep and eating patterns — which are often ubiquitous parts of college life — can go hand in hand with anxiety.

“Sleep is a big one — if they’re just not sleeping, or sleeping too much,” says Pisarik, who also treats many college-age clients at his private practice in Athens, Georgia. “This is really, really common — clients who can’t get to bed until 4 a.m., and then they can’t get to class, and it snowballs. Their thoughts just race with worry. … Sleep seems to be a big diagnostic indicator [for anxiety], and not being able to go to bed. [I ask clients,] ‘What are you thinking about, and can you stop thinking about this? Is that what’s keeping you from getting back to sleep?’ They get tired and fatigued, and it’s perpetuated.”

In addition, anxiety is often coupled with — or is an outgrowth of — other mental illnesses, most commonly depression. Counselors will need to treat a client’s anxiety alongside other diagnoses, Bennett says. For example, a client with schizophrenia will have hallucinations that provoke extreme anxiety. If the counselor doesn’t address the client’s anxiety, those symptoms will get worse, explains Bennett.

“Depression and anxiety are like brother and sister,” she adds. “They play off of each other and exacerbate the symptoms. You need to work through both. I don’t think I’ve ever worked with anyone who solely experienced anxiety.”

Stephanie Kuhn, an ACA member and LPC at the Anxiety Treatment Center of Greater Chicago, agrees. She regularly sees client anxiety paired with other issues such as specific phobias, insomnia, chronic pain issues, depression, panic disorders and OCD.

“It’s never really one thing,” Kuhn says. “It’s never just anxiety.”

Pumping the brakes on racing thoughts

The first step for many people who struggle with anxiety is to create awareness of their thoughts and then learn to manage those thoughts with a counselor’s help. Although the strategy of identifying negative self-talk and addressing one’s thoughts is old hat to most counselors, it may be an entirely new concept for some people, especially younger clients, says Pisarik, an ACA member who uses cognitive behavior therapy (CBT) in his private practice. Clients with anxiety often polarize, exaggerate or catastrophize details in their minds as they ruminate over them, he explains.

“Even being able to identify anxious thoughts is big,” Pisarik says. “They just assume it’s normal to walk around [feeling] anxious because of these thoughts. … It gives them a language and a real usable and rudimentary skill they can use in the moment when they’re walking in [to a stressful exam]. They can identify that their inner narrative isn’t healthy.”

For example, a college student might come to a counselor expressing worry about an upcoming exam in a class that he or she needs to pass for a major in pre-med. The student might have allowed negative and catastrophic thoughts to snowball: “If I get a C on this test, I will never get into medical school, which will derail my entire career plan and make my parents angry and disappointed.”

“For … a student who is 20 years old and [still] learning to think critically, it would be easy to blow everything out of proportion and catastrophize everything,” Pisarik says. “I am really big on helping them understand negative thinking and false cognitions, and getting them to self-monitor and renarrate [their unhealthy thoughts].”

Following the CBT approach, Pisarik says he would talk such clients through their thought patterns to identify and restructure their negative thoughts about the exam. He would also suggest that they focus on and remind themselves of prior successes, such as other exams or classes in which they earned A’s and B’s.

“I would try and systematically educate the client [about] what type of thinking that is,” Pisarik continues. “There are many doctors out there who got C’s and got into medical school, and probably [who] got C’s in medical school. I will explain that they are catastrophizing this … [and] try and get them to think about it in a different way, evaluate it carefully and create a different narrative about it. Are there people who have gotten C’s and gotten into medical school? If it stops you from getting into medical school, would that be the worst thing in the world?”

“It takes a consistent effort to practice and challenge one’s thinking,” adds Pisarik, who co-authored the article “A Phenomenological Study of Career Anxiety Among College Students.” The article will be published in the December issue of The Career Development Quarterly, the journal of the National Career Development Association, a division of ACA.

CBT works well for anxiety because “it lets people see that their own thinking and their behaviors are not productive for the way they want to live or the life they’re living right now,” says Kuhn, who uses both CBT and exposure therapy with her clients at the Anxiety Treatment Center of Greater Chicago. “It’s giving people an outside perspective — getting them to look at their own thoughts and behaviors objectively rather than letting those anxious thoughts take over everything, making it harder to function.”

One way Kuhn works with clients on challenging their unhealthy thoughts is by asking them to identify the best, worst and most likely outcomes of situations they are ruminating over. “I ask, ‘Would [the outcome] matter in a week, a month or a year from now?’ Typically the answer is no,” Kuhn says. “After we go through that, we reframe the original thought [and] transform it into something more rational, more realistic.”

Both Pisarik and Kuhn encourage their clients to keep thought logs to track anxious thoughts and the situations that triggered them. This exercise increases self-awareness, helps identify triggers and creates an opportunity to discuss how the client might change the negative narrative.

“Writing helps a lot because it slows people’s minds down, and they can go back and read about it,” Kuhn says. “Creating that awareness is the only way to understand yourself, understand what you’re worried about and be able to accept it and push it away.”

In addition to using thought logs, Pisarik gives his clients a list of automatic negative thoughts, or ANTs, to check themselves against. The collection lists the most common types of unhealthy, anxious thoughts and types of thinking, including catastrophizing and either-or thinking (polarizing).

Kuhn has a particular phrase that she often repeats with clients: “Handle it.” She acknowledges that it’s not the most empathic of mantras, but it does help to focus on the manageability of anxiety. With clients, she works toward a goal of “being able to sit with the uncomfortableness [of anxious thoughts] and tolerate the stress.”

Kuhn says her style when working with clients matches her personality: “Let’s go forward and hit our fears hard instead of tiptoeing around them.”

Exposure therapy, which introduces things in small, controlled increments in session that make a client anxious, is another good way to focus on handling anxiety, Kuhn adds. Whether the scenario is a fear of speaking up in class or a fear of being rejected by a loved one, exposure therapy can help clients learn to live with the issue and the anxious feelings that come with it.

“When I talk to people about ‘handling it,’ it’s creating that awareness and understanding [of] themselves that they’re able to manage or take on more than they think they can,” Kuhn says. “Anxiety a lot of the time makes us believe that we can’t handle the tiniest things. That’s why our body has created or learned how to respond to things in an overactive or hypersensitive way.” This is most commonly experienced in our fight-or-flight response, she says.

Managing worry and taming anxiety

From CBT and mindfulness to a focus on wellness and coping strategies, professional counselors have a wide range of tools to help clients who struggle with anxiety. Here are some ideas and techniques that can be particularly useful.

> Controlling the controllables. Kuhn says it can be helpful for clients to talk through and identify what is out of their control during situations that make them anxious. “A lot of times, anxious clients want control over everything, and that’s just not realistic,” Kuhn says. “It’s important to go over what’s controllable and what’s not. That creates awareness and a pathway to reevaluate [their] own thinking and behavior. I like to call it ‘controlling the controllables.’ I talk with clients about this a lot.”

Kuhn often uses an exercise with clients in which she draws a target with concentric circles. Things that clients can control, such as their own thoughts and behaviors, go in the center circle. Things that they partially control, such as their emotions or what they focus on sometimes, go in the middle ring. Things that are out of their control, such as what other people think or do, go in the outside circle. In a simpler alternative, Kuhn draws a center line down a piece of paper and works with clients to list what is and isn’t in their control in situations that make them anxious.

> Creating common ground. Kuhn says she also talks openly with clients about how common anxiety is, alerting them that they are among literally millions of Americans who are battling the same challenge. “I let them know they are not alone. It creates a universality,” Kuhn says. “To let people know that they’re not the only ones suffering like this can help. … It does create a common ground for people not to feel ashamed of [their anxiety] or feel like they can’t talk to someone about it. Just creating that education typically makes people feel a ton better.”

> Acknowledging and naming worry. Journaling and making lists to document anxious thoughts can help clients address and reframe the everyday rumination that accompanies anxiety. Kuhn offers two variations on this intervention: worry time and the worry tree.

With “worry time,” clients set aside a dedicated amount of time (Kuhn suggests 30 minutes) every day to write down any anxious thoughts that are troubling them. Clients don’t need to engage in long-form writing to complete this exercise, Kuhn says. Making a bulleted list or jotting thoughts down on sticky notes will work just as well. When the designated time is up, clients put all the notes in a box or container that they have set aside for this purpose. This action signifies that they are leaving those thoughts behind and can move on with the day.

“They have to leave those thoughts or sticky notes there and be done with them,” she says. “Obviously more [anxious] thoughts will come, but you have to remind yourself to leave them behind.”

With Kuhn’s “worry tree” intervention, clients create a flowchart of their anxious thoughts. With each item, clients ask themselves whether their worry is productive or unproductive (see image, below). “Is it something that you can actually do something about?” Kuhn asks. “If it’s unproductive, then you need to just let it go. Do something you enjoy or focus on something else to reset [your mind].”

 

> Mind-body focus and exercise. Mindfulness, meditation and other calming interventions can be particularly helpful for clients with anxiety. Kuhn recommends the smartphone app Pacifica, which prompts users with breathing, relaxation and mindfulness exercises, for both practitioners and clients. Kuhn, who has a background in sports counseling, and Pisarik, who is a runner himself, also prescribe exercise to anxious clients. Exercise boosts serotonin, a neurotransmitter connected to feelings of well-being, and comes with a host of other wellness benefits. In addition, exercise allows a person to get outdoors or disengage from work and home activities and other people for a brief period to “have time to hear your thoughts and challenge them,” Pisarik says. “You have to hear your thoughts if you’re going to challenge them.”

> The butterfly hug. Beth Patterson, an ACA member and LPC with a private practice in Denver, teaches deep breathing exercises to anxious clients to help them become grounded, focusing on the flow of energy through the body. She also recommends the “butterfly hug” technique. With this technique, clients cross their arms across their chests, just below the collarbone, with both feet planted firmly on the floor.

Clients tap themselves gently, alternating between their right and left hands. This motion introduces bilateral stimulation, the rhythmic left-right patterns that are used in eye movement desensitization and reprocessing. “It’s phenomenally self-soothing,” Patterson says. “Doing that with deep breathing really helps with anxiety. I love the idea that you’re hugging yourself. Even just doing that helps.”

> Walk it out. Along with deep breathing and grounding, Patterson also recommends walking and movement for clients who are feeling anxious. She instructs clients to focus on the feeling of each foot hitting the ground instead of their anxious thoughts. As with the butterfly hug, this action creates bilateral stimulation, Patterson notes.

Bennett also uses walking as a way to help clients refocus their thoughts. She will take clients out of the office during a session for a “mindful walk” up and down the block. During the walk, they talk about what they’re sensing, from the sunshine to the breeze to the smell of flowers. Bennett says this allows her to work with clients “in the moment,” recognizing and refocusing anxious thoughts as they come. Afterward, they process and talk through the experience back in the office.

“It’s a lesson that [anxious] thoughts are going to come up for you, and you can refocus on your sense of touch or hearing,” Bennett says. “Thoughts will come up, and it’s really easy to attach to those thoughts and become anxious, but we can acknowledge the thought, be accepting of it in the moment and refocus. Change and connection can come that way.”

> This is not that. Clients commonly transfer anxiety-provoking personal issues onto relationships or situations in other facets of life, including the workplace, Patterson says. For example, Patterson worked with a client who had a very domineering, controlling mother, and this client felt triggered by a female boss in her workplace. Patterson introduced the client to the mantra “this is not that,” and they worked on reframing the anxiety the client experienced when she felt her boss was being controlling.

“She had to work through it in a beneficial and compassionate way for herself and really remember ‘this is not that,’” Patterson says. “Our minds are brilliant, but they’re binary computers. When something happens, it will immediately associate it with something else it knows. If a co-worker is being overly competitive, it might trigger feelings about sibling rivalry. This [mantra] offers a great opportunity to work through family-of-origin issues [with clients] when you see them replicated in the workplace.”

> Abstain from negativity. Another empowering tool clients can use is to become conscious of and then avoid unhealthy or toxic situations and people who trigger their anxiety, Pisarik says. He advises clients to “stay away from groups of people or individuals who they know will engage in negative self-talk or negativity. If you’re feeling anxious already, the last thing you want to do is to go and talk to that toxic person.”

Similarly, he commonly advises anxious students to avoid waiting outside the room where they’re about to take a big exam, surrounded by 30 classmates who might be saying that they are going to fail, they didn’t study enough, they don’t feel prepared and so on. Counselors can coach anxious clients to think ahead and prepare ways to remove themselves from these types of situations, regroup and redirect their thinking, Pisarik says.

> Lifestyle choices. Counselors can also educate clients on the connection between anxiety and lifestyle choices such as sleep patterns, exercise and diet, Pisarik says. For young clients especially, this also includes social media use, he notes.

Pisarik says he frequently talks with his college-age clients about their alcohol consumption, drug use, irregular diet and other aspects of the modern university experience. “The lifestyle of a college student is absolutely conducive to generating anxiety,” he says. “While they are college students, I get that — their job is to have fun and sleep whenever [they] want. But building some sort of healthy routine is important, [including] getting enough sleep and making sure they eat well. I tell them to try and maintain the diet they had at home. … If you’re struggling with anxiety to begin with, any one of those [elements] can add to it, and those are really easy fixes.”

For Bennett, conversations with clients about lifestyle also include questions about smoking and caffeine use. Both tobacco and caffeine can make a person shaky or make his or her heart and mind race, which can trigger or exacerbate anxiety, she points out.

In addition to social media use, Pisarik also asks clients about their social engagement, such as participating in sports or other hobbies. Clients who struggle with anxiety often isolate themselves, he notes, so he works with them to identify social outlets, from volunteering to joining a school club. This sense of connection can reduce anxiety, he says.

> Narrative therapy and externalization. Patterson finds narrative therapy helpful when working with clients with anxiety because it allows them to externalize what they’re feeling. When clients uses phrases such as “I am worried” or “I am anxious,” Patterson will gently redirect them by saying, “No, you’re Susan, and you have a problem called worry.”

“Externalize the problem,” Patterson explains to clients. “Externalize it and dis-identify it. See it outside of yourself. … ‘I can deal with that because it’s not who I am.’ … If you’re carrying it around as if it’s you, you can’t do anything about it. The truth of the matter is, it’s not you.”

Counselors can also help clients with anxiety to focus on a time in their lives when they faced a similar challenge and got through it, Patterson says. She asks clients questions to help them probe deeper. For example: How did you handle that challenge? What worked, and what didn’t work?

 

Working with clients on medication

Anti-anxiety medications are commonly prescribed in the United States. Their prevalence means that counselors are likely to encounter clients who are taking medication to control their anxiety symptoms.

Regardless of their feelings about the use of psychotropic medications, practitioners must treat and support clients who are taking such medications the same as they would any other client, Kuhn says. “I never treat someone differently based on their medication. They get the same CBT therapy that anyone else would get,” she says, adding that the most important thing is to ensure that clients don’t feel judged by the counselor.

Kuhn has seen anti-anxiety medications work well for some clients. “It can take that little edge off that they need to get through the day and be able to function,” she says. At the same time, she also has clients who express a desire to be able to stop taking their medication eventually.

Pisarik notes that for anti-anxiety medication to work well, clients must remember to take it faithfully, keep track of how it makes them feel and schedule the repeated appointments needed to monitor and adjust dosage levels. Each of these elements can pose a challenge to college-age clients. “It’s a lot of work, and [college students] often lack the discipline and time to get it right,” Pisarik says.

Bennett agrees, suggesting that even though professional counselors are not the ones prescribing medications, they still need to discuss and explore medication use with their clients. She also stresses that practitioners should be knowledgeable about the different kinds of medications that clients may be taking and their possible side effects.

Bennett sometimes conducts conference calls with her clients and the medical professionals who are prescribing them medications so that she can help clients ask questions and otherwise be a support to them. “We [counselors] don’t prescribe, but at the same time it’s very important to collaborate with whoever is prescribing the [client’s] medication,” she says. “Be supportive and involve the client in conversations: How long have you taken it? Have you noticed any side effects? Has it been helping? Talk about how often they’re supposed to take it and if they’re adhering to that. There can be stigma about taking medications, so it’s important to normalize it. … It’s comforting too for the client to know that you’re on their side, and part of that is collaboration [about medication].”

 

See the person, not the anxiety

Given how common anxiety disorders are, it’s likely that any counselor’s caseload will be filled with clients presenting with symptoms of anxiety. It is important, however, for counselors to treat each client as an individual and to tailor the therapeutic approach to meet that client’s unique needs, Bennett emphasizes.

Building trust and a healthy therapeutic relationship are key in treating anxiety because clients can feel very vulnerable as they talk about what makes them anxious, Bennett points out. That is why it is critical to get to know these clients as individuals rather than through the lens of their anxiety.

“Don’t assume that because they’re anxious, they’re going to think and behave like other people with anxiety,” Bennett says. “Meet them where they are and find out what’s most effective for them based off of their interests. It can be empowering for clients to integrate their own interests and life experiences into the therapeutic process. Not only does this create buy-in for the client, but it can also help in creating a safe space to begin exploring the vulnerabilities that come along with anxiety. … Hear their story, find their strengths and give them a voice in the process. It’s important to honor them as individuals.”

 

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To contact the counselors interviewed for this article, email:

 

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

Letters to the editor: ct@counseling.org

 

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

Where’s Waldo? A creative tool to introduce CBT skills

By Brandon Ballantyne October 13, 2015

Regardless of how old I get, there are certain childhood activities, toys and outlets that continue to bring me positive memories and feelings. One of my fondest activities from childhood involved Where’s Waldo?

The Where’s Waldo? series was created by Martin Handford. In the books, the reader is invited to scramble and search through pages and pages of chaos and busy illustration in attempt to locate and find the main character, Waldo. Waldo is typically dressed in a red-and-white-striped hat and

"Where's Waldo" image via Flickr creative commons http://bit.ly/1NBXHy9

“Where’s Waldo” image via Flickr creative commons http://bit.ly/1NBXHy9

shirt. However, there are many lookalikes on each page, so attention to detail is very important for the reader.

As a licensed professional counselor who works with adolescents, I find it important to incorporate a certain level of creativity into the process of helping clients build coping skills. I have been strongly trained in the area of cognitive behavior therapy (CBT), so I commonly introduce interventions and skills associated with thought logs and coping thoughts.

With adolescents, I find that providing a basic understanding of CBT is effective in most cases. I typically introduce the theory of CBT as a relationship between thoughts and feelings. I provide education on the way in which thoughts directly influence feelings and establish a foundation of awareness that we can achieve more desirable feelings if we can find ways to change thoughts.

With this basic description of CBT in mind, the intervention of a thought log can be very effective in helping adolescents to practice “catching” negative thoughts, identifying the immediate emotions and then “inserting” coping thoughts to challenge the negative self-talk, thus leading to more desirable emotions and more effective problem-solving of the situation at hand.

I introduce a thought log to my adolescent clients as a type of journal. They can use it to sit down for a given period of time or while in the presence of an external event to actively practice recording negative self-talk/thoughts and any associated emotions that arise as a result of those thoughts. Next the client will identify and record an associated coping thought/positive affirmation to counter the negative self-talk and associated emotions.

It is important to ask clients to rank the intensity of their thoughts and emotions because some coping thoughts may create new emotions, while others may simply decrease the intensity of the negative self-talk. This helps clients form a personal conceptualization and understanding of which coping thoughts are more effective on the basis of the emotions that they want to achieve or decrease the intensity of.

 

The Where’s Waldo? connection

At this point, you may find yourself wondering how this CBT intervention relates to Where’s Waldo? In my professional opinion, the chaos and busy illustration featured on each page of Where’s Waldo? simulates the day-to-day chaos and conflict that clients may experience within their system of stressors: school, family, relationships, peers, jobs, etc.

In the Where’s Waldo? activity, finding Waldo is the goal. For many adolescents, personal goals and ambitions are often discouraged or lost among the chaos and conflict of their day-to-day stressors. This is because that ongoing chaos and conflict can create a stream of negative thought that adolescents often find too difficult to challenge.

In my work with clients, I ask them to practice completing a thought log while engaged in the Where’s Waldo? activity. I invite them to sit with a piece of paper while they search for Waldo and record any negative thoughts that they experience. Examples of negative thoughts while trying to locate Waldo: “I can’t do this”; “This is too hard”; “I want to give up”; “I do not succeed at anything.”

I also ask my clients to record emotions created by these thoughts — for example, frustration, anger, hopelessness and anxiety. It is important to sit with clients as they engage in this activity because the thought log is an active, ever-changing intervention and skill. The counselor not only educates clients on how to perform the thought log but also serves as a support, encouraging clients to counter their negative thoughts with coping thoughts that will help them resist the urge to give up on finding Waldo.

This activity provides clients with an outlet to practice emotional distress tolerance and implement CBT skills in the context of a simulated activity. It also offers them encouragement to apply those same skills to actual day-to-day stressors. To conclude the activity, counselors can invite clients to compare and contrast the negative thoughts and emotions they experienced during the activity with what arises when they encounter the presence of the day-to-day chaos of real life.

Processing the activity creates an opportunity for clients to access personal growth and insight. It also provides them with the confidence to take the thought log home and implement it with some of the specific stressors that may have brought them into treatment. I believe that change occurs when clients are able to apply what is learned in therapy to real-life dilemmas.

By simulating chaos and conflict through creative, nonintimidating outlets such as this Where’s Waldo? activity, we can help clients to acquire the tools and confidence to effectively apply those coping skills to the personal dilemmas that initially led them to treatment.

Remember, as overwhelming as the chaos may seem on each page of Where’s Waldo?, the truth is that Waldo really does appear on every page. This can help to reinforce the idea to clients that at times in real life, it is necessary to tolerate the distress that is present. Because for every moment that distress is tolerated, the opportunity to reach the goal increases.

 

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Brandon S. Ballantyne is a licensed professional counselor, national certified counselor and certified clinical mental health counselor with Reading Health System in Reading, Pennsylvania. Contact him at ballantynebrandon@yahoo.com.

Sex offender therapy: A battle on multiple fronts

By Michael Hubbard March 31, 2014

OffenderWorking with individuals with sex offense convictions is a specialized area of counseling. There are also “specialties within the specialty” when factoring in the different venues for treatment, including programs in prison, in private practice (often with those on postprison supervision or probation) and in mental institutions. The individuals within this population are generally quite different, and the dynamics are made even more complex when considering whether the offenders are adult males, adult females (yes, there are female sex offenders) or juveniles. The research on each population varies considerably. There is a paucity of research on female sex offenders, and research is still somewhat lacking (although growing) on the ever-complex juvenile offenders.

Sex offender therapy is challenging regardless of the nature of the clients, and other factors also come into play. There exists the constant issue of resistance to treatment, particularly when treatment is a condition of probation or parole. Criminogenic thinking pervades the scene, and counselors must be on guard for the often subtle signs of that mind-set. For instance, individuals convicted of sex offenses can be highly manipulative, not only with their therapist but also with others in their therapy groups. Power plays, deflection, grooming and lying are a few examples of the criminal thinking that may be evident. Many offenders will also present with a virtual encyclopedia of thinking errors. Often topping the cognitive distortion list are victim stance (“This label is unfair”), minimization (“All I did was grope her”), justification (“We’d had sex before and she didn’t complain”) and entitlement.

In addition to the cognitive distortions and potential for criminogenic behavior, counselors may also have to contend with other factors such as addictions, co-occurring disorders and, of course, shame, guilt and incredibly demeaning self-talk. The ultimate goal of sex offender therapy is relapse prevention, based first upon accountability and assumption of responsibility for offensive behavior. But when all of these factors are thrown into the mix, the counselor is often faced with denial on several levels: denial of facts (“It wasn’t me”); denial of intent (“I was drunk”); denial of impact (“She didn’t seem to mind”); and denial of the need for treatment.

Research supports the best practice of sex offender therapy being conducted in groups whenever possible. The peer support, which includes challenging denial and other thinking errors, is invaluable in treatment and also lends itself to generally better outcomes. Part of the reason for this is that so many sex offenses are based in secrecy. Bringing offenses out into the open is generally conducive to discussion and to the cognitive elements that are so important to reducing recidivism.

Of course, group therapy adds still other elements for the therapist to consider, including properly populating groups (for example, matching risk factors, genders and ages) and building and maintaining effective group dynamics. Sex offenders don’t want to talk about their “stuff” in front of others. Consequently, providing a safe environment and building trust are staples of effective sex offender therapy groups.

While this represents a formidable enough battlefront on its own, sex offender therapists are faced with another perhaps even more challenging front — that of our society, including our lawmakers.

Society’s perception 

In this discipline, we understand that risk mitigation is a primary concern. After all, society demands and deserves protection, and we all share the goal of ensuring that there will be no more victims of sex offenses. In fact, that is a primary directive.

Yet our society is also responsible for erecting many of the barriers that stand in the way of the recovery that sex offender therapists and our clients strive to achieve. Understandably, victim advocacy is far more palatable than the thought of treating a population that most would prefer to exile. However, the sad fact is that punitive barriers such as limited jobs, housing restrictions and sex offender registration raise significant risk factors for recidivism. These barriers often negate the efforts of sex offender therapists and those clients who possess legitimate desires to recover and return as productive members of society. In fact, our society may be contributing to future victimization — just the opposite of our primary goal.

As we all know, hopelessness is like a vampire to therapy. As our restrictive policies and biases feed that hopelessness, treatment and recovery are undermined, and relapse can become more likely. The short of it is that society’s efforts are based on a significant amount of misinformation and myths about sex offenders, and politicians and law enforcement officials often respond to the public’s demand for protection with tougher and more restrictive laws. Those laws and policies, even when couched as seemingly more sensible restrictions on living locations (as though all sex offenders are child molesters), send a clear message of “not on our block, in our neighborhood or in our town.”

In the meantime, the question of “Who is a sex offender?” is often overlooked. When I describe a 19-year-old who had consensual sex with his 16-year-old girlfriend of two years, some people will respond, “Well, he’s not a sex offender in that case.” Yet I have worked with a number of individuals convicted in similar situations who are now registered as sex offenders for life and required to complete treatment. In fact, there were so many such cases in Oregon that the state finally passed what is referred to as the “Romeo and Juliet law.” Under this law and similar laws in some other states, there is generally no charge of engaging in unlawful sex even if the “victim” is underage and the “offender” is an adult, as long as the age difference is no more than three years and the sexual act was consensual. My point here is that there is no set “profile” for all individuals labeled as sex offenders, yet society and the media frequently attempt to paint one.

Common myths

This particular battle is not restricted entirely to public sentiment. In the state institution in which our program operates, the public’s general misconceptions about sex offenders are often shared by some staff members. And I should point out that those in our counseling community are not immune. Some of the common myths about sex offenders are as follows.

Most sex offenders are predators. Reality: The most common sex offender is opportunistic, has one victim and is known to the victim.

Most sex offenders are dirty old men, strangers and pedophiles who will grab children off playgrounds. Reality: First, pedophiles (those sexually attracted to children) are not necessarily child molesters, for most do not commit offenses regardless of their attraction. Most sex offenders and child molesters are relatives or otherwise known to the family; only 2-3 percent of such offenses are committed by strangers. An estimated half of all child molestations are committed by teenagers.   

Once a sex offender, always a sex offender (most sex offenders will reoffend). Reality: Study results vary considerably depending on the nature of the crime, whether the offender was previously incarcerated, whether the offender received treatment, what kind of support exists and the time after release and/or treatment completion. Yet contrary to popular belief, studies and statistics (including those from the Bureau of Justice) indicate that recidivism rates for sex offenders are lower than those for the general criminal population. A five-year study from the New York State Division of Criminal Justice Services noted a rate of recidivism ranging from 6 to 23 percent, depending on the offense (incest had the lowest recidivism rate, while molestation of boy victims had the highest recidivism rate). The Center for Sex Offender Management cites a recidivism rate of 12-24 percent but adds that many such offenses are underreported. 

Treatment for sex offenders does not work. Reality: This statement has been a source of debate for decades. The effectiveness of treatment depends on a number of factors, including the type of offender, the type of treatment and how much management, supervision and support the offender has. Although the risk of recidivism exists even in the best of cases, most offenders can and will lead productive and offense-free lives after treatment.

 Most sex offenders were sexually abused when they were children. Reality: Although sex offenders are more likely to have been sexually abused than nonoffenders, the vast majority of individuals who were sexually abused will not go on to commit sex crimes. A 2001 study by Jan Hindman and James Peters found that 67 percent of sex offenders initially reported sexual abuse in their history. Yet, when subjected to a polygraph, that figure dropped to 29 percent, suggesting that reports of sexual abuse were initially exaggerated to justify or rationalize their offenses.

I recall my former graduate school classmates, and even some of my professors, asking me, “How can you do that kind of work?” Most often the question came from those working with victims of sexual and physical abuse. Others in law enforcement and victim advocacy programs often repeated the question. The implication from some is that a counselor who treats the instigators of sexual abuse cannot also identify with the victims of such abuse. That argument could not be more fallacious.

Other obstacles

In our sex offender treatment program at a state hospital, a primarily forensic mental institution, our first challenge is getting patients with sex offenses into our program. We run an evidence-based program, principally using cognitive behavior therapy (CBT), that serves all risk levels and populations that have regular and diminished cognition with a variety of biopsychosocial diagnoses. Most of the patients in our program are in the hospital under a “guilty except for insanity” adjudication and under the jurisdiction of Oregon’s Psychiatric Security Review Board (PSRB). No matter why they are here, any patient with a history of a sexual offense or who engages in inappropriate sexual activity is referred to our sex offender treatment program.

When referred, a sex offender risk assessment is conducted to evaluate risk and appropriateness for sex offender therapy and to provide recommendations. Participating in sex offender treatment at the hospital is not mandatory, although the PSRB — concerned with risk mitigation — may consider nonparticipation a risk factor when contemplating the patient’s release to a less restrictive facility.

The patients often balk at the thought of living with the “sex offender” designation, fearful they will be subjected to harassment and other abuse. Their fear is warranted; many are labeled with terms such as chi mo (child molester), pedophile or predator and become targets for possible physical assault. Staff members are not immune to falling into the judgment trap, sometimes in the form of what we call the “ick factor.” Even if they try not to show it, the patients can read it. Many sex offender patients carry so much shame and guilt that any suggestion of judgment can keep them from engaging in treatment or create a setback. We use a considerable amount of motivational interviewing to facilitate patients’ decisions to engage in the treatment they sorely need to progress through this institution.

Because our team operates in a state institution, we face some challenges not seen as often in private practice or other counseling venues. Our patients have mental illness, with everything from schizophrenia spectrum disorders to various personality disorders. In addition, more than one-third of the members in the groups we facilitate have diminished cognition. This represents another barrier to effective treatment, especially when considering that CBT and adjunct approaches such as dialectical behavior therapy and acceptance and commitment therapy are the most foundational and evidence-based practices when working with sex offenders. Indeed, the dynamic risk factors between the populations vary considerably.

As stated before, therapists in this field often deal with criminogenic thinking. Although we may expect that with many clients on postprison supervision, it is easy to forget in this hospital, where we are working with those who have been diagnosed with some form of mental illness. But the guilty except for insanity plea and accompanying diagnoses do not preclude criminogenic thinking. We witness manipulation, victimization and other criminal activities all too frequently. Given all these factors, providing sex offender therapy in our program is sometimes like looking through a fractured lens and still trying to divine a clear image of each patient and how to work with that patient for engagement and progress.

How might this apply to you?

Those of us currently in this field, as well as those counselors who may one day work with sex offenders, must realize that our approach to treatment will be negatively affected should we hold on to the same misconceptions and biases that are so prevalent in society. We are already familiar with the more general bias toward mental illness. Consider how much more that can play out in a charged atmosphere of offenses with the prefix sex. If you are a counselor and saying to yourself, “I have no intention of working with sex offenders,” here’s news for you: Most counselors will work with sex offenders, although perhaps without even knowing it.

Consider that a U.S. Department of Justice report from 2005 said studies suggest that sexual assault is one of the most underreported crimes. That same report estimated that 60 percent of rapes go unreported. As a counselor, you may be just as likely to work with a client who has committed a sexual offense, even though the client comes to you for another unrelated reason, as you are to work with a client who eventually discloses that he or she was sexually molested. Given the underreporting of sexual crimes, it is not unthinkable that you may have a client who has offended and is coming to you due in part to the guilt that he or she is experiencing. Or you may have someone well into therapy for a different reason (for example, depression), only to finally have that client confess to sexual offending.

So, how should you prepare? As with any area in counseling, seek out information, research and guidance. There are a number of excellent resources in the field of sex offender therapy, including the Center for Sex Offender Management, the Association for the Treatment of Sexual Abusers (ATSA) and the New England Adolescent Research Institute. All provide forums for research and to improve the work we do, both in treatment and in support for recovery. ATSA has many organizations under its umbrella on a state level that offer workshops on sex offender therapy and related topics. It also hosts an annual conference with a plethora of research and presentations.

For those inclined to explore or promote advocacy, these organizations (as well as others) produce important educational information. Speaking of which, another misconception exists that if a therapist advocates for a recovery-minded approach in treating sex offenders, that person is precluded from advocating for victims. Some people even view us as “offender defenders.” But most of us have treated, and continue to treat, victims of sexual and other abuse. In doing so, we often treat individuals who are both victims and offenders.

Current research indicates that the most evidence-based therapy for sex offenders, with the best outcomes, is CBT. In addition, a person-centered approach has been demonstrated to be most effective. This is understandable given the shame and suspicion felt by many offenders. An interdisciplinary team that communicates well is another key factor for optimal treatment and supervision. When working with clients on postprison supervision in private practice, this team would include the therapist, the parole officer and other professionals such as polygraphers. In our hospital setting, the communication and cooperation between our sex offender treatment program personnel and the unit psychiatrists, psychologists, nurses and other staff such as treatment care plan specialists are essential to crafting and implementing treatment plans, considering and managing outings and other privileges, and working toward the patients’ recovery and eventual transition to other settings such as group homes.

Other programs, such as one begun in Canada called the Circle of Support and Accountability (COSA), have recognized the need to provide ongoing support and guidance as sex offenders leave treatment and attempt to make their way back into society as productive members. Studies involving the original COSA and those established in states such as Minnesota have demonstrated a significant reduction in recidivism — in some cases, in excess of 70 percent. In turn, this has had a positive fiscal impact by reducing prison time due to relapse and reconviction. Most important, that translates to fewer victims.

As stated earlier, group treatment is best practice in the field of sex offender treatment. Of course, many counselors in private practice may not have enough clients to establish a group. When there are enough members, setting up and running sex offender groups presents another level of challenge. First, groups should be set up with homogeneity in risk level, age and gender. In other words, low-risk clients should not be mixed with high-risk clients, genders should not be mixed and juveniles should not be included in groups with adults.

Once established, group dynamics become a focal point. Even though all group members will have committed some form of sex offense, some members will not be above judging others. For instance, a person convicted of raping an adult female may object to being in the same room with someone who molested a child, a relative or a male adult. Although society may not make distinctions between sex offenders, the offenders themselves sometimes have their own hierarchy.

Another challenge, yet to be sorted out by sufficient research, is treatment of offenders who are developmentally delayed. Some therapists have raised valid questions about using CBT with those who have diminished cognition. In addition, there are some risk factor differences between those with regular cognition and those with diminished cognition. Many treatment programs that handle both populations simply modify their regular program for clients who are developmentally delayed. Others have more distinct programs, with the one for developmentally delayed clients focused more on addressing emotional dysregulation and other dynamic risk factors.

Closing thoughts

Sex offender therapy is a controversial topic. No matter your involvement (or lack of involvement) in working with or advocating for the treatment of this population, you may still experience the battlefront I have outlined. The research and dissemination of findings will be limited as long as there is polarization around sex offender issues and as long as those perceived “sides” are not willing to listen to each other.

As counselors, we all know that listening, and especially reflective listening, involves a number of skills, not the least of which is seeing through the issues without allowing our own emotions to get involved. The public needs to receive an education on these issues. In addition, politicians, government agencies and policymakers must be urged to listen rather than simply striving to establish more “tough on offender” laws that sometimes make little sense and may, in fact, ultimately contribute to additional victims.

As counselors, however, we first focus on caring and applying our skills as best we can. We know that we cannot cure, but we can do our best to prevent future victims. In the process, it’s very likely that you will be faced with the task and frequent frustration of educating others who will not care. In fact, many will suggest that you simply throw away the key rather than provide treatment.

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Michael Hubbard is a mental health specialist with the sex offender treatment program at Oregon State Hospital in Salem, Ore. Contact him at Michael.Hubbard@state.or.us.

 

For related reading, see Hubbard’s July 2014 piece on denial: ct.counseling.org/2014/07/no-i-didnt-denial-revisited/

 

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.