Tag Archives: Mental Health

Digging into the numbers

By Scott Rasmus February 9, 2017

It has been relatively well-publicized in the media that mental illness typically affects 20 percent of the U.S. population, or about 1 in 5 people, yet the source of this statistic is rarely disclosed. Furthermore, media sources typically discuss mental illness in general terms and don’t address its susceptibility by age or present statistics on the prevalence of mental illness over time. For instance, a basic comparison of mental illness prevalence statistics between children and adults, or in any given year versus over a person’s lifetime, is rarely offered.

Therefore, I wanted to offer a web-based meta-analysis of prevalence statistics for mental illness by including as many reputable sources of mental health information as I could identify. These sources include the Centers for Disease Control and Prevention, the National Alliance on Mental Illness, the American Psychological Association, the American Psychiatric Association, the National Institute of Mental Health (NIMH), the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Office of the Surgeon General. The focus of my research was on the most current web research available, spanning the years 2011 to 2015.

Prevalence data

What are the generally accepted definitions of one-year prevalence and lifetime prevalence for mental illness? The NIMH defines one-year prevalence as the proportion of people who have experienced a mental illness in the past year, whereas lifetime prevalence reflects how many people have experienced an incidence of mental illness at any point in their lives up until the point of assessment. These numbers are typically reported as a percentage of the population. It is important to note that these statistics do not necessarily reflect new cases of mental illness, but rather those individuals who have experienced an instance of mental illness — new, ongoing or otherwise — in a given time period. With these definitions in mind, let’s look at the prevalence numbers.

In reviewing the prevalence statistics from various sources, my web research indicated that the average one-year prevalence for adults with mental illness was 22.2 percent (see Table 1), ranging from 14.5 to 26.2 percent over eight well-accepted sources. The average number trends higher than the general prevalence statistic that is often cited in the media, indicating that mental illness is somewhat more common than what is typically reported. With this in mind, one-year prevalence statistics should be revised and presented to the public to reflect that mental illness affects between 20 and 25 percent of adults in any given year.

For youths, I found data only for those ages 8-18. My research indicated that the average one-year prevalence number for mental illness among youths supported the number that is typically reported in the media — 20 percent (see Table 1). However, whereas I identified eight reputable sources of statistics for prevalence of mental illness among adults, I could identify no more than two such sources for youths. This discrepancy in viable sources suggests that a need exists for better research to identify the prevalence of mental illness among our children and adolescents.

I next refined the study to look at the one-year prevalence statistics for severe mental illness (see Table 2). When investigating this special population that is rarely reported in the media, my research indicated that the one-year prevalence average of severe mental illness among adults was 5.7 percent, ranging from 4 to 9.5 percent over seven sources. For youths ages 8-18, the one-year prevalence for severe mental illness averaged about 14 percent over just two sources, with a wide range from 9 to 20 percent.

Putting these numbers in the context of general mental illness, it implies that among adults, severe mental illness constitutes about a quarter of all cases, whereas among youths, severe mental illness makes up more than two-thirds of cases in any given year. This highlights an interesting difference, but we may infer from these numbers that the prevalence of severe mental illness can differ widely based on the definitions applied to it.

My experience suggests that these definitions tend to be more ambiguous and often are termed “severe mental illness,” “severe mental disorder” or “severe emotional disturbance,” to name a few. In my work over the past several years, I have noticed that the interpretation of the definition for severe mental illness can vary so greatly that it may include as few as five mental illness diagnoses or more than 100. SAMHSA’s National Registry of Evidence-based Programs and Practices identifies 17 related terms for severe mental illness. These terms can vary by state and with the inclusion or exclusion of childhood mental disorders and functional impairment criteria. On top of this variance, mental health professionals understand that there is some subjectivity involved in the diagnosis of mental disorders to begin with, even before the classification of the mental illness is determined as severe or not.

Next, I looked at the lifetime prevalence of mental illness for both adults and youths (see Table 3). Interestingly, I found the number of credible sources for these statistics much more limited than those for one-year prevalence, with only two sources apiece for both adults and youths. For adults, the lifetime prevalence statistics averaged 48.2 percent, with a range from 46.4 to 50 percent. For youths, the lifetime prevalence of mental illness ranged from 13 percent (ages 8-15) to 46 percent (ages 13-18), averaging about 30 percent over the full 8-18 age range. Given that youths have had fewer years to experience mental illness, it makes sense that their lifetime prevalence rates are lower than the lifetime prevalence rates of adults.

Finally, when considering the lifetime prevalence of severe mental illness (see Table 4), I could find reliable statistics only for youths, with an average prevalence of approximately 21 percent over two sources. I didn’t find enough credible information about the lifetime prevalence of severe mental illness in adults to even report here. Given the scarcity of statistics for both youths and adults related to lifetime prevalence of severe mental illness, this appears to represent a large gap in the research.

Concerning numbers

After reviewing the prevalence data for mental illness, it makes sense to me to consider current research statistics related to how many individuals with mental illness actually receive treatment for their disorders in a given year. My research indicates that the statistics for both youths and adults seem very consistent with age, averaging about 45 percent overall, and ranging over four sources from 39 to 50 percent.

These numbers shocked me somewhat and were very concerning. Such statistics indicate that regardless of age, less than half of the people who experience an episode of mental illness receive the mental health treatment that they need. This statistic begs the question: Why is this the case?

I can only hypothesize about the answer, which likely has many facets, including a general lack of awareness about mental illness, the need for education around it and the powerful influence of stigma related to mental illness. The media associates mental illness with a number of negative outcomes, particularly highlighting its relationship to violence, which in reality is very rare. To better address this misperception, the board for which I serve as the executive director — the Mental Health and Addiction Recovery Services Board in Butler County, Ohio — has adopted a position statement based on multiple sources indicating that only 3 to 5 percent of those with mental illness are violent. Still, let me offer a practical example of how the prevalence numbers and treatment statistics can be applied to the county where I live and work.

Based on the 2010 census numbers, Butler County has a population of about 370,000 residents. Applying the one-year prevalence statistics for mental illness of 20 to 25 percent, this implies that between 74,000 and 93,000 residents in our county experience an incidence of mental illness in a given year. Of those residents, upward of half don’t receive the mental health treatment services that they need. Potentially, that’s more than 46,000 county residents who may not be living their lives in as fulfilling and productive a manner as they otherwise could, especially when we know that mental health treatment largely works. People recover through modalities such as talk therapy, medications, lifestyle changes and other treatment approaches, which often are incorporated in an integrated way. What a challenge we face in addressing the mental health needs not only in my county but in our entire country and beyond. There are so many lives affected and so much productivity lost to what are very treatable illnesses.

Compiling the information I have shared in this article on the prevalence of mental illness related to time, age and treatment has really impressed on me how much work remains to be done to obtain better estimates of the general incidence of mental illness in our country and the world. We especially need more detailed statistics related to the cultural and demographic aspects of mental illness. The bible of mental illness, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, contains some valuable information related to prevalence and cultural data for specific diagnoses. There remains, however, a need for better research via large random studies that look at mental illness in general, including developmental disabilities and substance use disorders. I often wonder if the published mental health statistics that I review include these categories of mental illness.

Furthermore, as better statistics are researched and reported, mental health prevalence numbers need to be compared with those of well-known physical illnesses such as cancer, heart disease, diabetes, obesity and hypertension. In this way, I believe we can better demonstrate and publicize how common mental illness truly is in our society. Taking these actions will go a long way toward educating the public about its incidence, thus normalizing mental illness and, I hope, reducing the stigma with which it is often associated.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Scott Rasmus is the executive director of the Butler County (Ohio) Mental Health and Addiction Recovery Services Board. He received his doctorate in counselor education from the University of Central Florida. He is dually licensed in Ohio as a licensed professional clinical counselor-supervisor and as an independent marriage and family therapist. He has presented internationally on mental health topics. Contact him at RasmusSD@bcmhars.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.

The (misguided) pursuit of happiness

By Laurie Meyers February 1, 2017

Happiness. Most Americans seem to believe that it is something to which we are entitled. After all, happiness — or at least the pursuit of it — is enshrined in our nation’s Declaration of Independence.

As a result, we invest a significant amount of time, money and effort looking for that magical thing/place/person/experience that will ultimately deliver the promise of happiness. We play the lottery, hoping for the big payoff that will make everything better. We buy books that promise us happiness in X number of steps. We go to spas and wellness retreats hoping to meditate, stretch or massage our way to happiness. There is even a whole school of psychological thought — positive psychology — that has devoted much of its time to the study of happiness.

But what is happiness? Is it a state of being? A process? A transient emotion? And whatever it is, can counselors help clients find or achieve it?

“I think our culture defines happiness as a relative emotional state of bliss or euphoria that comes and goes,” says licensed professional counselor Ryan Thomas Neace, the founder of Change Inc., a counseling practice in St. Louis that focuses on holistic practices to help clients achieve biological, psychological, social and spiritual wellness. “The great irony being that we tend to ignore that relative ‘coming and going’ and demand that happiness stick around permanently. It doesn’t end very well that way.”

Reaching for the wrong goal

Perhaps happiness isn’t exactly what most people are looking for after all.

“I think we struggle with the fleeting nature of happiness because our culture is so consumeristic,” says Neace, an American Counseling Association member who also blogs about spirituality and religion on The Huffington Post website. “Happiness, we think, like everything else, ought to be something we can obtain on a permanent basis if we just put together the right combination of life factors — a nice body, a good partner, a strong education, a large salary, etc. If we’re unhappy, we work out more and eat less, end a relationship and/or start a new one, change schools or jobs, etc.”

But none of those things can deliver lasting happiness, Neace asserts. “Even if some of these things are related to happiness, they don’t change its fundamental nature as fleeting and elusive,” he says.

People sometimes seek happiness by avoiding reality, Neace observes. “Anything that helps us to avoid reality on a relatively permanent basis cannot ultimately lead to happiness and is eventually — if not immediately — destructive,” he says. “I’m not talking about the person who has had a rough day and decides to smoke a joint or have a glass of wine to relax a little, and I’m not talking about people who use fantasy playfully in recreation or to spice up their sex lives.

“Instead, I’m talking about the clients I’ve had who plow through their lives doing anything they can to avoid facing up to their mismatched occupations, their wayward teenagers, their sexual identities, etc. I’m talking about the person who avoids looking at his or her failing marriage because they don’t want to be unhappy. It sounds so illogical from an outside, third-party perspective, but it happens all the time. What really happens isn’t that the person doing the avoiding somehow magically becomes happy; [it’s] that their unhappiness shifts locations, usually to someplace outside their conscious awareness. So the person in an unhappy marriage compulsively spends money or works excessively to avoid being at home. It’s like squeezing one end of a balloon — it just makes the other end swell.”

Even some of the most prominent voices in happiness research are rethinking happiness as a goal. For instance, Martin Seligman, the founder of positive psychology and author of the 2002 book Authentic Happiness, eventually rejected happiness as the ultimate goal. In his 2011 book Flourish: A Visionary New Understanding of Happiness and Well-being, Seligman discussed the limitations of happiness as the key to life satisfaction. This is because happiness is too based on mood, he said, so Seligman redefined positive psychology to focus on “well-being.”

True satisfaction

If happiness is not necessarily to be the stated goal in counseling, what is? “In therapy, I try to contrast that for clients with something that is probably more akin to contentment, which I define as a quality of ‘OK-ness’ that is nonrelative –— present for the most part without regard to circumstance or situation,” Neace says. “Contentment can include moments of happiness, but it doesn’t demand that those feelings, or any others for that matter, stick around. Contentment transcends happiness and allows it to actually be what we already know it is — sometimes fleeting and elusive, prone to slip away when the wind changes direction.”

Maya Georgieva, a national certified counselor whose counseling approach emphasizes wellness and focuses on the effects of emotional strain on the body, prefers to concentrate on helping clients live richer, fuller lives. Rather than helping clients strive for happiness, Georgieva views her goal as helping them to grow — a process that is unique to each individual. Instead of focusing on attaining some ephemeral state of being, she believes it is more important to find out what the client wants to achieve and what he or she wants to change.

Georgieva encourages “self-actualization” for clients. “We’re born with the ability and desire … to grow,” she says. Growth involves removing any barriers that hinder clients from learning and creating new relationships and accomplishments.

When clients show up to counseling looking for “happiness,” Neace emphasizes the importance of telling them that contentment should be the goal instead. “There’s typically a ton of work to be done there simply around insight and helping people recognize the problem underneath the problem,” he says. “In other words, clients typically come in and tell us that some relationship or job or situation is unsatisfactory and must change. [In their eyes], it is the problem. … It is our job to point out to them that perhaps it is their approach — trying to squeeze happiness out of every situation — that actually causes the real trouble and is, in fact, the problem underneath the problem.”

“The key here for counselors is helping clients understand that reality can actually be a decent source upon which to base their existence,” he continues. Reality might not always be happy, but it can serve as the basis for contentment, Neace observes.

The leisure perspective 

ACA member Rodney Dieser believes leisure is very important for overall well-being. As such, he is a proponent of the “serious leisure perspective,” which was developed by sociologist Robert Stebbins.

As explained by Dieser, a professor of leisure, youth and human services at the University of Northern Iowa, the serious leisure perspective has three components.

1) Serious leisure involves spending a large amount of time to master skills as a hobby. An example would be learning to play an instrument over time and participating in the community orchestra.

2) Casual leisure is what most people think of as leisure. Examples include relaxing, going to a restaurant, resting on a hammock or going to the beach.

3) Project-based leisure involves taking on a project that is somewhat complicated but that doesn’t involve more “serious skills.” Examples include planning a family vacation, engaging in fundraising for a local community project or participating in other kinds of volunteer efforts.

In addition to allowing the body to relax, leisure can help clients build and strengthen relationships, achieve a sense of purpose and establish a sense of community, Dieser says. For example, Dieser once worked with a middle-aged man who had stage 4 renal disease that rendered him unable to work. He was home on disability and depressed. Part of his distress involved his identity as a traditional male who viewed himself as the primary provider for the family. Now, because of renal disease, his wife had to work and provide financial support for the family instead.

“One of the things I did was ask him to reflect back on his life. Was there anything he did in his free time that he enjoyed?” Dieser recalls. “He said that he used to fish a lot and was a serious angler and fly fisherman. He still had the rods and tackle box, but all the gear hadn’t been out in 10 years.”

Dieser suggested that because the man now had extra time on his hands and already owned all the gear, he might consider taking up fishing again. The man started going out regularly and even taught his daughter how to fish. The father and daughter bonded over these experiences, which ultimately made their relationship stronger.

“When I first met him in assessment, his role/purpose in life was his family,” Dieser says. “So now he is fishing regularly with his daughter, which is fulfilling his existential purpose. One of the benefits of this terrible development is he gets to do things he wouldn’t have gotten to do [otherwise].”

In another case, Dieser was working with a single father in his 40s who had medical issues, depression and anxiety. His family was struggling financially, and the client felt isolated. During a counseling session, he talked to Dieser about the possibility of buying a Jet Ski. The man felt guilty about even considering the possibility because of the family’s finances, but operating a personal watercraft was something he had loved previously, and he wanted to share this activity with his two daughters.

“I let the guy talk about it and work through it out loud, [evaluating] the pros and cons,” Dieser says. When viewing it from a financial standpoint, the client thought his priority should be to pay some bills that were past due. But Dieser also had him look at it from a relationship perspective: Could he really put a price tag on spending time with his daughters? Was it possible for him to pay most of his bills and still buy the Jet Ski as an act of self-care?

The client decided to buy a used Jet Ski and started taking his daughters out with him as part of their family time. He also developed friendships with other owners of personal watercraft and ended up on a boating committee, which allowed him to contribute and provided a sense of purpose. Dieser says that all of these developments helped ease the client’s depression.

Final thoughts

Unfortunately, Dieser says, many Americans operate under the belief that they can buy happiness. In addition, he thinks that the individual nature of American culture often leads to isolation.

“The U.S. is the most individualist country in the world,” he says. “We are constantly not paying attention to relationships and belongingness. We are so focused on ourselves that we get lonely and there is no one there to provide a safety net when we fall.”

“The leisure-happiness connection is there, but it hasn’t really been defined,” Dieser says. “Leisure creates meaning, belonging, fulfillment and purpose. I think those are the same things that create happiness. Most people think of leisure as just doing nothing but relaxing. They don’t see it as about energy and engagement.”

“The real power of leisure is actually giving meaning in life,” he says. “I really see leisure connected to existential counseling.”

“It’s possible that any number of additional constructs are related to the search for happiness but, ultimately, no source outside ourselves can produce it,” Neace says. “Don’t get me wrong — we need a ton of support, encouragement, guidance, wisdom, friendship, etc., from outside of ourselves. But the ultimate goal isn’t just that we have a bunch of external sources of validation and satisfaction, but that we learn to internalize those sources into a united, inner chorus that helps us know we are enough, that things are OK — even if they aren’t OK right now — and that we’re going to make it. Perhaps that’s the key difference between happiness and contentment — the movement from an external to internal source of strength and resilience.”

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@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.

The value of contemporary psychoanalysis in conceptualizing clients

By Whitney Keefner, Hilary Burt and Nicholas Grudev October 5, 2016

branding-_sigmundAs students in the University of Vermont’s graduate counseling program, our professors have stressed both the benefits and critiques of Sigmund Freud’s psychoanalytic theory. We grew curious about how Freud’s pioneering ideas have evolved over time and how they can be applied to clients today. We think that contemporary psychoanalytic theory provides a great foundation for understanding human development, and this article allowed us to explore its progression.

Freud’s psychoanalytic theory has received widespread criticism since its establishment in the late 19th century. However, Freud’s original theories have undergone numerous evolutions, resulting in the de-emphasis of antiquated ideas pertaining to psychosexual fixation and a modern emphasis on the influence of early life family dynamics on later life relational patterns. This shift from examining repressed libidinal urges to the intrapersonal/interpersonal etiology of relational patterns allows counselors to place problems into an addressable context — namely, the bolstering of intrapersonal resources (i.e., ego strength) and the formation and maintenance of quality attachment relationships. These two branches of psychoanalytic thought are known respectively as ego psychology and object relations.

Ego psychology

From a contemporary psychoanalytic perspective, an individual’s mental health is dependent on the regulatory abilities of the ego. The ego is the contemporary psychoanalytic term for the psychological mechanism that governs the processing of reality and the regulation of instinctual urges and moral rigidity. The ego has many significant roles, including perceiving and adapting to reality, maintaining behavioral control over the id and defending the individual from undue anxiety. The undeveloped (or overstressed) ego can lead to a wide span of threats to a person’s wellness.

Mental health issues arise when the ego has not developed properly and its regulatory functions are either immature or absent. The Psychodynamic Diagnostic Manual (a psychoanalytic “companion” to the Diagnostic and Statistical Manual of Mental Disorders that is used by many practitioners of contemporary psychoanalytic theory) outlines several functions of ego health. These functions (collectively referred to in the Psychodynamic Diagnostic Manual as the Personality Axis, or P Axis) include:

  • The maintenance of a realistic and stable view of self and others
  • The ability to maintain stable relationships
  • The ability to experience and regulate a full range of emotions
  • The ability to integrate a regulated sense of morality into day-to-day life

Counselors might use these functions collectively as a guide to conceptualize the health of a client’s ego, while simultaneously considering specific aspects of ego function as possible starting points for counseling interventions. It is also worth considering how clients may defend their sense of self through the use of defense mechanisms.

Considering ego and relationships: Object relations

Whereas ego psychology represents contemporary psychoanalytic views on the development and regulation of the self, a separate yet related branch of contemporary psychoanalysis focuses on the self in relationship with others. Many theorists within the psychoanalytic school of thought place significant emphasis on the association between intrapersonal and interpersonal wellness.

From an object relations perspective, counselors may view barriers to client wellness as stemming from the quality of early interactions between the client and his or her caregivers and how the client internalized these early relational experiences. When an infant is first born, it is undifferentiated from the mother. Thus, the self has not yet formed. The self is composed of the ego, the internal objects (i.e., structures formed due to early experiences with a caretaker) and the affect that binds the ego and internal objects together.

The development of internal objects and ego is crucial to one’s functioning in later life because impaired object relations may result in the development of abnormal behaviors, cognitions or emotions. To elaborate, when an individual experiences negative relational experiences in the caretaker-child dyad, healthy object relations fail to formulate. These relational blunders occur after ego-relatedness (i.e., the phase of absolute dependence on the mother). When the child is not provided with an ego-supportive environment, growth of the ego is inhibited.

Fragmented ego strength during childhood may contribute to later issues in adulthood. Object relations bears a strong theoretical resemblance to attachment theory in that the relational experience between a caretaker and an infant carries implications for functioning across the life span. For example, the relationships that individuals hold with others (caregivers, friends, romantic partners, etc.) shape the development and regulatory ability of the ego. Individuals with fragmented ego strength are therefore at a disadvantage because they developed a faulty foundation for both self-regulatory abilities and social interactions later in life.

Defense mechanisms

In her book Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2011), Nancy McWilliams conceptualizes a person’s capacity to acknowledge reality — even when that reality is unpleasant — in terms of ego strength. Ego strength, like other aspects of wellness, is constantly in flux and can be eroded temporarily by the stresses of day-to-day life. When ego strength is compromised by anxiety-provoking circumstances, or even by mental fatigue (we note, for example, that our egos begin to feel considerably less sturdy by the end of the semester), ego defense mechanisms serve as a kind of respite from perceived threats. When sensitive topics are broached in the context of counseling, client defense mechanisms may present themselves. Because these same defenses likely arise in other contexts that are interpersonally challenging for clients, acknowledging and discussing these defensive processes may prove to be a generative pathway to change.

According to McWilliams, when clients use a defense mechanism, they are generally trying unconsciously to avoid the management of some powerful, threatening feeling (e.g., anxiety, grief, shame, envy). In the same way that fabled knights used shields to deflect the fiery breath of a dragon, clients may use defense mechanisms to ward off potential threats while attempting to maintain safety and stability in their stances.

It is important to note that the use of defense mechanisms is a common, if not daily, occurrence in the lives of most people. Indeed, the use of defense mechanisms is considered by most mental health professionals to be adaptive and necessary for sound mental health. George Vaillant (1994) described how defense mechanisms help people to regulate internal and external reality, and decrease conflict and cognitive dissonance. However, it is also important to note that defense mechanisms can be used in ways that are more adaptive or less adaptive. The degree to which an architecture of defenses might be considered adaptive pertains to the frequency and rigidity with which the defenses are used and the types of defenses employed.

In broad terms, defense mechanisms might be defined as primary or secondary defensive processes. McWilliams considers primary defenses to be less adaptive because they contain a greater degree of distortion in the boundary between the self and the outer world relative to secondary defenses. Primary defense mechanisms are characterized by the avoidance or radical distortion of disturbing facts of life.

For example, McWilliams explains how the primary defense mechanism of introjection involves substituting the perceived qualities, values, behaviors or beliefs of another person for one’s own identity. In effect, these individuals are uncritically adopting the attitudes, values or feelings that they perceive a valued other wants them to have. McWilliams suggests that such global distortions of self and reality likely have their origins in early developmental stress and the lack of developmental opportunities to cultivate a coherent and stable ego or a differentiated sense of self.

McWilliams considers secondary defenses to be “more mature” because they allow an uncompromised sense of self to remain relatively intact, even as an uncomfortable reality is held at bay. Secondary defenses allow for greater accommodation of reality and a stable sense of self. For example, counseling students may occasionally employ “gallows humor” (humor is one of numerous secondary defenses that McWilliams describes) before taking tests such as the National Counselor Examination. Humor in such cases helps to ease the tension by distracting from the reality of the situation without engaging in significant denial or distortion of the situation itself.

The degree to which developmental opportunities have allowed for the establishment of the aforementioned ego domains and the type of defensive architecture generally used (i.e., primary vs. secondary) contribute significantly to how clients perceive difficulties in their lives.

Ego dystonic vs. ego syntonic

An essential aspect of understanding an individual’s mental health is the presence or absence of an observing ego. According to McWilliams, an observing ego enables clients to see their problems as inconsistent with the other parts of their personalities. Such problems are termed ego dystonic. In terms of counseling individuals with ego dystonic problems, the client’s and the therapist’s understanding of the problems are likely to align because both parties recognize the problems to be undesirable. Thus, the observing ego allows for identification of unwanted problems and helps the client bring his or her personality back to a desirable level of functioning.

Problems that are unrecognizable by an individual are termed ego syntonic. According to McWilliams, such problems are likely to be rooted deep in the individual’s personality and often develop during early childhood. Because ego syntonic problems are intertwined in the person’s character, addressing these problems can be perceived to be a direct assault on the individual’s personality.

Taking away an adult representation of an adaptation from childhood could compromise an individual’s entire way of being. It is therefore important for counselors to handle ego syntonic problems slowly and delicately. For example, counselors could validate and empathize with a client’s ego syntonic experience while subsequently offering an alternative perspective. Establishing rapport and trust in the counseling relationship is perhaps the strongest tool when working with individuals whose maladaptive behaviors are intertwined in their personalities.

Substantial time is required for ego syntonic problems to become ego dystonic, and treatment is not possible until an individual can recognize his or her problems as such. The presence or absence of an observing ego determines whether an individual’s problems are neurotic or entwined in his or her character. Ego syntonic problems are telling of a dysregulated ego because the ego lacks the ability to acknowledge, understand and accept reality. Individuals who are capable of recognizing their problems likely have a better sense of self and a more developed ego.

Summary

Contemporary psychoanalytic thought emphasizes the impact of the ego on an individual’s well-being. Whether development is viewed from an object relations lens or an ego psychological lens, the ego is at the core of healthy development. The ego’s ability to balance the id and the superego, and process reality and emotions, can be learned only if an individual’s social relationships throughout his or her lifetime foster healthy ego development. Unhealthy development or underdevelopment of the ego can cause psychopathological problems because an individual’s abilities to process reality and emotions are likely to be impaired.

According to McWilliams, all of us have powerful childhood fears and yearnings. We handle them with the best defense strategies available to us at the time and maintain these methods of coping as other demands replace the early scenarios of our lives. Thus, defense mechanisms are useful in protecting the ego, but when used in excess, they may cause psychopathological problems. In this way, ego defense mechanisms are like sugar. When needed, sugar provides valuable energy that prevents the body’s systems from malfunctioning. But when consumed in excess, sugar can cause disease and negatively affect an individual’s well-being.

Conceptualizing clients through a contemporary psychoanalytic lens can provide counselors with a deep understanding of the past and present factors that are shaping clients’ lives. This approach illuminates how adaptations formed during childhood can present as maladaptive behaviors or cognitions in adulthood. Unlike classic psychoanalysis, contemporary psychoanalytic theory considers the social factors that contribute to ego health, therefore giving counselors a more comprehensive and applicable understanding of the client.

 

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The authors would like to extend a special thank you to Aaron Kindsvatter for his contributions and supervision.

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Whitney Keefner is a second-year student pursuing a dual master’s degree in clinical mental health counseling and school counseling at the University of Vermont. She is currently interning at Spectrum Youth and Family Services in Burlington, providing integrated co-occurring treatment for mental health and substance abuse issues. Upon completing her degree, she hopes to continue working with individuals struggling with substance abuse in a community mental health setting. Contact her at wkeefner@uvm.edu.

Hilary Burt is a second-year graduate student in clinical mental health counseling at the University of Vermont. She is interning at UVM Counseling and Psychiatry Services. After she completes her degree, she hopes to work with children and adolescents in a community mental health setting. Contact her at hburt@uvm.edu.

Nicholas Grudev is a second-year graduate student interning at the MindBody Clinic at the University of Vermont Medical Center. Upon completing his master’s degree, he plans to enroll in a doctoral program to study counseling psychology. Contact him at ngrudev@uvm.edu.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for getting published in Counseling Today, go to ct.counseling.org/feedback.

 

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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.

 

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The serious leisure perspective in mental health counseling

By Rodney B. Dieser, Jacob Christenson and Darcie Davis-Gage June 1, 2016

In his book The Gift of Therapy, Irvin Yalom explains the vital role of learning about a client’s “leisure-time activities,” “hobbies” and “recreation habits,” yet he never defines what leisure is and how it is connected to mental health or mental health counseling. Many other well-known mental health theorists have duplicated this same pattern of highlighting the relationship Branding-Images_Artistbetween leisure and mental health/mental health counseling but not explaining leisure with much precision, depth or breadth.

Historically, Sigmund Freud’s pleasure principle, Erich Fromm’s humanistic psychoanalysis framework, Eric Berne’s transactional analysis structuring of time and social activities and William Glasser’s genetically encoded need for “fun” within control/reality counseling theory have provided a superficial overview of leisure. More recently, Allen Ivey and his colleagues have mentioned the importance of leisure within their framework of developmental counseling and therapy but have never explained or defined leisure. Likewise, Russ Harris and Judith Beck follow this pattern of mentioning, but not explaining, leisure related to acceptance and commitment therapy and behavioral activation within cognitive behavior therapy, respectfully.

So, what is leisure, and how can it be utilized during mental health counseling?

SLP and the optimal leisure lifestyle

Approximately 13 differing theories of leisure exist. The serious leisure perspective (SLP) is one of the more credible theories, with hundreds of studies from more than 30 years of research from diverse researchers throughout the world supporting its theoretical and practical basis.

Robert Stebbins developed SLP in 1982 when he authored a conceptual paper in the Pacific Sociological Review. Since then, he has written 34 books related to SLP, along with hundreds of research articles. Today, as Stebbins has outlined in his more recent books, SLP comprises three main forms of leisure: serious leisure, casual leisure and project-based leisure. (The information about SLP that follows in this section is taken from Stebbins’ most recent book, The Serious Leisure Perspective: An Introduction, which he co-authored with Sam Elkington in 2014, and Serious Leisure: A Perspective for Our Time, which Stebbins wrote in 2007.)

The pursuit and balance of serious leisure, casual leisure and project-based leisure can lead to what Stebbins terms an “optimal leisure lifestyle.” He defines this as the deeply rewarding pursuit during free time of at least one serious leisure activity, supplemented by casual and project-based leisure.

Serious leisure

Serious leisure is defined as the systematic pursuit of an amateur, hobbyist or volunteer activity participants find so substantial, interesting and fulfilling that they launch themselves on a leisure career centered on acquiring and expressing special skills, knowledge and experience. The quintessential element is the development of special skills, knowledge and experience — which can take months or even years to develop. For example, it can take years to develop the skills needed to play a musical instrument well enough to become a member of a community orchestra or to track a bird by sound in a birding club.

Serious leisure can be divided into three types: amateur, hobbyist and career volunteer. Amateurs are found in the worlds of art, science, sport and entertainment, where they are inevitably linked in many ways to a professional counterpart, such as tournament bass anglers or members of an amateur community theater. Hobbyists lack the professional ego of amateurs but maintain small publics with similar interests. An example of serious leisure hobbyists are members of small stamp, coin or comic book collection organizations in which local collectors can buy and sell items and have conversations about their shared interest.

Career volunteering, the third type of serious leisure, is exemplified by a person who uses specialized skills, knowledge or experiences as an uncoerced means of helping that is not aimed at material gain. An example is a retired plumber who likes to volunteer his or her skills to help build homes for Habitat for Humanity, or a retired accountant who volunteers his or her specialized skills for a Boys & Girls Club.

Serious leisure provides many human wellness benefits such as personal fulfillment (meaning-making in life), personal enrichment (self-actualization), regeneration of oneself, financial return, self-expression and creativity, social attraction and the development of friendships, and group and personal accomplishments.

Casual and project-based leisure

Casual leisure is defined as immediate, intrinsically rewarding, relatively short-lived activities that require little or no specialized training to enjoy. The quintessential element of casual leisure is hedonism or pleasure.

Casual leisure can include relaxation (e.g., napping in a hammock), passive entertainment (e.g., watching television) or sociable conversation (e.g., chatting outside an ice cream parlor). Beneficial outcomes derived from casual leisure include development of interpersonal relationships, regeneration in life, serendipitous discovery/creativity, edutainment and general well-being (e.g., distraction from stressors).

Project-based leisure is defined as a short-term, reasonably complicated, one-shot or occasional (though infrequent) creative undertaking carried out in a person’s free time. It lies between serious and casual leisure because it requires considerable planning, effort and, sometimes, specialized skills like serious leisure, yet it is not intended to develop into serious leisure or become a long-term sustainable leisure activity. Examples include establishing a family reunion or getting involved in fundraising efforts toward a social cause, such as Mental Illness Awareness Week, in a local community.

Integrating leisure into the counseling process

With an understating of SLP, counselors can easily integrate discussion of leisure into the counseling process. As part of the intake process, counselors can have clients complete a leisure measure and inquire about their history of leisure and current level of activity. Gathering this information can inform counselors about how active clients are physically, socially and psychologically.

An optimal leisure lifestyle has been linked to one’s overall wellness, life satisfaction and ability to cope with emotional distress. According to a study published in Counselling and Psychotherapy Research by Elizabeth Marley in 2011 regarding self-help strategies to reduce emotional distress, mental health is improved by leisure, which can include such serious and casual activities as playing cricket, shopping, gardening, dancing, socializing and even driving a car.

With this in mind, clients may also benefit from integrating leisure activities into their counseling treatment. As indicated above, counselors can assess clients’ interest in various leisure activities by using formal assessment tools such as career, leisure and interest inventories. In addition, assessment tools from the areas of leisure services and therapeutic recreation, such as the Serious Leisure Inventory and Measure or the Leisure Motivation Scale, can be helpful. On the basis of these types of assessments and a client’s leisure history, counselors can encourage a discussion about how clients can engage in serious, casual or project-based leisure and which type of leisure would be most beneficial to add to their treatment.

Following the intake process, counselors can integrate goals regarding leisure into the treatment plan. Counselors can use active listening skills to find an avenue to introduce the idea that leisure can serve as an adjunct to other counseling activities. As the counselor listens to the client’s story, he or she will gain insight into those areas of the client’s life that may be amenable to such an approach. For example, clients will often mention how they spend their free time or what activities they enjoy. Such revelations occur naturally in sessions and provide a trailhead for counselors to follow to provide psychoeducation about the importance of leisure in overall well-being.

Once the concept has been taught and understood, counselors might reserve the first few minutes of each session to review what clients have done since the last session to engage in some form of leisure. Alternatively, the last few minutes of each session could be used to brainstorm possibilities for leisure and make assignments.

It is important to remember that the development of a serious leisure pursuit often takes time and requires patience. Clients should be encouraged to be deliberate in their approach, resisting the temptation to rush the process. They may need to try a number of different activities before finding something that will have the desired effect.

Throughout this process, the client’s views should be given preference when it comes to deciding on which activities to focus. When a particular activity is difficult or the client experiences setbacks and failures, the counselor should encourage the client to exercise self-compassion and nonjudgmental self-evaluation.

Two case examples

“David,” a former client of one of this article’s authors, struggled with debilitating anxiety and felt hopeless after being discharged from an inpatient unit. During the course of therapy, the counselor noticed that David talked frequently about wanting to help others who struggle with mental health issues. David and the counselor collaborated on a plan to provide him with opportunities to volunteer — as leisure — at a local community mental health center.

David frequently had days in which he failed to show up for his shift, but he was able to recommit after exercising self-compassion. He was eventually able to become more consistent and began to increase his capacity to offer support to individuals at the center by becoming involved in various programs. David later chose to further develop his interest in helping others by studying to become a counselor himself.

“Sally,” also a former client of one of this article’s authors, was able to develop an optimal leisure lifestyle related to her involvement in quilting. As previously mentioned, an optimal leisure lifestyle is possible when the SLP subtypes are pursued and balanced. This occurred to Sally, who became a well-known quilter, when her husband was out of the country for an extended period of time.

As a consequence of being left alone with a struggling young family, Sally found herself slipping into deep depression and anxiety. She had previously been involved in crafting as a casual pursuit, and when she brought this up in session, the counselor recognized this as an opportunity to introduce leisure as a part of the process. This casual pursuit was identified as an exception to the lack of energy and withdrawal Sally was showing as her depression deepened. The counselor provided some information about the importance of these types of leisure activities to overall well-being, and Sally agreed that she would benefit from becoming more involved in quilting.

As she got more involved, Sally started a blog so that she would have a venue for displaying her work and to show her husband what she had been able to accomplish. Growth in the readership of her blog led to recognition throughout the quilting community and provided Sally with opportunities to associate with others who held similar interests. Quilting also provided Sally an avenue for building her sense of self-worth, and she began to emerge from the darkness of depression.

Although Sally’s development of a serious leisure pursuit had produced valuable fruit, it was at this point she realized that her relationship with her children could suffer because of the amount of time she was quilting. So, with the help of the counselor, she decided to balance her pursuit of quilting with family-centered casual leisure. She began spending more time developing her relationship with her children and attending to their developmental needs. As a result, her relationship with her children was strengthened even as she continued to grow and develop as a quilter.

Today, Sally is a sought-after speaker and instructor by quilt guilds throughout the nation. She offers an inspiring perspective on the changes that have been brought about in her life through her leisure pursuits. In this case, a hobby was incorporated into Sally’s change process and has since been developed into an example of an optimal leisure lifestyle.

Conclusion

Although various mental health theorists have mentioned the importance of leisure, little has been written about it in an in-depth manner related specifically to mental health counseling. SLP is a mature theory of leisure with hundreds of studies supporting its theoretical and practical basis. We have presented two case studies to explain how SLP can be used in the counseling process to help clients manage life challenges and mental health struggles.

To learn more about SLP, counselors can visit seriousleisure.net. In addition, the authors of this article wrote a more research-based and theoretically explained article on integrating SLP into mental health counseling in the first issue of the 2015 Counselling Psychology Quarterly (volume 28, pages 97–111).

 

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Rodney B. Dieser is a professor in the School of Health, Physical Education and Leisure Services at the University of Northern Iowa. He is a certified therapeutic recreation specialist, national certified counselor and temporary licensed mental health counselor in Iowa. He practices as a therapist 10-15 hours per week. Contact him at rodney.dieser@uni.edu.

Jacob Christenson is an assistant professor in the marriage and family therapy program at Mount Mercy University (Iowa) and serves as the clinical director for the Olson Marriage and Family Therapy Clinic in Cedar Rapids. He has practiced as a therapist for more than 10 years and specializes in working with adolescents who are treatment resistant and those suffering from severe mental illness. Contact him at jchristenson@mtmercy.edu.

Darcie Davis-Gage is an associate professor in the clinical mental health counseling program at the University of Northern Iowa. She has more than 10 years of various counseling experiences, including working in private practice. Contact her at darcie.davis-gage@uni.edu.

Letters to the editor: ct@counseling.org

Accepting failure as part of professional advocacy

By Whitney N. White May 25, 2016

In recent months and years, I’ve seen counseling and mental health move up the list of “hot topics.” Influential actors, leaders and even government officials have spoken up and drawn these areas into the light in a new and brilliant way. As a culture, we are talking about mental health now and reaching out for help more than ever. I find this inspiring and believe that all of this bold new conversation and outreach is changing lives for the better.

First lady Michelle Obama has spoken publicly about the importance of mental health and the need to end associated stigma. Kate Middleton, the Duchess of Cambridge, recorded a video message this year in support of Children’s Mental Health Week. Actor Jared Padalecki, of Supernatural fame, talked publicly about his own mental health struggles and launched the Always Keep Fighting charity T-shirt campaign (I regularly see clients sporting the clothing that is sold to support the cause). MTV has run news segments on celebrities working to shut down stigma related to mental health. Leonardo DiCaprio talked about his struggle with obsessive-social justicecompulsive symptoms after filming The Aviator. While filming the movie, he stopped trying to control his tendencies toward obsessive-compulsive disorder and ended up developing stronger symptoms that lasted long after filming had ended.

For these reasons, I thought at least a tiny bit of the battle was over. What battle? The battle for counseling to be taken seriously as a profession, the battle to get people to understand that mental health is as important as all other aspects of health and the battle to get help to those who need it. I believed these changes and new discussions meant that the control tower had cleared the runway and all we needed to do as a profession was fly in and land.

 

A bubble burst

I didn’t want to be like many of the mental health professionals — counselors, caseworkers and others — I met during my school-related practicum. I’d hear them speaking about red tape, see the cynicism in their expressions and sometimes even sense their disdain for my fresh-out-of-the-box, new counselor, can-do attitude. But they knew what I’m beginning to understand.

The battle isn’t over. It won’t ever be over. We can’t rest from this as a profession. We have to keep going, keep working and keep educating. When a chiropractor points out that his church shut down its free counseling program because “counseling is just talking and doesn’t really work,” we have to smile and use that as an opportunity to educate. When a woman in line at Starbucks sees the American Counseling Association gym bag we’re holding and assumes that we just help kids get into college, we can speak up about what we really do.

My bubble was burst a few months into my first real counseling position at a nonprofit agency serving children in Texas. Texas is a large and, for the most part, very rural state. Many of its small cities don’t have any licensed mental health professionals. In addition, there are many people without the money or insurance to pay for services despite the Affordable Care Act, and many others lacking the resources to travel half an hour or more to access counseling services. Most families have parents and caregivers who work. Taking a block of time out of their workday for counseling has a price attached, both in terms of money and stress.

In an effort to provide services to populations in these circumstances, the agency where I work allows counselors to set up satellite offices in neighboring communities. This helps when families can’t make the trip to the main office or can’t afford to take off work to make that trip. To take this a step further, we often gain permission from schools in these outlying areas to see children in the schools where they attend (with proper consent and releases). Because of other tasks that require their time and expertise, school counselors don’t typically have the time to provide in-depth mental health counseling to students in need.

I received a few calls from residents of a nearby town who wanted a counselor to come provide services to children in the community. Each of the referral calls came from families with children in the local school district, so I was surprised when I reached out to the school to offer counseling services and got a “no” in response. The school’s lead administrator informed me that I could use space on the campus one day per week, but students would be permitted to miss only music class.

This was bad news on a couple of levels. First, because the school is small, each grade level goes to music class together. In other words, I wouldn’t be able to have two clients in the same grade because my sessions are 45 minutes long and music class is 50 minutes. Second, it would be impossible to protect the privacy of my clients under those circumstances. It wouldn’t be long before every kid in the school knew that if a student left music class, he or she was going to counseling. Never mind the underlying message that music (the arts) is frivolous — just like counseling.

I responded to the stipulated offer by explaining the privacy concerns I had about the situation. I also reiterated that multiple families with students in the school had sought services and that I wouldn’t be able to see everyone during music classes. I mentioned that I always talk with parents and children about what time of day will work best for them based on the child’s performance in each class and when that class occurs. I reminded the school administrator that Texas permits children to miss school to attend counseling appointments, just like they are permitted to miss class to see a medical doctor.

I communicated this all very professionally and from a place of love and advocacy for my would-be clients, my profession and my agency. In response, I got another “no” that included an explanation of how and why academics are the focus of this particular school. This school’s administration either doesn’t understand the way that mental and emotional health (which counseling supports and develops) affect academic performance, or they do and choose to ignore it. I’ll never know. I did my best to provide a basis for conversation and education about counseling. It didn’t work, and I was frustrated. A school — the place where so many issues are first identified — was refusing to help its students.

Months prior to this disappointing outreach, I had volunteered to present at a local high school career day. After the rejection of my services by the other school, I was hesitant to follow through on this career presentation. How would I possibly line up next to police officers, doctors and teachers as a career option? Had anyone even signed up for my presentation on mental health counseling as a career? Would the cynicism building up inside of me because of others’ rejection and resistance to mental health progress dull my eyes, spirit and voice as I talked to potential future counselors?

When the day arrived, more than 120 students had signed up to hear my presentation on mental health counseling. They asked great questions. For instance, a freshman asked, “How does working with others and their problems affect you as a counselor?” A ninth-grader asking about vicarious traumatization! They were listening! And interested! I opened up about what it is like for me to be a counselor.

 

Getting to ‘yes’

In a nonprofit agency, we often wear many hats. Sometimes we are counselor, case manager, outreach coordinator, guest speaker, educator and secretary. Sometimes we are all those things and more within a single hour of the day. We are advocates for our clients and would-be clients. I advocated for potential clients with the area school in hopes of making services available and easily accessible and to require less time out of class. I failed, but I tried. Sometimes we’re disappointed that others — professionals affected by our work — don’t understand its importance or take it seriously. But on some days, we get through. Some days we get a “yes.” That “yes” means the world to the people we work to serve.

It is vitally important that as a profession, we continue to advocate and communicate with professions that touch ours. Medical professionals, teachers and many others have contact with our clients. Their perspective on counseling can have an effect on how our clients view counseling — on whether or not they seek and receive the services they need. In the face of frustration, it is important to remember to talk openly and to stay educated about the research that supports our field and the interventions we use. The next time you’re brave enough to speak up, you may get a “yes” that changes minds and outcomes for better down the road.

The disconnect I’ve experienced across professions is often a result of my desire to avoid perceived conflict by not speaking up and telling someone how fantastic my research-supported profession is. Talk about our profession. Talk about it anytime you’re given a chance like I was at my chiropractor’s office. When you’re in line at Starbucks, talk about it with the woman who comments on your ACA bag. Talk about it on social media. Speak up about what we do and the research that supports it, and be ready to power through the possible frustrations of a “no” or disagreement.

We don’t just expect children to learn algebra “naturally.” We educate them from their first day of school until their last, which prepares them to do algebra in real-world settings. Yet the attitude of public educators is at best “refer for counseling”; at worst, “kids can do that away from ‘education’ time.”

The “yes” I hope to witness someday is a big one. In my head, every school in my state — in the United States — will welcome vetted agencies to enter schools and provide in-depth services on campus when they’re needed and with appropriate consent from guardians. I envision a time when I’ll call or visit a school campus that welcomes me and my bag of counseling goodies every time (it does happen!). I close my eyes and see schools with life skills courses — entire courses devoted to bettering the whole person in which kids can learn about emotions, coping skills, communication and healthy relationships.

My vision of counseling science as a cornerstone of health and education is a big one. Imagine! Sending kids into a classroom to learn how to communicate effectively with one another. Producing high school graduates with all the tools to truly live life to their fullest, most successful potential. This vision may seem very far away, but there was a time when children weren’t educated about math beyond what they might learn at home. In my moments of frustration, I close my eyes and see these things and remember to speak up for my profession, my colleagues and my clients.

Recently, Prince Harry, who has long been outspoken on mental health issues related to veterans of war, spoke with Good Morning America. He stated, “Psychological illnesses can be fixed if sorted out early. … We’ve got to keep the issue at the forefront of people’s minds. … Just talking about it makes all the difference.” The counseling profession must continue that battle, talking not just about mental health but about what we are able to do to help.

 

 

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Whitney N. White holds a master’s degree in clinical mental health counseling. She is a national certified counselor and a licensed professional counselor intern in Texas, where she is employed in the nonprofit sector working with youth. Some of her passions are working with youth struggling with self-injury; using yoga to connect body, breath and mind; and spending time with her family. Contact her at whitneywhite82@gmail.com.