Tag Archives: Eating Disorders

Disordered eating and body bashing

By Kiphany Hof March 17, 2014

Today I ate a piece of chocolate cake, and I survived. This sounds silly, I know. But not too long ago, there were countless days in a row when I truly thought my life was measured by the number on the scale, the size of my jeans, the number of calories I ate or my ability to refuse chocolate cake.

Sadly, this is no exaggeration, and many of you know this because you too are dealing with or have dealt with living in a self-made prison where the bars are made of supermodel standards, fear of rejection, endless exercising, obsession with body image, overeating, undereating, laxatives, diuretics, self-induced vomiting and self-loathing. Would you be able to tell, just by knowing someone, if they are one of the inmates in this prison of torment that destroys both body and soul? Are you one of these people who secretly hope that your warden of self-criticism will unlock the door and free you?

eatingdisorder

I am writing this article because I am a former inmate in the jail of disordered eating and body bashing. I was stunned at the number of people I met, both men and women, who were cellmates of mine, although I did not know it at the time. You too might be surprised at the number of occupants.

This article is not a forum for me to tell my story, however, because my story is really the story of thousands of other men and women across the nation who are locked up and rotting in that same prison. Rather, I hope to catch your attention, even if for the briefest of moments, and remind you that freedom to live freely in a world made up of self-acceptance and contentment is possible, even when you eat chocolate cake.

The etymology of the word disorder is “dis” — meaning “not” — plus the verb, “order.” Translation: not ordered. Ironic, isn’t it, when we consider how much time and effort we expend to “order” ourselves around eating, exercising and the attainment of an acceptable and attractive body?

Even the term “body awareness” is somewhat ambiguous in interpretation. In its positive context, awareness of the way our bodies are uniquely created and the multiple miracles our bodies perform each day is cause for celebration. In its negative context, awareness of how much we hate our bodies and fantasize about them being different is awareness I am sure most people would rather not have.

Personally, I do not think the term “eating disorder” is an accurate description of what happens when someone’s behaviors become so ordered that she or he is more consumed with appearance than with consuming a required, life-sustaining substance: food. It is not about the eating, the calories, the fat grams or even about the food.

What is it about then? When and how did the detailed “order” of it all cross into the “disordered” spectrum?

There are many theories and possible explanations behind the hows and whys of eating disorders and negative body image. Some blame the media for saturating our visual world with unrealistic expectations about the perfect body. Others focus on the influence of societal pressures to look, behave or speak a certain way. Still others believe familial influences contribute to disordered eating and negative thinking.

All of the above may contribute to either a positive/negative, healthy/unhealthy or rational/irrational image of our bodies. Although the roots of our body perceptions may differ, we share a common thread of wanting to be accepted, recognized, admired and wanted by someone at some point in time. Sadly, everyone is painfully aware that physical appearance can either deliver or deny these desires. However, physical appearance is not the only route to fulfillment; it is just the most visible and advertised journey to get there. And that journey is oftentimes costly.

Take a few moments to venture on your own body image journey this week. Are you walking the path of freedom, or are you an inmate in the prison of body hate? Are you visiting someone who is locked up in his or her own fear, guilt and shame? Have you been a person who contributes to the building of those prison walls? Will you choose to celebrate your body this week, without judgment, as you become more aware of its impact on your life? Will you choose to help others unlock the cell door? Will you ask for help in being freed? Will you look beyond the body and see the simultaneous pain and beauty of a human soul? Will you question the meaning of “ideal” and expand your field of vision?

I encourage you to reflect on your own thoughts and feelings about your body and notice who defines them: Is it you or others? As you ponder, challenge yourself and others to find their own personal freedom; it is there, waiting for you to embrace it.

 

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Kiphany Hof, a provisionally licensed mental health practitioner, works as a counselor at University of Nebraska Kearney Counseling Care, a mental health clinic that offers personal counseling to students. Contact her at hofkj@unk.edu.

 

 

Behind the Book: Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment

Heather Rudow March 11, 2013

78076Laura Choate, associate professor of counselor education at Louisiana State University, is the editor of Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment, a new book published by the American Counseling Association. Choate believes the book is a unique resource for counselors that sheds new light on how to treat and prevent eating and obesity-related disorders.

What inspired you to write Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment?

Rates of body dissatisfaction-disordered eating and problems with body weight and shape are increasing in populations across the life span. For example, young women are particularly at high risk for eating-related concerns such as binge eating, and obesity rates are increasing rapidly in the general population, putting individuals at risk for negative health outcomes. Furthermore, those individuals who experience body dissatisfaction and subthreshold eating disorders are at high risk for the development of potentially life-threatening, full-syndrome eating disorders such as anorexia nervosa and bulimia nervosa. The book provides insight into these problems and offers detailed information for the prevention and treatment of these concerns.

How does this book compare with similar books on market?

There is little information available in the field written primarily for a counseling audience. Many of the best-practice treatments are located in manuals that are hard to access. This resource provides essential foundational information for counselors such as sociocultural influences, gender differences, ethical issues, information on current assessment and diagnostic concerns, effective prevention programs for communities and schools, and best-practice treatments for a range of eating-related problems.

The book is distinct from others on the market due to the fact that it is written specifically for counselors. It contains both detailed prevention and treatment guidelines; it has a school and community focus; and it is accessible for practitioners who may not specialize in the area of eating disorders and obesity.

Some special features are as follows:

  • The book contains chapters from authors in the field who are well known among eating disorders professionals but who might not be known to counselors, such as Margo Maine, Linda Smolak, Douglas Bunnell, Diane Wilfley, Marian Tanofsky-Kraff, Eric Stice, Heather Shaw and Niva Piran. The book also contains chapters by authors from Canada and Australia. Counselors will benefit from an interdisciplinary perspective on eating disorders prevention and treatment that is tailored specifically toward their needs
  • The book contains information on sociocultural dynamics, assessment, diagnosis, conceptualization, prevention and treatment. Counselors will have information on a variety of topics located in one resource.
  • The book is written in an accessible format, with chapter highlights, case examples, and recommended online and print resources. Because it is reader friendly, counselors will be able to access and use the information.

How did you choose contributing authors, and how did this enhance the content? 

The idea for the book came from my experience as guest editor for the special section on eating disorders prevention and treatment published in the summer 2012 issue of the Journal of Counseling & Development. Based on the response to that collection of articles, I decided to compile a book on both eating disorders and obesity, and to address the areas of foundation, assessment and practice frameworks, prevention and evidence-based treatments. I invited some of the authors from the special section to contribute chapters based on their fit with one of these four areas, then sought out specific leading experts in the eating disorders/obesity prevention and treatment field to round out each section. The authors are practitioners as well as researchers and come from psychiatry, psychology and counseling disciplines, and all are doing important work in the U.S. as well as in Canada and Australia. I was honored to have a chance to work with each of them.

How did you get involved with subject?

The idea for this edited book originates from a variety of influences. First, my desire to compile this type of book stems from being a mother of elementary-age children who are exposed daily to harmful media images and messages regarding narrow cultural definitions of how they “should” look and act. Because I want my children and all others to be equipped with the skills they need to stay healthy and resilient in the face of cultural pressures around eating, weight and shape, this book is dedicated to assisting counselors and their clients to become empowered to effect positive change in this area within the multiple systems  —family, school, community — in which they are embedded.

The origins of this book are also grounded in my professional experience as a licensed professional counselor and counselor educator. I have been involved in the prevention and treatment field in a variety of roles. I have counseled clients, supervised and taught graduate students, published articles regarding body image resilience and eating disorders treatment, and presented at local schools to adolescent girls as well as to professionals at state and national conferences. I have observed that counselors are often unclear as to their role in preventing eating disorders and obesity and in providing early intervention and treatment, and they often lack training in best practices in this field. Therefore, the overarching purpose of this book is to provide a much-needed resource specifically targeted to counselors that provides accessible information practitioners can implement in their daily work with clients across the continuum of care. The book strategically includes chapters that address assessment, prevention and treatment, including information for working with children and adults as well as with clients from diverse cultural groups.

What are the most important take-away messages for the reader?

Readers will have access to current information on assessment, diagnosis, prevention and treatment of eating-related problems, eating disorders and obesity. Each chapter contains information to provide a knowledge base as well as essential resources for further education and training in that particular area of the field. 

Who is the best audience for the book?

This book is intended for all counselors, not just those who specialize in eating disorders and obesity treatment. Therefore, all school counselors, mental health counselors, counselors with interest in health and wellness — specifically eating disorders and obesity — child and adolescent counselors and counselor educators will benefit from this book.

Why is this book important to the counseling profession?

Both practical and comprehensive, this long-needed book provides a clear framework for the assessment, treatment, and prevention of eating disorders and obesity. Focusing on best practices and offering a range of current techniques, experts in the field examine these life-threatening disorders and propose treatment options for diverse clients experiencing problems related to eating, weight and body image.

Parts I and II of the text address risk factors in and sociocultural influences on the development of eating disorders, gender differences, the unique concerns of clients of color, ethical and legal issues, and assessment and diagnosis. Part II explores prevention and early intervention with high-risk groups in school, university and community settings. The final section of the book presents a variety of best-practice treatment interventions, such as cognitive behavioral, interpersonal, dialectical behavior and family-based therapy, which are empirically supported and have been used successfully in a variety of settings.

Click here to purchase a copy of Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment.

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.

 

Binge eating disorder to be recognized in the DSM-V

Heather Rudow December 11, 2012

(Photo: Flickr/46137)

As the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is set to be released in May, counselors are preparing for the changes that will come along with it, including the inclusion of binge eating disorder as a mental illness.

Binge eating disorder had previously been listed as “under review” because symptoms can sometimes be similar to mood disorders such as depression and anxiety.

The disorder is identified by “a sense of lack of control over eating during the episode” with the individual also exhibiting three or more of the following:

  • Eating much more rapidly than normal.
  • Eating until feeling uncomfortably full.
  • Eating large amounts of food when not feeling physically hungry.
  • Eating alone because of feeling embarrassed by how much one is eating.
  • Feeling disgusted with oneself, depressed or very guilty afterward.

However, Eric Cowan, a professor in the Department of Counseling and Graduate Psychology at James Madison University, has reservations about the new classification.

“Binge eating has long been recognized by clinicians as a compensatory symptom and one possible manifestation of any number of underlying disorders,” says Cowan, a member of the American Counseling Association who co-wrote a Knowledge Share article about bulimia in the December issue of Counseling Today. “However, I think that making binge eating a discrete diagnosable disorder will create a problem for some clinicians.”

Cowan says he is concerned that there will be too much overlap between individuals whose disordered eating could be considered a mental illness and those who tend to display what he calls “problematic eating” behaviors but are otherwise normal.

“This is especially true,” Cowan points out, “in that our culture’s relationship with food, both physically and emotionally, could be considered disordered. In other words, because the criteria for binge eating disorder are behaviorally based and a person either meets the criteria or not without regard to other contextual and relevant factors, it could pathologize behaviors that in the past we have considered as within the range of the ordinary. We don’t have this issue with other eating disorders. Both anorexia and bulimia have associated behaviors and symptoms that are clearly disordered, such as the severely altered perception of one’s own body or purging behaviors. Binge eating disorder, on the other hand, is somewhere on the continuum of eating behaviors that includes mere habitual overindulgence.

With the DSM-IV, says Cowan, if counselors judge that their client’s binge eating is a “significant factor in the client’s presentation, they could classify it as [an] Eating Disorder [Not Otherwise Specified]. The binge eating might occur with other eating behaviors that did not meet the criteria for anorexia or bulimia. With binge eating now a [concrete] disorder, counselors will now have to parse out these symptoms. It is possible that binge eating disorder could be the client’s only diagnosis, regardless of whether it reflects the most salient aspects of the client’s presentation or pathology.”

As with all diagnoses, Cowan warns that there is now a danger of losing information, as counselors must fit clients’ symptoms into narrower categories.

Clients may also be impacted by the change in that more of them will fit the criteria for a mental disorder, he adds.

“In reclassifying these behaviors as pathology,” Cowan continues, “we are not merely diagnosing, we are also communicating, both with other mental health professionals [and also with clients] about how they should think about themselves.”

Some practitioners contend that adding binge eating disorder to the DSM will allow clients to receive treatment with insurance coverage and allow mental health professionals to seek insurance reimbursement. But Cowan disagrees.

“I don’t think that not having binge eating disorder in the DSM-IV hindered mental health professionals from getting insurance reimbursement,” he says. “Almost always, significantly disordered eating is a symptom of underlying problems of thought or affect that are themselves discrete diagnosable disorders for which insurance reimbursement is accepted. Not to mention that binge eating could always be classified as Eating Disorder NOS.”

But what strikes Cowan most about classifying binge eating as a mental illness in the DSM, he says, is “that these symptoms are invariably a manifestation of a more fundamental disorder of self. The binge eating behaviors stand in for underlying processes involving affect regulation, self esteem and so on. Though the DSM system does not intend to address causation, the myriad ways in which these self disorders can manifest must make us cautious about reifying any one configuration of symptoms and assuming that because we have named it we have also better understood it. All normal behaviors that are taken to an extreme can be classified as pathological. We have to be careful about where, for the sake of helping our clients, we draw the line on the continuum.”

 Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.

Understanding bulimic dissociation to create new pathways for change

Rebecca Heselmeyer & Eric W. Cowan December 1, 2012

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

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

Self-psychology and the vertical split

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

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

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

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

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

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

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

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

Dissociation, revisited

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

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

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

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

Clinical applications

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

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

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

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

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

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

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

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

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

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

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