Tag Archives: Wellness

Wellness

When brain meets body

By Laurie Meyers February 22, 2017

Chinese medicine has always acknowledged the link between the body and the mind. In Western medicine, from the time of the ancient Greeks through the Elizabethan era, the thinking was that four bodily humors (black bile, yellow bile, phlegm and blood) influenced mood, physical health and even personality. Shakespeare built some of his characters around the characteristics of the humors (such as anger or depression). It sounds faintly ridiculous, but the idea that good health came from a balance of the humors — in essence, that the physical and the mental were closely related — was not so far off the mark. Then along came René Descartes and dualism — the school of thought that says that mind and body are separate and never the twain shall meet, essentially.

In the past few decades, however, Western medicine has once again begun to acknowledge that the body and mind don’t just coexist, they intermingle and affect each other in ways that researchers are only beginning to understand.

Counselors, of course, are well-aware of the mind and body connection, but it is becoming increasingly evident that a person’s thoughts can directly cause changes in physiological processes such as the regulation of cortisol. This cause-and-effect relationship suggests that in some cases, symptoms typically considered psychosomatic in the past might actually be indicators of physical changes that are having or will have an effect on the client’s physical health.

Take, for instance, something that most people have experienced at some point in their lives: a “nervous” stomach. It turns out that having a “gut feeling” and “going with your gut” are not just metaphors. Researchers have begun to refer to the stomach as the “second brain” and the “little brain.”

Although no one is going to be making reasoned decisions or solving algebra equations with the little brain anytime soon, the enteric nervous system (ENS) does possess some significant brainlike qualities. It contains 100 million neurons and numerous types of neurotransmitters, including serotonin and dopamine. In fact, researchers have found that most of the body’s serotonin (anywhere from 90 to 95 percent) and approximately half of its dopamine are found in the stomach. The main role of the ENS is to control digestion, but it can also send messages to the brain that may affect mood and behavior.

Researchers are still teasing out whether (and how) the gut-brain conversation causes emotion to affect the gastrointestinal system and vice versa, but a major area of focus is the microbiome — the vast community of bacteria that dwell primarily within the gut. So far, research suggests that these bacteria affect many things in the body, including mood. Gut bacteria may directly alter our behavior; they definitely affect levels of serotonin. (For more discussion of the microbiome and its possible influence on mental health, read the Neurocounseling: Bridging Brain and Behavior column on page 16 of the March print issue of Counseling Today.)

The bacteria in the gastrointestinal system may also play a role in depression and anxiety. Digestive issues such as irritable bowel syndrome and functional issues such as diarrhea, bloating and constipation are associated with stress and depression. Some researchers believe a causal connection may exist that is bidirectional — meaning it is not always the psychological that causes the gastrointestinal problems but perhaps vice versa. Interestingly, research has shown that approximately 75 percent of people who have autism have some kind of gastro abnormality such as digestive issues, food allergies or gluten sensitivity.

Most people have heard the injunction to “think with your heart, not your head.” And in Western culture, the notion of heartbreak is commonly understood not just as an emotional metaphor but as an actual sensation of physical pain. Once again, these aphorisms and metaphors represent an instinctive understanding of another significant connection: that between emotion and the heart.

Coronary artery disease (CAD) is linked to emotion and mental health — depression in particular. Research indicates that 25 to 50 percent of people with CAD have symptoms of depression. Some experts believe not only that depression can cause CAD, but that CAD may cause depression. Increased activity in the amygdala is associated with arterial inflammation, and inflammation is a factor in CAD.

Research indicates that inflammation in the body plays some kind of role in many chronic diseases, including asthma, autoimmune disorders, chronic obstructive pulmonary disease, obesity and type 2 diabetes. Some researchers believe that inflammation may also be a causative factor in mental illness.

Letting go

If physical and mental health are so tightly bound, what role do counselors play in balancing the two? A vital role, believes licensed professional counselor (LPC) Russ Curtis, co-leader of the American Counseling Association’s Interest Network for Integrated Care.

Yes, counselors can help clients manage chronic health conditions and cope with stress and mental illness, Curtis says, but it’s the client-counselor relationship — the therapeutic bond — that he views as the most important element. He believes the simple act of listening, taking clients’ concerns seriously and becoming their ally can help jump-start their healing process. “Once you sit down and build a rapport with clients and treat them with respect and dignity, you are helping them heal,” says Curtis, an associate professor of counseling at Western Carolina University in North Carolina.

Curtis, who has a background in integrated care, doesn’t equate “helping” with “curing.” But he does believe that inflammation in the body strongly affects mental and physical health, and he says that counselors possess the tools to help clients ameliorate the factors that may contribute to inflammation.

For example, gratitude and forgiveness, and particularly letting go of anger, are essential to emotional wellness, and in some studies, Curtis says, they have been shown to have a physical effect. In one study, participants were instructed to jump as high as possible. Those who thought of someone they had consciously forgiven despite being wronged by them in the past were able to jump higher than participants who received no such instruction, he says. Another study found that cultivating forgiveness by performing a lovingkindness meditation produced a positive effect on participants’ parasympathetic systems.

Curtis, who also researches positive psychology, asks clients in his small part-time private practice to keep gratitude journals, which is something that he also does personally. In addition, he uses motivational interviewing techniques to help clients develop forgiveness.

If a client isn’t ready to forgive, the counselor might explore the ways in which anger may be affecting the person’s emotional and physical health and functioning in daily life, Curtis says. If the client is still resistant to the thought of issuing forgiveness, then the counselor can broach the idea of the client at least letting go of his or her anger, he adds.

Anger is particularly toxic to personal well-being, stresses Ed Neukrug, an LPC and licensed psychologist who recently retired from private practice, where he focused in part on men’s health issues. “Anger is a difficult topic for many clients to understand and address appropriately,” he says. “Usually, individuals who have angry outbursts have not learned to monitor their emotions appropriately. They most likely have had models who had similar outbursts. These individuals need to obtain a better balance between their emotional states and their thinking states.”

“Oftentimes, just teaching clients about mindfulness can be helpful because it begins to have them focus on what they are feeling,” continues Neukrug, a member of ACA and a professor of counseling and human services at Old Dominion University in Virginia. “Once they begin to realize that they have angry feelings, they can then talk to the person who they are angry at in appropriate ways, to reduce the anger and resolve the conflict early on. If they wait too long, they are likely to have an outburst.”

Anger, like stress, can cause physical changes in the body, such as a surge in adrenalin, cortisol and other stress hormones; raised blood pressure; and increased heart rate and muscle tension. Over time, as the body is constantly put into this “fight or flight” mode, the immune system may treat chronic stress or anger almost like a disease, triggering inflammation.

To help ameliorate the effects of toxic emotions, Neukrug recommends that counselors teach clients how to sit and engage in quiet contemplation. He notes that many people don’t realize that they are involved in a constant, almost unconscious, running mental commentary throughout the day. By taking time for self-reflection, clients can become better aware of how they are reacting to these thoughts, both emotionally and physically, and can then engage in stress reduction techniques such as progressive relaxation and mindfulness exercises.

Neukrug also recommends what he calls “life-enhancing changes” such as exercising, eating healthfully, journaling, confronting and resolving personal conflicts, and getting enough sleep. He also is a big proponent of nurturing personal relationships, taking regular breaks from work and going away on vacations to lessen the effects of stress.

Healthy habits

David Engstrom, an ACA member and health psychologist who works in integrative health centers, teaches his clients mindfulness exercises and recommends that they engage in daily gratitude journaling. But he also emphasizes a factor that is often overlooked despite its unquestioned importance to physical and mental well-being: sleep.

“It’s the first thing I focus on [with new clients],” he says. “There are few people who can be real short sleepers,” meaning less than six hours per night. “Most of us if we are [regularly getting] under seven hours a night have a higher risk of diabetes, obesity, heart disease, hypertension, chronic cardiovascular problems, depression and anxiety.”

Engstrom has his clients keep a sleep log detailing information such as the number of hours of sleep they get each night, when they went to sleep, how often they woke up in the night and the overall quality of their sleep. He also has them track their alcohol intake and physical exercise. He notes that exercise can vastly improve sleep quality, whereas drinking any alcohol after about 5 p.m. hinders sleep.

For clients who are having trouble falling asleep, Engstrom recommends mindfulness techniques such as being still and present in the bedroom and practicing deep breathing. He also sometimes gives clients MP3 files and CDs that contain guided mindfulness activities.

Counselors also can also play a role in changing clients’ health behavior for the better through psychoeducation, Curtis says. He recommends the use of simple cards that list information such as the benefits of smoking cessation or strategies for preventing or controlling diabetes. Curtis believes that clients are best served physically and mentally by integrated health care, a model in which a person’s physical and mental health needs can be attended to in one location by multiple professionals from different disciplines, such as LPCs and primary care physicians. He currently serves on two integrated care advisory boards for local mental health centers and also supervises students serving internships in integrated care settings.

When he practiced in integrated care, Curtis says a significant percentage of the clients he saw had not just mental health issues but also serious physical issues such as diabetes or cancer. “I was part of providing real support,” he says. “Instead of just having a 20-minute session with the doctor and being told what to do, clients were able to sit with me and process their fears and what they were feeling. I was also making sure that they understood what to take, where to go for bloodwork and making sure they didn’t feel lost [in the process].”

Neukrug uses a structured interview intake process in which he asks clients about their medical histories, any past or current issues with substance abuse and any experiences of major trauma. He has found that many clients are more likely to reveal issues such as a history of trauma or concerns about their physical health in written form rather than verbally. He notes that men in particular can be hesitant to raise common health-related issues with which they are struggling, such as erectile dysfunction, sexually transmitted diseases and prostatitis.

“Men [are] fragile about their egos,” he says. “If they have a disease that affects how they view their manliness or impairs them, they may just not want to talk about it. But any of these diseases can impact their relationships, their ability to earn an income, which is related to male identity and being the provider, so counselors just need to have that attitude that they are open to hearing about anything.”

Trauma’s toll on the body

Examining the health of adults who have experienced childhood abuse and neglect paints a particularly vivid portrait of the connection between physical and mental health. A large body of research — most of it using information gathered from the joint Centers for Disease Control and Prevention-Kaiser Permanente study “Adverse Childhood Experiences” (ACE) — has demonstrated that early exposure to violence and trauma can lead to significant illness later in life.

The initial study was conducted in 1995-1997 and surveyed 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. Participants answered detailed questions about childhood history of abuse (emotional, physical or sexual), neglect (emotional or physical) and family dysfunction (for example, a parent being treated violently, the presence of household substance abuse, mental illness in the household, parental separation or divorce, or a member of the household who was engaged in or had engaged in criminal behavior). Respondents who reported one or more experiences in any of the “adverse” categories were found to be more likely to develop chronic conditions and diseases such as heart disease, obesity, cancer, chronic obstructive pulmonary disease, liver disease, depression, anxiety and other mental illnesses. The risk of developing these health problems also increased in correlation with the number of adverse incidents the study participants reported experiencing.

Although some of the health problems developed by adult survivors of trauma can be traced directly to injury or neglect, in many cases, specific cause and effect cannot be established. Nevertheless, the correlation between trauma and illness is significant, and some research findings — such as an increased incidence of autoimmune diseases among adult survivors of child abuse and neglect — suggest that the connection can be systemic and affect the entire body.

Causation versus correlation aside, clients who have experienced long-term trauma are often living with both mental and physical complaints, and the number of prospective clients who have a background of adverse childhood events may surprise some clinicians, say trauma experts. More than half of the ACE respondents reported experience with one adverse category, and one-fourth of participants had been exposed to two or more categories of adverse experiences.

Given the prevalence of traumatic exposure, ACA member Cynthia Miller, an LPC who has a private practice in Charlottesville, Virginia, believes it is important to ask about early childhood experiences as part of her intake process, and she urges other clinicians to do the same. She has clients fill out a written scale based on the questionnaire used in the ACE study. If clients indicate a history of abuse or neglect, Miller uses it as a way to explore how trauma has affected their lives.

“I think counselors need to know that trauma can affect the body in unexpected ways — ways in which the client may not even be aware,” Miller says. “I ask what impact they think these experiences had on their lives and then segue to asking, ‘What effect do you think this has had on your health?’”

Miller focuses on self-care practices for clients. For instance, clients might be using food to self-soothe, which can lead to obesity, diabetes and a whole host of other problems. Miller helps them to examine how the behavior is related to what they have been through and to identify what they are trying to soothe.

Miller also teaches her clients to tune in to their bodies. That can be extremely difficult because trauma survivors often use a kind of dissociation or “tuning out” as a survival mechanism, she explains. Clients who have been through physical trauma often exist, in essence, from the chin up, totally separating themselves from what is happening with their bodies, Miller says.

“Where in your body do you feel that anger?” Miller asks in trying to help them reestablish that whole-body connection. “Where do you feel the stress?”

According to Miller, yoga and mindfulness, particularly progressive muscle relaxation and diaphragmatic breathing, can be very useful for helping clients learn how to self-soothe and pay attention to how their bodies are responding to what they are doing.

On a more basic level, counselors can also play an essential role in ensuring that their clients get proper health care. “A lot of times I’ve found trauma patients don’t even go to the doctor,” Miller says. “Sometimes they may have issues with getting help, such as thinking there’s nothing they can do [to help the situation], and it all feels too hard. One of the questions I routinely ask is, ‘How long has it been since you had a good physical?’ If they say a year or more, I ask, ‘Would you go have one now? If not, why? What are your concerns? How can I help?’”

Miller says counselors can play an essential role in educating clients about the effects of trauma on the body and how that can cause chronic inflammation. Counselors can encourage clients to seek any needed medical care and also talk to them about what they can do personally to help counteract their bodies’ inflammatory responses, she says.

A partner in health

Another area where counselors can help clients with their physical health is by talking with them about why it is important to take medication, Miller says. She notes that in the general population, only about 50 percent of people who are prescribed medications for chronic conditions take them regularly. Counselors can uncover the legitimate concerns that get in the way of treatment compliance, Miller continues, such as the complexity of the regimen, whether the client has adequate access to obtain needed medication or treatment, and whether the client has easy access to the basics such as food, shelter and water.

It is also important for counselors to explore clients’ in-depth thoughts and feelings related to treatment, Miller says. For example, do they even believe in taking medication, or do they simply dislike taking pills?

Once counselors uncover the reasons that a client might not be adhering to medical regimens or engaging in healthy behavior, they should also consider whether the client is even ready to make a change, says Miller, adding that she finds motivational interviewing helpful in this regard.

Counselors can also help clients break down the change into small steps. For instance, Miller says, “When you talk about exercise, people think you are automatically talking about 60 minutes on the treadmill or kickboxing. [But] what is reasonable? If a person is very depressed, maybe you start [the process] in session. If it’s a decent day outside, can you do the session outside and maybe take a walk?”

Clients also need to be made aware that change is often slow, Miller says. If they did five minutes of exercise this week and didn’t exercise the week before, that five minutes is worth celebrating, she says.

Miller also works with clients on sleep hygiene, including tracking how much caffeine they ingest, how late in the day they stop consuming caffeine and the amount of sugar they eat. “Are they setting a sleep time?” asks Miller. “Are they being exposed to blue light? Is there a TV in the bedroom?”

She also helps clients develop a pre-bedtime routine and, if they have trouble going to sleep, encourages them to get up and do something boring until they feel sleepy again.

“If they are still having disrupted sleep and nightmares [even with sleep hygiene], I refer to a physician,” Miller says. “I’m not against someone taking a sleep medication if all other routes have failed because not getting sleep becomes a self-perpetuating cycle.”

Miller, like the other experts interviewed for this story, is an advocate for integrated care because it provides a more complete picture of — and a stronger connection between — clients’ physical and mental health. “If we have counselors who are embedded in primary care, we get a better picture of the client,” she says. “If we are separate, we’re not necessarily going to hear about how long they’ve been struggling with obesity or keeping their blood sugar down. We might not know that they’ve told the doctor that they’re struggling to take medicine regularly.”

 

****

 

Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association.

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Wellness” by Dodie Limberg and Jonathan Ohrt
  • “Complex Trauma and Associated Diagnoses” by Greg Brack and Catherine J. Brack

Books and DVDs (counseling.org/publications/bookstore)

  • Relationships in Counseling and the Counselor’s Life by Jeffrey A. Kottler and Richard S. Balkin
  • A Counselor’s Guide to Working With Men edited by Matt Englar-Carlson, Marcheta P. Evans and Thelma Duffey
  • Stress Management: Understanding and Treatment (DVD) presented by Edna Brinkley

Podcast (counseling.org/knowledge-center/podcasts)

  • “The Brain, Connectivity and Sequencing” with Jaclyn M. Gisburne and Jana C. Harr

 

****

 

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

Letters to the editor: ct@counseling.org

 

****

 

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.

What counselors can do to help clients stop smoking

By Bethany Bray November 29, 2016

Nearly half of the cigarettes consumed in the United States are smoked by people dealing with a mental illness, according to the Substance Abuse and Mental Health Services Administration. The federal agency says that rates of smoking are disproportionately higher — a little more than double — among those diagnosed with mental illness than among the general population.

It is widely accepted that the nicotine in cigarettes is highly addictive, but people struggling with mental health issues often turn to cigarettes for reasons that go beyond their addictive qualities. For instance, many people smoke as a coping mechanism to deal with difficult feelings. In addition, despite their negative health effects, cigarettes are still largely viewed by society as an “acceptable” addiction in comparison with other substances.

The reality? “[Smoking] is a devastating addiction and a difficult one to quit,” says Gary Tedeschi, clinical director of the California Smokers’ Helpline and a member of the American Counseling Association. “This clientele [those with mental illness], in particular, need the encouragement and support to go forward [with quitting], and many of them want to, despite what people might think. … To let people continue to smoke because ‘it’s not as bad’ [as other addictions] is missing a really important chance to help someone get healthier.”

To drive home his point, Tedeschi points to a statistic from the 2014 release of The Health Consequences of Smoking — 50 Years of Progress: A Report of the Surgeon General, which says that more than 480,000 people die annually in the United States from causes related to cigarette smoking. Close to half of the Americans who die from tobacco-related causes are people with mental illness or substance abuse disorders, Tedeschi says.

In Tedeschi’s view, the statistics connecting smoking to mental illness are “so obvious that it’s almost an ethical and moral responsibility to help this population quit.”

Part of a package

Ford Brooks, a licensed professional counselor (LPC) and professor at Shippensburg University of Pennsylvania, says he has never had a client walk in to therapy with a primary presentation of wanting to stop smoking.

Tobacco use “is always part of a package” that clients will bring to counseling, Brooks says. In his experience as an addictions counselor, smoking is often piled on top of a laundry list of other challenges that may include alcohol or drug addiction, depression, a marriage that is on the rocks, the loss of a job or financial trouble.

“They’re on the train to destruction, and their nicotine use, in their minds, is on the back end [in terms of importance]. … Is the smoking related to what their presenting issue is? Chances are it probably connects somehow. Don’t be afraid to bring it up,” advises Brooks, co-author of the book A Contemporary Approach to Substance Use Disorders and Addiction Counseling, which is published by ACA.

Tedeschi, a national certified counselor and licensed psychologist, notes that many people who call the California Smokers’ Helpline are struggling with comorbid conditions or mental illness in addition to tobacco use. The phone line is one in a system of “quitlines” operating in each of the 50 U.S. states, the District of Columbia, Puerto Rico and Guam.

For clients struggling with mental health issues, smoking may serve as a coping mechanism to deal with uncomfortable feelings or anxiety, Brooks says. Years ago, when smoking was still allowed in many indoor spaces, Brooks led group counseling in detox, outpatient and inpatient addictions facilities. “When powerful emotions would come up in group, [clients] would fire up cigarette after cigarette to deal with those feelings and quell anxiety,” he recalls.

With this in mind, counselors should help prepare clients for the irritability, anxiety and other uncomfortable feelings they are likely to experience when they attempt to stop smoking cigarettes. “Talk about what it will feel like to be really anxious and not smoke” and how they plan to handle those feelings, Brooks says. “… If a person has anxiety or depression and stops smoking, what initially happens is they could get more depressed or more anxious without nicotine to quell the emotion.”

The counselors interviewed for this article urge practitioners to ask every single client about their tobacco use during the intake process, no matter what the person’s presenting problem is. “If you’re helping them to get mentally and physically healthier, this [quitting smoking] is a very critical part of the overall wellness picture,” Tedeschi says.

Counselors shouldn’t be afraid to ask their clients whether they smoke, says Greg Harms, a licensed clinical professional counselor (LCPC), certified addictions specialist, and alcohol and drug counselor with a private practice in Chicago. “It can feel weird the first couple of times, especially if this is not your area of expertise,” says Harms, who does postdoctoral work at Diamond Headache Clinic in Chicago, an inpatient unit for people with chronic headaches. “A lot of times, clients have heard all the bad stuff about smoking. A lot of them, deep down, they know they’d be better off if they were to quit smoking. They may have failed so many times in the past that they’re discouraged. They might be hesitant to bring it up because this is a counselor and not the [medical] doctor. If you bring it up, more often than not, the client is going to engage with that. Even if they don’t, if it’s not the right time for them, you’ve planted that seed. … It might come to fruition down the road. I’d much rather plant that seed than not say anything at all.”

When Harms was a counseling graduate student, he completed an internship at the Anixter Center, a Chicago agency that serves clients with disabilities. While there, he worked as part of a grant-funded program for smoking cessation for people with disabilities that was spearheaded by the American Lung Association. He also presented a session titled “Integrating Smoking Cessation Treatment with Mental Health Services” at ACA’s 2013 Conference & Expo in Cincinnati.smoking

If a client doesn’t feel ready to begin the quitting process right away, the counselor can put the topic on the back burner to address again once the client has made progress on other presenting problems or has forged a stronger relationship with the practitioner. However, that shouldn’t mean that the topic is off the table completely, Harms says. A counselor should talk regularly with the client about quitting smoking, even if it’s only for a few minutes each session.

“Give them a little nugget of information [about quitting], and then you can focus on what they’re there for,” Harms says. “Help them find ways to deal with their presenting problem, then they’ll trust you. Once they’re in a better place, revisit [the idea of quitting]. We don’t have to address it and get their buy-in during the first session. It would be fantastic if that was the case, but it’s OK if it’s not. In most cases, time is on our side to develop the relationship, plant the seed and revisit it. If the client is not ready, we can harp on [quitting] all we want, [but] it won’t do anything.”

“You really have to take the client’s lead and go at the pace they’re willing,” Harms continues. “Don’t push. Respect their decision. Even if they’re not ready for [quitting], let them know that [you’re] there for them and respect their autonomy to make that decision.”

Positioned to help

Counselors are particularly suited to help clients quit smoking because the profession has an array of tools focused on behavior modification, Tedeschi asserts. Motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and other models can be useful in helping clients stop smoking. But techniques from any therapy model that counselors are comfortable using can be adapted to help clients navigate the challenge of quitting, Tedeschi says, especially when combined appropriately with pharmacologic aids approved by the Food and Drug Administration.

“We’re in the business of helping people change. The principles that a counselor uses to help someone understand an issue and begin to make steps toward change apply to smoking cessation as well,” Tedeschi says. “Counselors help people understand their motivation to change and help them come up with a plan to change.”

Harms agrees, noting that in most cases, a counselor will have significantly more time with a client than a medical professional will. Instead of “hitting [the client] over the head” with the dangers of smoking, Harms says, a counselor can afford to focus on the positive, use a strengths-based approach and build on what the client wants to work toward rather than what he or she wants to avoid.

“We [counselors] are so strengths-based. It’s our natural inclination to tell the client, ‘Yes, you’re strong enough to do this,’ rather than [taking] a scare approach,” Harms says. “We can find their strength and have that unconditional positive regard for them, regardless of how long it’s taking. We have the patience to sit with a client as they’re going through [quitting]. We can build that relationship and be a resource.”

Start small

Tedeschi recommends that counselors use the “five A’s” to discuss smoking with clients. In this approach, a practitioner should:

  • Ask each client about his or her tobacco use
  • Advise all tobacco users to quit
  • Assess whether the client is ready to quit
  • Assist the client with a quit plan
  • Arrange follow-up contact to mitigate relapse

Each of these steps is important, but providing support and follow-up as the client begins to quit is particularly critical, Tedeschi says.

“The first week of quitting is the hardest. If [a counselor] waits for a week to talk to the client, you could lose about 60 percent of people back to relapse,” he says. “If someone is able to quit for two weeks, their risk of relapse drops dramatically.”

If clients resist the idea of quitting or do not feel ready to quit entirely, Tedeschi suggests that counselors work with them to stop smoking for one day or even just an afternoon. During this time, have clients monitor how they felt: How was their anxiety level? What were their cravings like? This technique can introduce the idea of stopping and prepare clients for the quitting process, he says.

Brooks recommends using motivational interviewing to help clients make the life change to quit smoking. “Nicotine is a drug, and it’s no different than if [clients] were to say they want to stop drinking. Work with their motivation to identify what they can possibly do for that,” he says.

Part of the quitting process involves clients going through an identity shift, Tedeschi notes. Clients can be behaving as nonsmokers — abstaining from cigarettes — long before they make the mental leap that they are no longer smokers, he says. It is important for clients to make that mental shift from “a smoker who is not smoking” to a “nonsmoker,” Tedeschi says. Counselors need to work with these clients to identify as and accept the nonsmoker label. “As long as someone calls [himself or herself] a smoker, they will be open to turning back to cigarettes,” he explains.

Kicking the habit

Counselors can use the following tips and techniques to better equip clients to meet the challenge to stop smoking.

Set a quit date. This is an important step, but one that clients must take the lead on and choose for themselves, Tedeschi says. Research shows that simply cutting back without setting a quit date isn’t very effective, he adds. The behavioral patterns that often accompany smoking (for example, smoking after eating or taking smoke breaks at work) make it very hard to keep tobacco use at a low level. Setting a quit date creates accountability and is a “sign of seriousness,” he says. At the same time, be flexible. “For some people, it’s just too hard to think about [sticking to a quit date],” Tedeschi says. “For some — especially those who are struggling with other substances — they need to take one day at a time.”

Be aware of psychotropic medications. Counselors should be aware that if clients are taking prescription medicines for anxiety, depression, bipolar disorder or other mental illnesses, their dosages might need to be adjusted as they quit smoking. Nicotine is a stimulant, so it speeds up a person’s metabolism. This means a person who smokes will burn through psychotropic medications faster than someone who doesn’t smoke, Harms explains. Counselors should be certain to talk this through with clients and work with their doctors to modify their dosages, he says. “This is especially noticeable with mood stabilizers. It’s acute with bipolar disorder,” Harms says.

The same holds true with caffeine, Tedeschi notes. After they quit smoking, clients may notice that they get jittery from caffeine and may need to cut back on their coffee intake.

Use cognitive strategies. Counselors can help clients create a list of personal reasons why they want to stop smoking — beyond the health implications, Tedeschi says. The list doesn’t need to be long, but the reasons need to be compelling and motivating enough to carry clients through a nicotine craving. For example, one of Tedeschi’s clients wanted to quit because his young grandson asked him to. As a reminder, the client kept a toy car that belonged to his grandson in his pocket. “When he had a craving [for a cigarette], he would pull [the toy car] out of his pocket, look at it, hold it and squeeze it,” Tedeschi says. “It helped.”

Turn over a new leaf. As they quit smoking, encourage clients to organize, clean and purge their homes and cars of smoking-related materials such as ashtrays, advises ACA member Pari Sharif, an LPC with a practice in Franklin Lakes, New Jersey. That action will help clients turn a new page mentally and start fresh, she says. Sharif also encourages clients to air out their homes and clean their closets so their clothes and furniture no longer smell like smoke.

On a similar note, if clients have a certain mug that they always use to drink coffee while smoking, Harms suggests that they get a new mug. Or if they always stopped at a certain gas station to buy cigarettes, he suggests that they now change where they buy gas.

When cravings strike, breathe. Sharif, a certified tobacco treatment specialist, introduces breathing techniques to all of her smoking cessation clients. She asks these clients to take measured breaths for roughly two minutes, inhaling while slowly counting to four, then exhaling for four counts.

“Instead of the reflex habit to grab a cigarette, take a moment to stop and ask why. Be more in control of yourself and your mind,” she tells clients. “Pause to do breathing and body scanning from head to toe. Ask yourself, ‘What am I doing? Why do I need this [cigarette] to calm down?’ … [Through breathing exercises,] your breath becomes deeper and deeper. Close your eyes. Your body starts relaxing and your anxiety level goes down.”

Sharif also recommends that clients download a meditation app for their smartphones and use a journal to record how they’re feeling when cigarette cravings strike. This helps them log and identify which situations and emotions are triggering their need for nicotine,
she explains.

Get to the root of it. Asking clients about the circumstances that first caused them to start smoking can help in identifying what triggers their nicotine use and the bigger issues that may need to be addressed through counseling, Sharif says. In some cases, a specific traumatic event or stressor caused the person to start smoking. In other instances, it was a learned behavior because everyone in the household smoked as the client was growing up. “Find out when they started smoking and why,” Sharif says. “Gradually, when they become more aware of themselves, they quit.”

Change social patterns. Cigarettes are often used as a coping mechanism when people experience anxiety in social situations, Harms says, so clients may need to focus on social skills as they start the process of quitting smoking.

“[Cigarettes] are their way to socialize and get out and meet people. If you have social anxiety, you can still go up to someone and ask for a cigarette or ask for a light. It’s programmed socialization,” Harms explains. “It gives you an excuse to be close to people, feel more sociable. If you take away their cigarettes, you’ve got to replace that.”

Brooks agrees, noting that clients who smoke likely have friends who are also smokers. For example, he says, it is not uncommon to see people smoking and talking together outside of Alcoholics Anonymous meetings. Counselors can help clients prepare to avoid situations where smoking is expected and practice asking people not to smoke around them, Brooks says. Counselors can also support clients in creating social networks of people who don’t smoke, including support groups for ex-smokers, he adds.

Break behavioral habits. Similarly, Brooks says, counselors can help clients change the behavioral habits they connect to smoking, such as starting the morning by reading the paper, drinking coffee and smoking a cigarette. Counselors can suggest activities and new rituals to replace the old ones, such as taking a daily walk, he says.

Harms encourages clients to replace their former smoke breaks with “clean air breaks.” They can still take their normal time outside, but instead of smoking, he suggests that they walk around the block, sit and read a book, eat an apple or use their smartphones outdoors. If they had a favorite smoking spot outside, he urges them to find a new place to go instead.

Find comforting substitutes. “The whole ritual of lighting up a cigarette — tapping the pack to pull out a cigarette and flicking the lighter — the behaviors that go with [smoking] can be very comforting,” Harms says. “Sometimes that’s what’s so hard to break — the behaviors that go with it.”

Tedeschi recommends that counselors work with clients to have comforting alternatives ready to go even before the clients attempt to quit smoking. It is hard for people to figure out alternatives in the heat of the moment when a craving strikes, he explains. Tedeschi offers several possible substitutes for consideration: sugar-free gum, beef jerky, cinnamon sticks and even drinking straws cut into cigarette-sized lengths through which clients can inhale and exhale.

If clients are comforted by having something in their hands, Brooks suggests keeping a pen, stress ball or prayer beads nearby. Staying hydrated and carrying a water bottle can also help these clients, Tedeschi adds. Most of all, counselors should work toward the idea of replenishment and filling in where clients feel they are losing something, he says.

Don’t dismiss pharmacotherapy. A wide variety of quitting aids are available, from nicotine patches, lozenges and gum, to prescription pills such as Chantix. The counselors interviewed for this article agree that these stop-smoking aids can be helpful when used alongside counseling. However, Tedeschi says, counselors should work with their clients’ physicians when such medications are being used, or make sure that clients are talking with their physicians. Counselors should also be aware of the potential side affects that these medications can have, such as aggressive behavior.

Brooks notes that none of these options is a magic solution to quit smoking. For example, nicotine gum and other medications can be prohibitively expensive, and some clients can continue to smoke even while using nicotine patches or gum. As for electronic cigarettes, Sharif and Harms agree that they are not a recommended alternative. Electronic cigarettes are carcinogenic, addictive and mimic the “puffing” behavior of regular smoking, Harms notes.

Connect clients with other supports. Counselors should equip clients with resources they can turn to outside of counseling sessions, such as local support groups for ex-smokers or the phone number for their state’s tobacco quitline, Brooks suggests. Nicotine Anonymous (nicotine-anonymous.org) is an ideal resource for clients who are trying to stop smoking, Brooks says. The 12-step method at Alcoholics Anonymous (AA) can also be applied to tobacco use for clients who attend AA meetings already or who don’t have a Nicotine Anonymous support group in their local area, he adds.

Sharif suggests that counselors keep brochures and other information about quitting smoking alongside the materials they might have about depression or suicide prevention in their offices or waiting rooms. It is better for counselors to distribute information that they have vetted themselves rather than having clients search the internet for information on their own, she notes.

 

Try and try again

On average, it takes a smoker 10-12 attempts to fully quit cigarettes, according to Tedeschi. For that reason, it is imperative that practitioners not give up on clients after their first, second or even 10th try, he stresses.

Quitting smoking is hard, Tedeschi acknowledges, but possible with perseverance. “Don’t be discouraged as a clinician if your client relapses. [Quitting] is definitely not a one-time event; it’s a process. … Relapse prevention is important, but it’s equally important to be ready for the relapse,” he says. “One of the best things a counselor can give a client is that reassurance. Any attempt to quit for any length of time is a success rather than a failure. That’s just the reality of this addiction. As long as they keep trying, they’ll get there. The only failure is to stop trying. The most important message a counselor can give a client is to never give up.”

 

****

 

Statistics: Smoking and mental health

  • Roughly 50 percent of people with behavioral health disorders smoke, compared with 23 percent of the general population.
  • People with mental illnesses and addictions smoke half of all cigarettes consumed in the U.S. and are only half as likely as other smokers to quit.
  • Smoking-related illnesses cause half of all deaths among people with behavioral health disorders.
  • Approximately 30-35 percent of the behavioral health care workforce smokes (versus 1.7 percent of primary care physicians).

— Source: U.S. Substance Abuse and Mental Health Administration (see bit.ly/1sEx97a)

 

****

 

Resources

 

****

 

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

Letters to the editorct@counseling.org

 

****

 

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 Counseling Connoisseur: Nature-informed counseling for children

By Cheryl Fisher October 13, 2016

“Once there was a tree … and she loved a little boy” — from The Giving Tree by Shel Silverstein

 

*****

 

I recently returned from a wonderful week in Nova Scotia featuring painted clapboard cottages against blue skies and a seascape of majestic hills and swirling tides. With a history rich in forts, fur trades and complex propriety, Nova Scotia also affords miles of pristine trails for the avid (and not so avid) hiker.

On one such hike, I ventured up Cape Split, which offered a spectacular view of the Bay of Fundy following a two-hour uphill jaunt. The inland path was lush with evergreen and paved in centuries-old rocks. Snarled roots from ancient maples protruded from the narrow trail, and patches of mud provided slippery terrain. At times the trail seemed endless and unforgiving. However, just at that moment when body and morale were failing, the forest opened to a grassy knoll that blanketed the age-old rock formation overlooking the (now) returning six-foot tides of the Bay of Fundy.

Damp with perspiration from navigating the trail, we sat down and unloaded our backpacks, laying out a feast before us of lobster rolls and blueberry lemonade. The cool breeze from the bay mingled with the warmth from the sun. In that moment, I was sure there was nothing sweeter than communion with nature and the physical and emotional exertion and spiritual nourishment it afforded.

 

Camps and communion

For many children (and their excited parents), the end of summer signifies a return to school, studies and schedules. It is a time when we bid farewell to the lackadaisical whimsy of carefree days. Summer memories of camps, cookouts and canoes fade, making way for the cooler activities of autumn. However, for many children, summer camp did not include nature hikes, bonfires or kayaking; it involved indoor activities centered around a theme such as weight management, music acquisition or computer skills.

photo-1447875372440-4037e6fae95dResearch suggests that connecting to nature can result in reduced stress, increased energy, improved sleep, reduction of chronic pain, and accelerated healing from injuries and surgery. In particular, Peter Kahn and Stephen Kellert have argued that “a child’s experience of nature exerts a crucial and irreplaceable effect on physical, cognitive and emotional development.”

Yet modern living has insulated us from the positive ionic exchange between grass, trees, river and sky, resulting in a physical, psychological and often spiritual connection from the Earth and her creatures. According to researcher and therapist Martin Jordan in his book Nature and Therapy: Understanding Counselling and Psychotherapy in Outdoor Spaces, this detachment is associated with a variety of dis-ease, including epidemic rates of obesity and depression.

Richard Louv, author and founder of the Children & Nature Network, coined the term “nature deficit disorder” in his book Last Child in the Woods to refer to a generation of children who no longer spend time outdoors hiking, camping and otherwise interacting with the natural world. Direct contact with nature appears to benefit children physically, emotionally and spiritually.

 

Physical

Interacting with natural elements provides a varied and complex terrain and physical stimulation for children. Negotiating inclining hills or slippery declines, catching and releasing tadpoles or crickets, and chasing butterflies, for example, create opportunities for skill-building in a variety of areas, including large and fine motor skills, balance and hand-eye coordination. Most people can remember the challenge of a new skill … and the thrill of successful mastery.

 

Emotional and cognitive

According to Kahn and Kellert, a child’s experience of nature “encompasses a wide variety of emotions” and an “unfailing source of stimulation.” I remember the awe and wonder I experienced when my childhood naturalist neighbors taught me how to look for the tiny green caterpillars grazing on the cabbage leaves in the garden; then observing their transformation as they ate their way to chrysalises; and the unbearable waiting and waiting until these dormant creatures emerged into beautiful white butterflies.

More recently, I ventured into raising the threatened monarch butterfly. Still with the curiosity of a child, I planted my milkweed, purchased my microscopic caterpillars and watched in amazement as larvae transformed into J’s hanging from the top of my butterfly shelter. Sadly, a virus attacked my precious guests and killed each before they could take their first flight. I experienced genuine grief over this loss.

 

Moral

Nature provides endless teaching opportunities around issues of moral conscience. Kellert identified nine values of the natural world:

  • Aesthetic: Physically appealing
  • Dominionistic: Mastery or control over nature
  • Humanistic: Emotional bonding with nature
  • Moralistic: Ethical or spiritual connection to nature
  • Naturalistic: Exploration of nature
  • Negativistic: Fear and aversion of nature
  • Scientific: Knowledge and understanding of nature
  • Symbolic: Nature as a source of language and imagination
  • Utilitarian: Nature as a source of material and physical reward These values tend to emerge in a developmental manner, generally shifting from more self-centered, egotistical values to more social and other-centered values.

 

Nature-informed counseling

Nature-informed counseling refers to a vast array of scientifically based psychological therapies that use nature in clinical practice. Among the foundational assumptions of nature-informed counseling are that we are not machines; we are human beings who are sensual, curious and creative. We are interdependent with the full ecosystem in which we reside.

Furthermore, ecotherapy is an organic model of care that tends to the whole relationship between humans and the other-than-human. Here are several ways to incorporate nature-informed methods into your counseling practice:

1) Animal-assisted therapy: I am fortunate to be able to bring my goldendoodles to my office to be co-therapists. However, in addition to dogs, there are other smaller pets that may work more easily in your practice. For example, I had a betta fish (who was named Olive by a client) that I used with clients. Or place a bird feeder outside your window (if you are fortunate enough to have a window).

2) Horticulture therapy: There are numerous ways to integrate plants in a therapeutic manner. Have clients plant seeds and tend to their care. Or keep small pots of herbs in your office, providing an opportunity to explore aromatherapy. It is a wonderful release to pinch off a bit of rosemary, mint or thyme and inhale the calming, soothing or energizing fragrance.

3) Wilderness therapy: I have used “kayak therapy” with trauma survivors with great success. However, you may not work in a community with easy water access or even know how to kayak. Therefore, your wilderness approach might be more in line with taking clients on a walk on a trail or observing wildlife with them in a nearby lake or pond.

You can also co-create homework around nature walks. For example, I was working with a couple who seemed stuck, so I asked them to go for a walk together (without talking) and collect items along the way that reminded them of their marriage. When they returned to my office, they emptied their treasures, which included a rock (“that used to be how I saw our marriage”), a feather (“we are drifting away”) and a few twigs (“we have roots still”). After a discussion centered around the items gathered, I had the couple finish the session by using the items to create a sculpture that reflected the relationship they wanted to craft.

4) Other ideas:

  • Assess your clients’ relationship with nature. Where is their “happy place”? How often does they get to visit it? Where are their favorite memories housed?
  • Invite a family with which you are working to spend the night in a tent in the backyard and reflect on this experience in session.
  • Teach cloud spotting. Teaching clients mindfulness takes on a fun twist as you lie on your back and gaze at the ever-changing cloud formations.
  • Use transitional objects. I keep a box in my office filled with seashells, sea glass and rocks lovingly collected by my own mother when she walks the beach. I use these as transitional objects when clients might benefit from imprinting an image or experience to an object that they can carry in their pockets or purses throughout the day.

 

Ethical consideration

As with all forms of practice, ethical standards must be followed to avoid harm and litigation. So what are the ethical considerations when utilizing the wisdom of nature in psychotherapy? This depends on the extent and type of nature-informed therapy you are using. For example, the ethical guidelines for hiking a trail with a client may look a bit different than the guidelines forphoto-1469440317162-d9798b137445 planting a sunflower seed and tending to it as metaphor for self-care and growth. However, in general the following issues must be addressed.

1) Do all parties feel physically and emotionally safe? Although you may thrive sitting in a field of poppies, your client may possess strong allergies to flower pollen that render therapy outdoors a physically uncomfortable experience. In addition to allergies, the client may exhibit phobias around the outdoors that need to be understood and appeased. Temperature and air quality may also be variables to consider.

2) Framing the relationship. For some therapists and clients, an office space with a designated chair arrangement signifies a professional relationship and the tasks that will ensue. A client may feel uncomfortable with the more lax and familiar atmosphere of sitting cross-legged on a hollow log while disclosing current therapeutic issues. Trading leather chair for log stump may alter the relationship in ways that prove unsettling for either the client or the therapist.

3) Is it confidentiality compliant? I have clients who love taking a walk during therapy. Some lament that it is the only time they have for physical activity. However, if we are walking in a heavily populated area, their confidentiality may be at risk. At the same time, an area that is too isolated may not be prudent should an emergency situation arise.

4) Get appropriate training. If you do not know how to kayak, taking clients on a wilderness kayak expedition probably isn’t wise. Always get training before using any modality in therapy.

5) Informed consent. It is always prudent to have clients sign an informed consent form that stipulates the possible risks and benefits of any therapy used in session. Therefore, a specific consent form that addresses the specific type of nature-informed therapy — including possible benefits and risks — needs to be explained and signed prior to taking that walk in the woods or a stroll in the garden during session.

 

Conclusion

Nature provides endless opportunities for metaphors, messages and meaning construction. Incorporating nature-informed approaches into our practices is not only creative but also clinically sound. It is as easy as taking the time to reflect on the sights, sounds, and smells just outside the door.

 

****

 

For more information:

  • Ecotherapy: Healing With Nature in Mind by Linda Buzzell and Craig Chalquist (2009)
  • Nature and Therapy: Understanding Counselling and Psychotherapy in Outdoor Spaces by Martin Jordan (2014)
  • Children and Nature: Psychological, Sociocultural and Evolutionary Investigations by Peter H. Kahn and Stephen R. Kellert (2002)
  • Last Child in the Woods: Saving Our Children From Nature-Deficit Disorder by Richard Louv (2008)

****

 

Cheryl Fisher

Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland, and a visiting full-time faculty member in the Pastoral Counseling Department at Loyola University Maryland. Her current research examines sexuality and spirituality in young women with advanced breast cancer. She is currently working on a book titled Homegrown Psychotherapy: Scientifically-Based Organic Practices, of which this article is an excerpt. Contact her at cy.fisher@verizon.net.

 

 

 

 

****

 

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.
****

Treating psychogenic nonepileptic seizures

By Jason Wright August 26, 2016

Imagine what it’s like to suffer from seizures that can strike anytime, anywhere. Imagine losing your driver’s license, job and social life because of seizures that seem to be uncontrollable. Imagine the emotional turmoil that ensues as these seizures take over more and more of what you once enjoyed, considered necessary or maybe even took for granted.

Now imagine your neurologist or epileptologist telling you there is no medical reason for your condition. The seizures have a psychological origin and are your brain’s way of coping with Branding-Images_seizuresemotional stress. Unlike what your primary care physician told you, your condition isn’t epilepsy, meaning all those drugs you’re taking to treat epilepsy are absolutely worthless.

Finally, imagine dealing with the skepticism of your family and friends now that they know these seizures are “all in your head — the doctor even said so.” This is a snapshot of what it is like for people who suffer from psychogenic nonepileptic seizures (PNES).

My first case

It was a Tuesday afternoon at my clinic, one of the week’s two “walk-in” days in which both regular and new clients could see a clinician without an appointment. On this particular day, a young woman in her 20s (I’ll call her Charleen) walked in, trembling and barely able to speak. All our clinicians were busy, but the receptionist told her that if she had a seat, someone would be with her shortly. The front office staff said she seemed slightly disoriented and not fully able to explain why she was in our office or who had referred her.

After I finished another client’s session, I walked into the waiting room and introduced myself. Charleen made no eye contact, and about a minute into our conversation, she told me she had to leave and return home to “take her dogs out.” She assured me that she would be back, however. Later that day, she called the office and made an appointment with me for the following week.

During that appointment, Charleen told me she had been suffering from PNES and anxiety, and that a local mental health agency had referred her for those conditions. She had left so abruptly the day she walked in because she was on the verge of having a seizure episode and didn’t want to have it in my office. She then tearfully proceeded to tell me about her life, and losses, with PNES, which included the experiences mentioned at the beginning of this article.

Although I was aware of PNES, I had never worked with anyone diagnosed with the condition. With more than 20 years of experience as a licensed counselor, however, I had extensive experience with clients struggling with anxiety. There were no other places that worked with PNES within a reasonable distance for Charleen, so I agreed to become her counselor. I began reading everything I could get my hands on related to PNES, starting with Psychogenic Non-epileptic Seizures: A Guide, by Lorna Myers, and even attended an online training given by Myers.

My work with Charleen progressed nicely, and I began to contact other referral sources in my area for more PNES cases. The treatments I used were bringing impressive results to a condition that, as I found out later, many clinicians feared. As the successes continued, I contacted Myers, director of the PNES Treatment Program and the Clinical Neuropsychology Program at the Northeast Regional Epilepsy Group in New York, to be placed on the national referral registry for PNES. Given the dearth of providers for PNES, I began getting referrals from other states. My zeal for working with PNES sufferers has continued to grow since that time.

Diagnosis

Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not include the acronym PNES, it does describe the condition as a conversion disorder (functional neurological symptom disorder) “with attacks or seizures” (F44.5). Professionals treating the condition most often use the acronym PNES, but NEAD (nonepileptic attack disorder) is also used on occasion.

The DSM-5 diagnostic criteria for psychogenic seizures include “altered voluntary motor or sensory function” that do not have a medical or neurological origin and are “not better explained by another medical or mental disorder” and that cause “clinically significant distress” in all facets of life. The term pseudo-seizures is often used to describe this condition. This is inaccurate, however, because there is nothing fake (or pseudo) about these seizures. PNES is not the same as malingering (looking for secondary gain) or factitious disorder (an attraction to being ill). Individuals who experience PNES subjectively believe and feel that they do not have control over their condition.

Several tests can help rule out seizures with a medical origin. The gold standard for diagnosing PNES, however, is the video EEG, a test that measures brain waves. During a video EEG, the person is admitted to an inpatient facility and observed for an extended period of time (generally multiple days). Whenever a seizure occurs, the brain’s electrical activity is analyzed. When a seizure has a medical origin, the EEG will display abnormal brain wave activity. In the case of PNES, brain wave activity remains unchanged during the seizure. Currently, this is the only way to reliably diagnose PNES.

In some cases, individuals who suffer from psychogenic seizures may also have epilepsy or experience other medically oriented seizures. In their paper “Defining psychogenic non-epileptic seizures,” Selim Benbadis and Valerie Kelley write that “about 10 percent of patients with PNES also have epilepsy.”

Traumatic experiences and treatment options

In most cases, sufferers of psychogenic seizures have endured at least one significant traumatic experience in their past, often including sexual victimization. Whatever the traumatic experience may be, psychogenic seizures are believed to serve as a psychological shut-off valve of sorts when sufferers become emotionally distressed. The stress may be due to external circumstances (e.g., social anxiety, job stress) or internal stimuli (e.g., flashbacks from traumatic experiences, hallucinations). It is common for PNES to occur comorbidly with other psychiatric conditions such as posttraumatic stress disorder (PTSD), dissociative disorders and anxiety disorders.

What can counselors do to help those suffering from psychogenic seizures? There are several treatment options to consider.

Psychoeducation: Psychoeducation is extremely important for those suffering from PNES because many of the clients who seek counseling do so only after years of unsuccessful treatment for epilepsy or other medically oriented conditions. They are typically referred to counseling after finally being successfully diagnosed by an epileptologist or neurologist but still may not have a proper understanding of how something that seems to have a medical origin is actually psychological in nature. Proper education for clients and their loved ones will help minimize the confusion and stigma that are often associated with this condition.

Journaling and mindful awareness: This phase of treatment involves clients learning two vital exercises: keeping a seizure journal and mindful awareness.

Before individuals become incapacitated by psychogenic seizures, they generally report a variety of prodromal symptoms, including trembling, headaches, dizziness and fatigue. The typical response one feels when a seizure is approaching is to become more anxious. This response is logical, especially considering the havoc and disruption the seizures have caused in the person’s life previously. However, an increase in stress is exactly what makes psychogenic seizures more likely to occur (stress and anxiety typically activate the seizure to begin with). Therefore, learning how to be mindful of prodromal symptoms is vital for the person to do what is necessary to avoid progression to a full-blown seizure — namely, by practicing anxiety and stress reduction.

Keeping a record (a journal) of seizure activity and each seizure’s antecedents will provide the client and counselor alike with vital information regarding when and where seizures are most likely to occur. This also keeps the client and counselor informed on therapeutic progress. Seeing one’s successes on paper can be inherently motivating and help foster the confidence that is so beneficial in combating anxiety and stress.

Anxiety/stress reduction: The next phase of treatment includes a variety of well-established and empirically verified interventions aimed at minimizing stress and reducing anxiety. This can be extremely effective in halting seizure progression.

I have found that a combination of deep breathing, progressive muscle relaxation and positive visualization can help reduce anxiety significantly. This intervention is the first choice for many of my clients suffering with PNES. Cognitive restructuring, including the recognition of stress-inducing schemata, identification of limited thought patterns and utilization of balancing thoughts that directly counter stress-inducing schemata, can also be effective in controlling anxiety and stress. Learning conflict resolution skills and receiving anger management counseling may be helpful for clients whose stress occurs more as anger. In short, by helping clients find the interventions that keep their stress levels low, counselors will give those who suffer with PNES the best chance to gain control over their seizures.

Biological considerations: Despite the psychological and emotional antecedents to psychogenic seizures, it is also important to consider physiological themes during treatment. Dietary factors are an element that deserves strong consideration in the treatment of nonepileptic seizures. When these issues affect seizure activity, they are referred to as physiogenic seizures.

I have found that many clients who suffer from psychogenic seizures also struggle with physiogenic seizures. For example, many PNES clients who regularly consume coffee will acknowledge that caffeine makes their seizures more likely and that reducing or eliminating its use is beneficial. This is most likely because caffeine stimulates the nervous system, increasing the possibility of elevated stress and anxiety levels and, thus, psychogenic seizures. In addition, avoiding foods with a high glycemic index will help to ensure that blood sugar levels remain stable. Unstable blood sugar levels can lead to hypoglycemia (low blood sugar), which, according to the Epilepsy Foundation, can trigger nonepileptic seizures.

Within the biological sphere of consideration, many patients find psychiatric medications to be beneficial. This is likely because the correct medications will help foster an emotional/mental state that reduces the likelihood of seizures occurring. It is important to note, however, that psychiatric medications do not treat the seizures directly. As is the case with other conditions, when a client with PNES is receiving treatment from a psychiatrist or other provider, it is very important for the counselor to keep open lines of communication with all said providers. In some cases, a change in psychiatric medications, or the addition of other medications, may result in an increase in seizure activity. It is necessary for the counselor to know what medication changes may have preceded the client’s seizure surge.

Working through trauma: A final phase to strongly consider when treating PNES is helping clients work through traumatic experiences. This phase of treatment can include a wide range of established interventions such as journaling, the empty chair, autogenic training, systematic desensitization and even family therapy, although many other effective interventions also exist for this stage. Myers suggests that the use of prolonged exposure may be helpful in the treatment of PTSD and may also be used to treat psychogenic seizures. At times, treatment will be more challenging depending on how many comorbid conditions are present.

In my experience, I have found that some clients will gain considerable control over their seizures before this final phase and will even opt out of this phase of treatment. As a client-centered clinician, I must respect a client’s choice to end therapy before this stage, although I always explain the potential benefits (and drawbacks) of engaging in this material.

Conclusion

As a clinician, I have found working with those suffering from PNES to be a very rewarding experience. It is a wonderful thing to watch these clients gain more confidence and hope as they slowly and methodically reduce their seizures and begin to regain what they lost while buried in the throes of their unfettered condition.

In their article “Psychogenic (non-epileptic) seizures: A guide for patients and families,” Selim Benbadis and Leanne Heriaud suggest that the competent treatment of PNES will result in the elimination of seizures in 60 to 70 percent of adults, and the results for children and adolescents may be even more impressive. The treatment of PNES is evolving as research continues. But the numerous empirically validated treatment options currently available to competent counselors can be just what PNES clients need to begin the journey of gaining hope and confidence, reducing seizure activity and taking back their lives from the grip of psychogenic seizures.

 

****

 

Jason Wright is a licensed professional counselor and licensed marriage and family therapist at the HumanKind Counseling Center in Lynchburg, Virginia. He holds a doctorate in counseling. Contact him at dothejcbeat@aol.com.

Letters to the editor: ct@counseling.org

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

 

****

 

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 Counseling Connoisseur: Dandelion strong: Lessons from a weed

By Cheryl Fisher June 13, 2016

 

“A weed is a plant whose virtues have not yet been discovered.” — Ralph Waldo Emerson

 The cool misty rain offers my gardens ample moisture for the tiny seeds to swell in the early spring. The feathery green carrot tops and sprouting beans and squash gently push through the dark earth. Chamomile and mint pry loose from the grip of the cool soil. The sunflower leaves unfold intently toward the sun, capturing the nourishing rays in the creases.

Still so fragile and prey to hungry predators, the seeds swell and sprout … stretch and climb … creating an offering that will one day provide nourishment for my family. With a watchful eye, I monitor the germination of my tiny seedlings, removing anything that may hinder their growth and final path. Invariably, as I water and weed, I will witness the perseverance of the dandelion.

The dandelion is the most misunderstood of all weeds. Its young green leaves contain substantial levels of vitamins A, C, D and B, in addition to iron, zinc, magnesium, potassium and a variety of other minerals. When plucked, dandelion greens make a divine summer salad. The root has been used for medicinal purposes for centuries and (when fermented) offers an earthy Dandelionlibation. The burst of yellow provides early nectar for the pollinating bees and butterflies. Furthermore, according to research being conducted at Johns Hopkins University, this prolific weed may contain anti-cancer properties.

Dandelions grow under the most challenging of circumstances, often making their home in extremely unlikely locations such as concrete cracks. Then, just as their vibrancy begins to fade, the white puffy seedlings are carried along by the breeze, eventually landing, swelling and creating another generation of dandelions.

 

Dandelion or orchid?

The moxie of the dandelion has been metaphorically captured in a typology related to human resilience. The dandelion child versus the orchid child (originally coined by Bruce Ellis at the University of Arizona) has in recent years been a research topic that examines the interaction between genetics and environment in resilient behavior patterns.

The dandelion child is someone who appears to flourish despite adversity, whereas the orchid child tends to be more sensitive to her or his surroundings and environmental influences. In theory, this sensitivity may result in a greater propensity for both physical and psychological unwellness when exposed to adverse circumstances.

Yet our orchid friends need not fret. Given the right tools, these delicate creatures demonstrate their own resiliency.

 

Dandelion strong

Resiliency is the ability to adapt to a variety of challenging experiences. According to psychologist and researcher Susan Kobasa, there are three elements associated with resilient people: the ability to accept the challenge, the ability to be committed to one’s life and the ability to clarify personal control in any situation.

Here are the ABCs to becoming dandelion strong:

1) Accept the challenge. Physically prepare for any challenge by getting plenty of sleep, eating healthfully and engaging in physical activity. Let’s face it, our ability to cope is significantly reduced when we are tired, hungry and weak. Optimal health promotes resiliency.

Furthermore, life is filled with challenges, and each has the potential to be a teacher. This may require leaning into the situation despite discomfort.

As a student of jiu-jitsu, I learned the importance of leverage and flow. Force against force creates a wall and, invariably, a lack of movement. However, leaning into the energy of your opponent will disarm her and allow for movement, which in jiu-jitsu means submission and successful completion of a match. Therefore, lean into that anxiety or fear. It may be telling you to better prepare for that exam or end that dysfunctional relationship.

Finally, viewing an obstacle as temporary allows for a more positive assessment of the situation and promotes a “can do” attitude. A plethora of research supports the power of positive thinking in overall wellness. Surround yourself with inspirational messages that remind you of your ability to get through this challenging moment. I have a sign in my office that reads, “She thought she could … so she did!” So I DID earn that Ph.D. at the age of 50!

2) Be committed. Resiliency is accompanied by a commitment to life, goals and relationships. Alfred Adler, Viennese physician and founder of Adlerian psychology, held that humans are goal-oriented and experience an overall sense of wellness when contributing to community through work, intimacy and friendships. What is most compelling is the desire for these goals (work, intimacy and friendship) to be not only achievable but meaningful. Therefore, find a greater value in your work and relationships.

For example, I remember counseling a client who was experiencing some struggle around the recent death of her estranged mother. Although this client struggled with many issues related to her relationship with her mother, she held firm to the value of her vocation as a janitor. She had worked for a local high school for more than 25 years. She described in detail how it gave her pleasure to take care of the rooms of “those hardworking teachers.” She saw her role as necessary and supportive in the overall education system. She viewed it as a higher calling.

My client recalled a time when she was putting away supplies long after the school day had ended. In the process, she came across a student sitting alone in the corner of the supply room. She told me how she had put her equipment away and then sat down on the cold cement slab next to the student. She described how this student disclosed to her that he felt lost and scared. He had just found out that his girlfriend was pregnant, and he couldn’t deal with it.

“He was going to hang himself! Right here in my closet,” my client told me, shaking her head in disbelief. She went on to tell me how she had talked this young man out of killing himself and stood by his side while he called his mom to tell her that he was in trouble. She beamed as she told this story. She realized the sacred work she provided as a high school janitor.

3) Clarify control. Resiliency includes a clear understanding of personal control. Compassion and empathy do not require the expenditure of energy worrying about things that are out of the person’s control. This is often one of the most difficult lesson to learn. You do not need to take on the drama offered by others. Nor do you need to manage the emotional state of others. Allow other people to manage their own emotional regulation and well-being.

In any given situation, a resilient person will ask “what do I have control over?” and act accordingly. If you don’t have control, then take a deep breath and (sing it with me) … LET IT GO!

 

Conclusion

Some people just seem to take life in stride, naturally maneuvering the unpredictable terrain. However, the rest of us can develop skills that allow us not only to join the hike but actually take the lead (by accepting the challenge, committing in a full and meaningful way, and clarifying our personal control in the situation).

There is an element of truth in Friedrich Nietzsche’s words: “That which doesn’t kill you, makes you stronger.” Like the dandelion, we can learn to persevere in the most unlikely of circumstances.

However, as I stand here in my garden, thoughtfully contemplating my next move in relation to this bright yellow hardy bud that has started to take residence among my herbs and vegetables, I am reminded of one final lesson offered by this garden-variety Taraxacum officinale: Look for the wishes among the weeds!

 

****

 

Cheryl Fisher

Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is visiting full-time faculty at Loyola University Maryland in the Pastoral Counseling Department. Her current research examines sexuality and spirituality in young women with advanced breast cancer. She is currently working on a book titled Homegrown Psychotherapy: Scientifically Based Organic Practices, of which this article is an excerpt. Contact her at cy.fisher@verizon.net.

See Fisher’s debut column “Seeking connections to ourselves, others and the sacred