Tag Archives: cognitive behavioral therapy

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.

 

A protocol for ‘should’ thoughts

By Brandon S. Ballantyne October 31, 2017

As a licensed professional counselor, I believe that cognitive behavior therapy (CBT) offers clients a natural platform to gain insight into the relationship between thoughts and emotions. Using cognitive behavioral techniques, I invite clients to explore the specific nature and content of their thoughts and examine the ways in which these thoughts influence emotional distress.

Through CBT-oriented trial and error, thought records and behavioral experiments, clients can develop a comprehensive tool belt for responding to stressful events in a self-structured and practical manner. The active identification and disputation of negative thinking leads to improved emotional states and healthier behavioral reactions. I often introduce this concept as an enhanced version of the common treatment goal of learning how to “think prior to reacting.”

 

Framework

Before an individual forms an emotion, that individual needs to observe an event. This event can be a person, place, thing or activity. The important criteria here is not what the individual observes but simply the fact that an event has been noticed.

Once an event is observed by the individual, the brain produces a thought. A thought is very different from an emotion. A thought is a statement that is verbalized or experienced silently. A thought has sentence structure. Every thought has punctuation. Some thoughts end in a period. Some thoughts end in a question mark. Some thoughts end in an exclamation mark. It is important for the counselor to offer this education to the client. To experience success with CBT coping tools, it is essential for the client to be able to differentiate between thoughts and emotions.

Once a thought is produced and experienced by the individual, an emotion is formed. I tell my clients that in some cases, it feels as if the emotion occurs before the thought, but CBT tells us this is not exactly true.

Individuals experience emotions as an internal continuum of distress. This means that emotions can fluctuate from low distress to moderate distress to high distress. Most of the time, individuals will experience emotions consistent with mad, sad, glad or fearful. The continuum of emotional distress is often experienced parallel to physical symptoms. In other words, certain emotional states will produce certain physical symptoms. Counselors can assist clients in recognizing which physical symptoms are most typically associated with each emotional state.

For example, the emotional state of mad often occurs parallel to a headache or clenched fists. The emotional state of sad often occurs with tearfulness and internal weight between the stomach and lungs. The emotional state of glad most often occurs with smiling or laughter. The emotional state of fear most often occurs with a rush of adrenaline, quickening heart rate and sweaty palms. Of course, individuals can experience many other emotional labels and physical symptoms, but acquiring this basic education about emotion-body response can enhance our clients’ abilities to more clearly identify what they are feeling at any given time. This also provides clients with another important layer in understanding the difference between thoughts and emotions.

Once an emotional state is experienced, a behavioral reaction will be provoked. A behavioral reaction is simply something that the individual says or does that leads to a desirable or undesirable environmental/social outcome. Behavioral reactions that lead to undesirable outcomes typically create more barriers and perpetuate the cycle of life problems. Positive behavioral reactions lead to desirable outcomes and ignite a cycle of positive change.

The key to all of this is for individuals to identify where they can initiate intervention in their cognitive behavioral processes. Intervention can occur immediately after thoughts or immediately after the formation of the emotion. As long as intervention is implemented prior to the behavioral reaction, then positive change can take place.

Counselors can assist clients in building cognitive behavioral skills through the examination of self-talk. Self-talk is another term used for thought. Because thoughts have sentence structure to them, the sentence content in our thoughts is directly responsible for the formation of emotion.

Certain “words” increase emotional distress when they are experienced within our self-talk. One of the biggest culprits is the word “should.” When individuals experience “should” in their thoughts, it produces an emotional state associated with a demand to achieve extreme standards or ideals. The emotional consequence is likely to be guilt, frustration or depression. When directing their “should” thoughts toward others, individuals are likely to feel anger and resentment.

 

Protocol/intervention

I have developed the following intervention as a tool that counselors can use with clients consumed with persistent “should” thoughts and who identify unpleasant emotional responses that have led to patterns of undesirable behavioral reactions and environmental/social consequences. The intervention’s goal is to offer a protocol for effective identification, practice, application and implementation of cognitive restructuring, specifically in the context of problematic “should” thoughts.

 

S-H-O-U-L-D

Say: It is important to encourage the client to verbalize the “should” thought out loud. This brings life to the negative thought process and makes the negative self-talk a concrete, tangible item to work on in the counseling process. It also creates a safe opportunity for the counselor and client to work at restructuring negative internal dialogue within the realm of trust and rapport that they have developed.

Counselor: “Help me understand these should thoughts. I would like to invite you to verbalize them out loud to me.”

Client: “I should not feel depressed. I have no reason to be depressed.”

 

Hold: It is important for the client to learn to tolerate the distress created from the negative self-talk. The counselor encourages the client to practice tolerating the emotional discomfort through a pause and delay. This creates an opportunity to enhance distress tolerance ability, while engaging in safe examination of the negative self-talk.

Counselor: “There is pressure to react to these emotions. Try not to react. Let’s slow things down so we can address this rationally. I would like you to try and sit with these emotions, in the presence of my support, for as long as you can tolerate. Let’s try to pause and delay a reaction for one to two minutes.”

Client: “I will try my best.”

 

Offer: The counselor and client engage in a discussion of possible alternative ways of thinking that could potentially lead to more desirable emotional states and healthier behavioral reactions. This is a brief trial-and-error component within the intervention. The counselor will engage with the client in a balanced, rotational practice of coping thoughts.

Counselor: “If we were to remove the word should from your negative self-talk, what can we replace it with that might reduce the emotional pressure that you feel? Let’s discuss all the possibilities together.”

Undo: It is important to identify one coping thought that the client can continue to practice within his or her routine internal dialogue. For example, the counselor might ask the client to write one coping thought on an index card that can be kept in a safe, visual space. This encourages proactive, routine practice of healthier self-talk. It also makes the coping thought a concrete, tangible tool that can be used both in the present and in the future, as needed, in the context of counseling goals.

Counselor: “Which one of the coping thoughts that we discussed today do you feel you could continue to utilize as positive self-talk during future episodes of distress?”

Client: “I have experienced depression for a reason. I have permission to feel how I feel. I am always working on finding ways to cope with my life stressors, and I am doing the best that I can.”

 

Learn: The counselor and the client identify a homework assignment or task for the client to complete that encourages ongoing utilization of this tool. For example, the counselor might invite the client to begin a thought log, in which the client actively records dates and times when the tool is utilized and how effective it was in reducing emotional distress or contributing to healthier behavioral reactions. This provides opportunities for the client to begin constructing a cognitive behavioral blueprint for effective thought substitution.

Counselor: “I would like to introduce you to an exercise called a thought log. This will provide you with a platform to practice replacing ‘should’ thoughts with more positive self-talk this coming week. Remember, the most effective change takes place when you can take the skills learned in counseling and apply them to situations outside of these office walls.”

 

Do: Follow-up is essential to the counseling process. If the counselor and client agree on homework assignments or behavioral experiments, it is important for the counselor to follow up with the client to examine the client’s beliefs about what is effective versus ineffective. This holds both the counselor and the client accountable for maintaining diligence and dedication in their roles within the counseling relationship.

Counselor: “In the prior session, we discussed problematic ‘should’ thoughts, and I offered you the assignment of a thought log. How did you do with that?”

 

Conclusion

As a professional counselor, I am always looking for ways to enhance my practice and also share my interpretation of theories and treatment approaches. I hope that this piece will help you reflect on ways in which you may be able to use a tool such as the one I described with the clients you serve. Through continued consultation, collaboration and publication, mental health professionals can become unified in our mission to initiate genuine counseling processes that contribute to the enhanced well-being of our clients. I would love to hear your feedback on how this CBT tool is working for you and the individuals you serve.

 

 

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Brandon S. Ballantyne is a licensed professional counselor and national certified counselor who has been practicing clinically since 2007. He currently practices at Reading Health System in Reading, Pennsylvania, and Advanced Counseling and Research Services in Lancaster. He has a specialized interest in using cognitive theory to help his clients recognize problematic thought patterns and achieve more desirable emotions and healthier behavioral responses. Contact him at Brandon.Ballantyne@readinghealth.org.

 

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Other articles by Brandon S. Ballantyne, from the Counseling Today archives:

 

 

 

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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.

 

 

A light in the darkness

By Bethany Bray October 30, 2017

Erin Wiley, a licensed professional clinical counselor in northwestern Ohio, once had a client tell her that seasonal depression was like diving into a deep, dark pond each fall. Wiley understands the comparison. With seasonal depression, “you have to prepare to hold your breath for a long time until you get across the pond, reach the other side and can breathe again,” she says.

Wiley routinely sees the effects of seasonal depression in her clients — and in herself — as summer wanes, with the days getting shorter and the weather getting colder. Ohio can be a hard place to live when daylight saving time takes effect and the sun starts setting just after 4 p.m., she says.

Seasonal depression “feels like a darkness that’s chasing you. You know it’s coming, but you don’t know when it’s going to pin you down,” says Wiley, a member of the American Counseling Association. “[It’s like] getting pinned down by a wet blanket that you just can’t shake, emotionally and physically. … For those who get it every year, you can have anxiety because you know it’s coming. There is a fear, an apprehension that it’s coming. [You need] coping skills to have the belief that you have the power to control it.”

For Wiley, the owner of a group practice with several practitioners in Maumee, Ohio, this means being vigilant about getting enough sleep and being intentional about planning get-togethers with friends throughout the winter months. Keeping her body in motion also helps, she says, so she does pushups and lunges or walks a flight of stairs in between clients and leaves the building for lunch. If a client happens to cancel, “I will sit at a sunny window for an hour, feel the sun on my face, meditate and be mindful,” she adds.

Seasonal depression, or its official diagnosis, seasonal affective disorder (SAD), can affect people for a large portion of the calendar year, Wiley notes. Although there is growing awareness that some people routinely struggle through the coldest, darkest months of the year, it’s less well-known that it can take time for these individuals to start feeling better, even once warmer weather returns in the spring. According to Wiley, seasonal depression can linger through June for her hardest-hit clients.

“It takes that long to bounce back,” she says. “They’re either sinking into the darkness or coming out of it for half the year.”

Symptoms and identifiers

SAD is classified as a type of depression, major depressive disorder with seasonal pattern, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. According to the American Psychiatric Association, roughly 5 percent of adults in the U.S. experience SAD, and it is more common in women than in men. The disorder is linked to chemical imbalances in the brain caused by the shorter hours of daylight through the winter, which disrupt a person’s circadian rhythm.

People can also experience SAD in the reverse and struggle through the summer, although this condition is much rarer. Wiley says she has had clients who find summers tough — especially individuals who spend long hours inside climate-controlled, air-conditioned office environments with artificial lighting.

Regardless, a diagnostic label of SAD isn’t necessary for clients to be affected by seasonal depression, say Wiley and Marcy Adams Sznewajs, a licensed professional counselor (LPC) in Michigan. Sznewajs says that SAD isn’t a primary diagnosis that she sees often in her clients, but seasonal depression is quite common where she lives, which is less than 100 miles from the 45th parallel.

“I live in a climate where it is prevalent. I encounter it quite a bit and, surprisingly, people are like ‘Really? This makes a difference [with mental health]?’” says Sznewajs, an ACA member who owns a private practice in Beverly Hills, Michigan, and specializes in working with teenagers and emerging adults. “We change the clocks in November, and it’s drastic. It gets dark here at 4:30 in the evening, so kids and adults literally go to school and go to work in the dark and come home in the dark.”

Likewise, Wiley says that she frequently sees seasonal depression in clients who don’t have a diagnosis of SAD. “I notice it with my depressive clients,” she says. “I have been seeing them once a month [at other times of the year], and they ask to come in more often during February, March and April, or they need to do more intensive work in those months. It’s rare for someone to be healthy the rest of the year and struggle only in the winter. It’s [prevalent in] people who struggle already, and winter is the final straw. They need extra help in the winter and reach out [to a mental health professional] in the winter.”

In other instances, new clients begin to seek therapy because life events such as the loss of a job or the death of a loved one push them to a breaking point during a time of the year — typically winter — when they already feel at their lowest, Wiley notes.

Cindy Gullo, a licensed clinical professional counselor in O’Fallon, Illinois, says that she doesn’t encounter clients who have the SAD diagnosis very often. However, she says that roughly 2 out of every 10 of her clients who have preexisting depression experience worsening mood and exacerbated depression throughout the fall and winter months.

The symptoms of SAD mimic those of depression, including loss of interest in activities previously enjoyed, oversleeping and difficulty getting out of bed, physical aches and pains, and feeling tired all of the time. What sets seasonal depression apart is the cyclical pattern of symptoms in clients, which can sometimes be difficult to see, Sznewajs says. If a client presents with worsening depressive symptoms in the fall, counselors shouldn’t automatically assume that seasonal depression is the culprit, she cautions. Instead, she suggests supporting the client through the winter, spring and summer and then monitoring to see if the person’s symptoms worsen again in the fall.

“If they show improvement [in the spring/summer], and then I see them in October and they start to slide again, that’s when I have to say it could be the season. And certainly if they point it out themselves — [if] they say, ‘I’m OK in the summer, but I really struggle in the winter.’ It’s really when you start to notice a pattern of worsening mood changes in November and December [that alleviate] in the summer.”

Sznewajs recalls a female client she first worked with when the client was 13. She saw the client from October through the end of the school year, and the young woman showed significant improvement. The client checked in with Sznewajs a few times during the summer, but Sznewajs didn’t hear from her much after that. Then, when the client was 16, she suddenly returned to Sznewajs for counseling — in the wintertime. In recounting the prior few years, the young woman noted that her struggles usually seemed to dissipate around April each year, even though the pressures of the school year were still present at that point.

“‘I don’t know what’s going on with me,’” Sznewajs remembers the client remarking. “‘I’m a mess right now.’ It was very evident that there was a pattern [of seasonal depression] with her.”

Wiley notes that clients with seasonal depression often describe a “heaviness” or feelings of being weighed down. Or they’ll make statements such as, “It’s just so dark,” referring both to the lack of sunlight during the season and the emotional darkness they are enduring, Wiley says.

Gullo, an ACA member and private practitioner who specializes in working with teenagers, keeps an eye out for clients who become “very flat” and engage less in therapy sessions in the fall and winter. Other typical warning signs of seasonal depression include slipping grades (especially among clients who normally complete assignments and are high achievers at school), changes in appetite, sluggishness, weepy or irritable mood, and withdrawal from friends and family. For teens, the irritability that comes with seasonal depression can manifest in anger or frustration, Gullo says. For example, young clients may have an outburst or become agitated over small things that wouldn’t bother them as much during other times of the year, such as a parent telling them to clean their room, Gullo says.

John Ballew, an LPC with a solo private practice in Atlanta, estimates that up to one-third of his clients express feeling “more grim,” irritable or unhappy as winter approaches. He contends that the winter holidays “are a setup to make things worse” for clients who are affected by the seasons.

Overeating and overconsumption of alcohol are often the norm during the holidays, and this is typically coupled with the magnification of family issues through get-togethers, gift giving and other pressures, notes Ballew, a member of ACA. In addition, many coping mechanisms that clients typically use, such as getting outside for exercise, may be more difficult to follow in the winter. And although many people travel around the holidays, that travel is often high stress — the exact opposite of the getaways that individuals and families try to book for themselves at other times of the year.

“It’s a perfect storm for taking the ordinary things that get in the way of being happy and exacerbating them,” Ballew says. “People feel heavily obligated during the holidays, more so than in other seasons. It means that we’re not treating ourselves as well, and that can be a problem.”

[For more on helping clients through the pressures and stresses of the holiday season, see Counseling Today‘s online exclusive, “The most wonderful time of the year?https://wp.me/p2BxKN-4TI]

In the bleak midwinter

The first step in combating seasonal depression might be normalizing it for clients by educating them on how common it is and explaining that they can take measures to prepare for the condition and manage their feelings.

“Educating [the client] can give them control,” Sznewajs says. “People often feel shame about depression. Explain that you can take steps to treat yourself, just like you would for strep throat. You can’t will yourself to get better, but you can do things to help yourself get better. When you know what’s causing your depression, it gives you power to take those steps.”

Ballew notes that many of his clients express feeling like a weight has been lifted after he talks to them about SAD. “Many of them won’t think they have [SAD], but they will say, ‘Winter is a hard time for me’ or ‘I get blue around the holidays.’ They’re caught off guard by this unhappiness that seems to come from nowhere. People seem to feel a certain amount of relief to find that it’s something they will deal with regularly but that they can plan for and be cognizant of. It doesn’t mean that they’re defective or broken. It’s just that this is a stressful time. That helps us take a more strategic and problem-solving approach.”

Many counselors find cognitive behavior therapy (CBT) helpful in addressing seasonal depression because it combats the constant negative self-talk, catastrophizing and rumination that can plague these clients. CBT can assist clients in turning around self-defeating statements, finding ways to get through tough days and taking things one step at a time, Sznewajs says.

Gullo gives her teenage clients journaling homework (she recommends several journaling smartphone apps that teenagers typically respond well to). She also encourages them to maintain self-care routines and social connections. For instance, she might request that they make one phone call to a friend between counseling sessions.

Wiley guides her clients with seasonal depression in writing a plan of management and coping mechanisms (or reviewing and updating their prior year’s plan) before the weather turns cold and dark. She types out the plan in session while she and the client talk it over. Then she emails it so that the client will have it on his or her smartphone for easy access. The plans often include straightforward interventions — such as being intentional about going outside and getting exposure to natural light every day — that clients may not think about when dealing with the worst of their symptoms midwinter.

“It sounds simple, but those [individuals] who are down may not realize that the sun is shining and they better get outside to feel it on their face,” Wiley says. “We list exercises that are feasible. You might not join the gym, but what can you do? Can you walk the staircase at your house five times a day? Or, what’s one [healthy] thing you can add to your diet and one thing you can take away, such as cutting down to having dessert once per week, cutting out your afternoon caffeine or drinking more water. And what’s one thing you can do for your sleep routine? [Perhaps] take a hot shower before bed [to relax] and go to bed at the same time every night.”

Wiley also reminds clients to simply “be around people who make you feel happy.” She suggests that clients identify those friends and family members whom they enjoy being with and include those names on their therapeutic action plans for the winter.

All of the practitioners interviewed for this article emphasized the importance of healthy sleep habits, nutrition and physical activity for clients with seasonal depression. “All of these things are really hard to do when you feel lousy, so that’s why the education [and planning] piece is so important,” Sznewajs says. “Let them know that this [the change in seasons] is why you feel lousy, and it’s not your fault. But there are ways to feel better.”

Sznewajs typically begins talking with clients about their seasonal action plans in early fall and always before the change to daylight saving time. One aspect of the discussions is brainstorming how clients can modify the physical activities they have enjoyed throughout spring and summer for the winter months.

One of the cues Wiley uses to tell if clients might be struggling with seasonal depression is if they mention cravings for simple carbohydrates (crackers, pasta, etc.), sugars or alcohol when the days are dark and cold. They don’t necessarily realize that they are self-medicating in
an attempt to boost their dopamine, Wiley says.

Of course, exercise is a much healthier way of boosting dopamine levels. “Exercise is important, but it’s really hard to get depressed people to exercise,” Wiley acknowledges. “Telling them to join the gym won’t work when they just want to cry and lay in bed. So, turn the conversation: What is something you can do? If you already walk your dogs out to the corner, can you walk one more block? Take the stairs at work instead of the elevator, or park farther away from the grocery store.”

Effectively combating seasonal depression might also include counselor-client discussions about proper management of antidepressants and other psychiatric medications. Gullo recommends that her clients who are on medications and are affected by seasonal depression set up appointments with their prescribers as winter approaches. Sznewajs and Wiley also work with their clients’ prescribers, when appropriate, to make sure that these clients are getting the dosages they need through the winter.

Wiley will also diagnose clients with SAD if the diagnosis fits. “For someone who is really struggling and could benefit from [psychiatric] medication, the prescriber is often thankful for a second opinion. It adds weight and clarity to what the client is saying and what the doctor is hearing,” Wiley says. “It also helps the client to have a diagnosis so they don’t just wonder, ‘What’s wrong with me?’ It removes the blame and shame for people who are really struggling.”

Seeking the light

Many factors contribute to seasonal depression, but a main trigger is the reduced amount of daylight in the winter. It is vitally important for clients with seasonal depression to be disciplined about getting outdoors to feel natural light on their faces and in their eyes, Wiley says. She coaches clients to be disciplined about making themselves bundle up and get outside on sunny days or, at the very least, sit in their car or near a window for extra light exposure.

Wiley cautions clients against using tanning beds as a source of warmth and bright light to fend off seasonal depression. However, she acknowledges that she has seen positive results with tanning beds in severe cases of seasonal depression in which individuals were verging on becoming suicidal. In those extreme cases, counselors must weigh the long-term risks of using a tanning bed versus the more immediate risks to the client’s safety, Wiley says.

In addition to encouraging those with seasonal depression to get outdoors, Gullo and Sznewajs have introduced their clients to phototherapy, or the use of light boxes. Roughly the size of an iPad, these boxes have a very bright light (more than 10,000 lumens is recommended for people with seasonal depression) that clients can use at home.

Sznewajs recommends that clients use a light box first thing in the morning for at least 30 minutes to “reset their body,” increase serotonin and boost mood. If a client responds positively to phototherapy, it also serves as an indicator that he or she has SAD (instead of, or in addition to, nonseasonal depression), she notes.

Neither Gullo nor Sznewajs require clients to purchase light boxes. Instead, they simply introduce the idea in session and suggest it as something that clients might want to try. Insurance doesn’t typically cover light boxes, but they can be purchased online or at medical supply stores.

Gullo does keep a light box in her office so she can show clients how it works. She also recommends “sunrise” alarm clocks, which feature a light that illuminates 30 minutes before the alarm sounds. The light gradually becomes brighter and brighter, mimicking the sunrise. Gullo uses this type of alarm clock at home and finds it helpful.

The light box and sunrise alarm clock “are game changers,” Gullo says, “and a lot of people don’t know they exist.”

Powering through

In The Lion, the Witch and the Wardrobe, the second book in C.S. Lewis’ The Chronicles of Narnia series, characters struggle through never-ending cold that is “always winter but never Christmas.” Grappling with seasonal depression can feel much the same way: an uphill battle in a prolonged darkness in which occasions of joy have been snuffed out.

The key to making it through is crafting and sticking to a plan. Sznewajs says she talks with clients in the early fall to help them prepare: Yes, winter is coming, and you’re probably going to feel lousy, but it won’t last forever, and there are ways of getting through it.

“People need to understand that this is a totally predictable kind of concern,” Ballew concurs. “It’s not weak or self-indulgent [to feel depressed]. This is a hard time of year for many people, and you need to plan for it. … We [counselors] are in a great place to validate clients’ concerns, but also help them to strategize beyond them.”

 

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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.

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.