Monthly Archives: November 2013

Situation with NFL player further shows that bullying goes beyond child’s play

Heather Rudow November 5, 2013

(Photo: Wikimedia Commons)

(Photo: Wikimedia Commons)

His tormenters reportedly called him “Big Weirdo.” He was sometimes ostracized, with his peers refusing to sit with him in the cafeteria.

It sounds like sad, yet typical, bullying behavior in high school or even elementary school. Yet in this case, the victim being bullied is professional football player Jonathan Martin, an offensive tackle for the Miami Dolphins who stands 6 feet 5 inches tall and weighs well over 300 pounds. And the bullies are allegedly his teammates – other grown men making salaries in the millions as players in the National Football League.

Martin left the team last week due to what was reported as an unidentified illness. It has since been learned that Martin had an emotional breakdown, the result of repetitive bullying from teammates.

Martin has since gone on an indefinite leave of absence, with reports surfacing of “threatening and racially charged” text messages from teammate Richie Incognito. Given the gravity of his actions, the Dolphins have indefinitely suspended Incognito from the team, though tales of Incognito being bullied for his weight as an adolescent add more complicated layers to the story.

While the circumstances surrounding this story have been met with both outrage and shock, licensed professional counselors have noted a rise in bullying among adult clients, with nearly half of all working Americans reporting a direct experience or witnessing bullying in the workplace. In Counseling Today’s March feature story, “Grown-up bullying,” counselors shared their experiences with adult bullying and how to help clients combat it.

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

The addition of PMDD to the DSM: Q&A with Laura Choate

By Heather Rudow November 4, 2013

sadwomanAmong the changes found in the recently released fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the addition of premenstrual dysphoric disorder, or PMDD. During the two-week span between ovulation and the first day of their period, women with PMDD typically feel symptoms which include severe depression, anxiety and tension. But whether the addition of PMDD into the DSM-5 constitutes a positive step for women’s mental health is somewhat of a contentious debate.

Laura Choate, a licensed professional counselor and author of the American Counseling Association-published books, “Girls and Women’s Wellness: Contemporary Counseling Issues and Interventions” and “Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment,” spoke with Counseling Today about the debilitating disorder and how its addition into the DSM-5 will impact counselors whether they support the change or not.

What were your thoughts upon hearing that the DSM-5 would be featuring PMDD?

Honestly, I was not surprised, given that it was already included under the Depressive Disorder, Not Otherwise Specified category in the DSM-IV-TR. However, it is getting a lot of additional attention now that it has been upgraded to a stand-alone, full diagnosis.

Was this a good decision? Why?

In short, yes. I agree with the DSM-5 work group’s analysis that the small but significant group of women who do experience PMDD on a monthly basis (around two to eight percent), need support regarding appropriate diagnosis and treatment so that their needs can best be met. According to the work group, recognizing PMDD as a disorder sets it apart as a clinically significant problem that warrants treatment for the group of women who experience it; it is not to be considered a normal part of all women’s menstrual cycles. I think the controversy related to this decision comes when there is a lack of public understanding of the difference between a disorder, which indicates that something is out of the “normal” realm of functioning, and women’s normal, healthy menstrual cycles.

How will the inclusion impact counselors?

The inclusion can help counselors in conceptualizing and treating women’s depressive symptoms when they can’t be explained by other depressive disorders. If counselors can encourage their women clients who have unexplained episodes of depression to keep a monthly mood chart, perhaps they can start to recognize the relationship between their cycles and their moods. If a pattern emerges, then counselors can assess for whether a woman may be experiencing Premenstrual Syndrome (PMS) or the more severe PMDD. The counselor can then consider the implementation of treatment options based on severity of symptoms.

What can counselors do for clients with PMDD?

First, as with other types of depression, psychotherapy and lifestyle change may be considered first. If symptoms are mild, counselors can first work with women to keep a monthly mood chart; many women are helped just by understanding the relationship between their symptoms and cycles. It helps to understand why she is feeling as she is, and it also helps to know that the symptoms will end when her period begins. Counselors can also implement CBT techniques; helping women change their perception of the disorder can change the way they experience their symptoms (“It’s unbearable” or “I’m going crazy” versus “I can provide myself with extra self-care during the next week until my symptoms subside”). Many professionals also recommend simple lifestyle changes such as changes in diet, exercise, and stress management.

Finally, for moderate to severe symptoms, medical professionals recommend selective serotonin reuptake inhibitors (SSRIs) as the first- line treatment to consider. This of course requires referral to her physician who can assess her symptoms and make the decision as to whether medications are warranted.

What does the addition of PMDD into the DSM say about the state of women and mental health in society?

On the one hand, some feminist groups have criticized the inclusion of PMDD as a move that pathologizes women’s normal physiological makeup and their healthy menstrual cycles. Opponents of the inclusion claim that some critics might use this move to claim that women are inferior or incompetent because they are inherently emotionally unstable, that women are “PMS-ing” whenever they are assertive or direct, or that women can’t be promoted to elected offices or high levels of responsibility because they might become unstable on a monthly basis.

While these dangers of public miseducation do exist, on the other hand, the inclusion of PMDD as a full diagnosis in DSM-5 represents advances in research that can provide a sizeable group of women with sorely needed recognition and more effective treatments for symptom relief.  With increased recognition, more research funding may be generated for new studies in this area.

Overall, I believe that there is a potential for general misunderstanding about PMDD unless the public is educated about the fact that PMDD represents not just a constellation of mild PMS symptoms (which many women experience and cope with well) but a large set of severe symptoms that significantly impacts a woman’s life functioning. A group of women do experience symptoms at this level, but they do not represent women’s “normal” functioning. Instead, they are experiencing high levels of distress that warrant our support and the provision of effective treatment.

 

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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.

Lessons learned from intensive in-home counseling

Hannah Yakovah Hennebert November 1, 2013

KnockIt was my first intensive in-home counseling session with Josh, a delightful blue-eyed 10-year-old who was living with his 72-year-old aunt, Katherine. She had been granted custody of Josh a few months before I was assigned to the case. Previous reports and intakes described Josh as a child at risk of being placed in a residential facility because of his oppositional and defiant behavior, his past history of running away and, most recently, his involvement in petty theft, both at school and at home.

The boy now in front of me was completely different from the one I had pictured after reading Josh’s chart. The report did not reference his loving and kind behavior, nor did it mention his enlightening curiosity, amazing intelligence or sharp intuition. Josh was not “his chart,” that was for sure.

Katherine, however, was not of the same opinion.

Katherine and Josh share a family history that includes rape, emotional neglect, physical abuse and domestic violence. In addition, alcoholism has run in the family for several generations and has already left Josh with unpleasant childhood memories.

Josh’s situation is not uncommon for in-home counseling. The families are often dysfunctional, the living conditions chaotic. The parents or other caretakers tend to be struggling with financial burdens, immigration problems, substance abuse or some combination thereof. When all that information merges into a single file, you are tempted to ask yourself, “How can I help this child?” The answer, in most cases, is that the family expects you to ease the situation, and you end up believing that you can.

But this is my real secret: I have fallen into the superhero trap numerous times. I have learned to escape it by accepting that healing is a complex process that does not depend solely on my skills as a counselor.

The challenge of establishing therapeutic alliance

The first visit to Josh’s home tried my empathy. It was like walking through a minefield, and signs of “danger” seemed to be everywhere. Katherine made sure I felt truly uncomfortable in her house. There weren’t any “welcome” signs or polite offers to take a seat. In fact, she seemed annoyed by my presence. Strangely enough, I appreciated her congruent behavior because I knew that authenticity was essential for building a therapeutic alliance. 

Sweet and kind with me, Josh avoided all eye contact with his aunt during this first session. There was an aggressive, almost hateful, tone in his voice as well.

Katherine was equally aggressive. Her demeaning words indicated how challenging it was to cope with Josh’s defiant behavior. Despite being aware of the horrendous abuse Josh had endured, Katherine was not yet ready to show empathy for him.

Her list of complaints about Josh, in combination with her pointed put-downs of him, exceeded the acceptable. Feeling the need to intervene, I gently asked Katherine how she thought her words were helping Josh to adjust.

Katherine’s response to my intervention was infused with powerful emotions. She sounded furious and was particularly troubled by my being on “Josh’s side.” Katherine had expected intensive in-home counseling services to be all about Josh’s “terrible” behavior, not her rage toward him.

Josh is a beautiful child with a unique sense of humor. Quite often, he displays appreciation when adults show him respect and give him space to express his feelings. But Katherine was not friendly, nor did she think I would be a good resource for the family. I knew I would feel awkward returning to the house in a few days after all the friction surrounding this initial visit. But I decided right then that I would reflect on my feelings regarding this case before the next session. I didn’t want counseling this family to turn into an artificial process.

And I did return to the house with a new attitude, ready to attend to the family’s needs. After all, this was not about me.

Suggestions for in-home counseling practitioners 

My work with children and adolescents began in 1992 when I was still living in Brazil, first as a teacher and then as a counselor for adolescents at risk. Looking back, I see how intense and rewarding it was. I have been an in-home counselor here in the United States since 2009. During this time, I have worked with very challenging and complex cases, inspiring me to share what I have learned so far. These are practices that have worked for me; I hope they will be helpful to other mental health practitioners as well.

  • Be prepared as an in-home counselor to apply your crisis intervention skills. Your phone will ring at the most unexpected moments, and you need to be ready to help immediately. If you can’t be on-site, you may be able to assist over the phone. In cases of emergency, it is preferable to be with your client as soon as you can or contact an available practitioner from your agency and ask for help. Although intensive in-home service can at times sound like a “solitary flight,” having a good team in your agency to support you is critical. 
  • Use your supervision hour wisely. My most effective insights took place when I was exploring challenges and case outcomes with my supervisor. Clients benefit the most when a supervisor and supervisee work toward a common goal of supporting the client’s healing process.
  • Creativity is a plus. Through the years, I have developed a good sense for how to use playful and creative interventions when working with children. I have encouraged clients to speak about their traumas by using puppets, drawing mandalas and solving puzzles with me. Other times, I have used music and dance as a focusing exercise. It is important though to find the right tone with each client. 
  • Assess and work with the client’s circle of healing — the support system that holds the client’s safety until the family is able to manage the distress more effectively. This circle might include, but is not limited to, extended family members, the school system, community and legal agencies, counseling services and so on. Katherine, as Josh’s guardian, became a fundamental component of his circle of healing (as you will see). Extended family members play an important role in intensive cases such as Josh’s, and counseling practitioners need to locate this support and find common ground so the child will feel safe again. 
  • Set clear boundaries. The very nature of intensive in-home counseling challenges practitioners on this issue. For instance, when you arrive, the family might be eating a meal together or have other visitors in their home. After awhile, the family will look at you as a new family member. This is a delicate situation that almost all intensive in-home practitioners face. It is important to work with your team when boundaries become an issue. I typically encourage other practitioners to avoid trying to resolve complex situations alone. 

Here are some other thoughts on the issue of setting clear boundaries:

1) Be aware of your own emotional and personal needs.

2) Invest in self-care.

3) Consult your supervisor to address any difficulty you have setting boundaries with your clients.

4) Kindly remind your client (and yourself) that you are his or her counselor. Children and adolescents will benefit from understanding that they are in a therapeutic relationship.

5) If you are working with clients who are part of a minority group and you are part of the same group, double your attention to your own needs. I worked with clients of Latino heritage who made me feel especially at home because I am a Latina myself. Sharing this experience with my supervisor helped me guard against beginning to feel too much at home.

  • LUV your clients. LUV stands for listening to, understanding and validating clients’ needs when working with crisis intervention. LUV offers comfort not only to the client in distress, but also to the counselor who needs a therapeutic frame to reassure himself or herself that “something” is truly happening in therapy. During the crisis in Josh’s case, I was constantly “LUVing” the family. Katherine and Josh responded well to this approach, and that gave me more confidence when I had to face the next crisis (which comes almost weekly when you are working as an intensive in-home practitioner).
  • Focus on strengths. Access clients’ strengths and encourage the family to transcend through creative coping. This might mean offering family members opportunities to engage in common projects together — such as cooking a meal or creating some artwork — to break the sense of hopelessness and remove focus from the negative aspects of their relationship. 

Katherine held the most negative ideas about Josh. Perhaps to avoid frustration or disappointment, she did not want to believe in his potential for change. So, I had to think of ways to move Katherine toward a place of hope.

One approach that seemed helpful was scaling Josh’s behavior. Every two sessions, I would ask Katherine to pick a number from 1 to 10 that would describe Josh’s progress at school and at home that week. Scaling was an opportunity to explore new ideas for supporting Josh in his struggle to adapt to his new home. Slowly but steadily, Katherine responded to my intervention. When she realized things were indeed getting better, she started showing trust in my assessment and other interventions. I also applied scaling when asking Josh about his aunt’s relationship with him.

Now that we had a good alliance, I was also able to intervene by highlighting Katherine’s own survivor story. I encouraged her to think about how she could thrive (and had already thrived) despite all the adversities life had presented her. I often linked her story to Josh’s, emphasizing the personal traits that made him so resilient — just as Katherine had proved to be.

In one of our sessions, Katherine offered me a hug in appreciation for my efforts to help her nephew. Although surprised by her sudden openness, I had a warm feeling of hope for Josh’s case.

Working with families assigned to intensive in-home services is a humbling experience. If you are a counselor-in-training, chances are good that intensive in-home counseling will be your first job. Reflecting back, I remember arriving at my first client’s house with my mind totally set up for outpatient counseling. Intensive in-home service had not been part of the program in my training. I believe it would be very beneficial to include the intensive in-home approach in the crisis intervention syllabus. In fact, I have applied some of the interventions described in Lennis Echterling, Jack Presbury and Edson McKee’s textbook, Crisis Intervention: Promoting Resilience and Resolution in Troubled Times. For instance, their description of the LUV triangle guided my approach when I had to establish a new beginning with Katherine and Josh.

Taking care of ourselves

Counselors inevitably connect with their most powerful self to attune to the here and now when working in a crisis situation. It took me awhile to recognize this force within and judiciously use it as my most effective counseling tool. I like thinking of my counseling style as mother-in-counseling.

Mother-in-counseling becomes a container that always holds space for one more child. Josh’s case is an example among many of how the warmth of acceptance and love can make the difference. In an ideal situation, mothers develop unconditional love for their children. Love in counseling can be understood as support, trust and validation.

The mother-in-counseling character is intimately connected to my Jewish-Brazilian background, which makes me aware of the gifts and limitations I will encounter on my path. One of the most important gifts I have received from becoming mother-in-counseling is the sense that the process is not about me, which makes me feel safe and inspired to offer the care my clients need. Yet, as clinicians, we are invited to walk the path of self-awareness.

What character describes your counseling style? It feels liberating to be aware of my strengths, and challenges, as I strive to find my safe place as a clinician. I encourage you to look for this safe place as a technique to help manage stress and avoid burnout.

Seeing my mother come home from the hospital where she worked was part of my daily routine growing up. She never hugged us before first taking a shower because she was very conscientious about the risks of passing on any kind of infection to her children. It was hard to hold back my longing to hug her, and at times I felt as though she did not love me as much as I loved her.

I am not a nurse as my mom was, but I can certainly use some of her rituals to ensure that I am not passing on emotions that should have been left in the counseling room. In our encounters with clients in distress, we are at risk for bringing home feelings of rage, grief, anxiety and other emotions that do not necessarily belong to us. To protect against this after leaving Josh’s house, I would take some time to “sanitize” my mind and arrive home attuned to my own emotions.

I have found that both before and after an intensive session, listening to joyful songs while driving or going for a walk can have a cleansing effect on my emotions. Also, saying a short prayer while in the car helps me to focus on the soothing aspects of my life and access my own circle of healing. In my experience, it is well worth it to find a ritual that fits one’s own routine and hectic schedule as a counselor.

I want to close by reminding readers that counseling is about hope. There is a deep sense of spirituality that embodies the work of crisis intervention practitioners. In addition to my faith and spiritual belief that we are destined to be good people, I have also found comfort in establishing meaningful relationships with other practitioners whom I can trust to give me honest feedback. Finding inspirational and meaningful ways to deal with our own crises can inject an extra dose of enthusiasm into our work with intensive in-home cases.

 

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Hannah Yakovah Hennebert is a therapist at Liberty Point Inc. in Staunton, Va., and a doctoral candidate with concentration in Jungian studies at Saybrook University. Contact her at archetypes.rock@gmail.com.

Letters to the editor: ct@counseling.org

 

Facing a rising tide of personality disorders

Sebastian Montes

CoverTwenty years ago, the preponderance of Elaine Beckwith’s most troubling cases tended to center on substance abuse and the outpouring of near-psychotic clients cast into the general population after the onset of deinstitutionalization.

The past few years have brought a new pattern to the fore, one as pronounced as it is problematic. More and more, the Florida-based counselor is seeing signs of personality disorders running rampant among the clientele in her private practice. It seems now as if she’s dealing with 50 percent more personality disorders than at any time in her 30-year career.

“It almost feels like every time we turn around it’s, ‘Well, there’s another borderline mother,’” says Beckwith, an American Counseling Association member who is also adjunct faculty in the Palm Beach State College Psychology Department.

Though not yet quantified in appreciable detail, personality disorders appear to have surfaced at an alarming rate in counselors’ offices and on college campuses, by some accounts in unprecedented proportion.

The surge comes as the counseling profession recalibrates its approach to defining personality disorders, thanks in large part to the alternative diagnostic landscape laid out in updates to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Those two forces combined are compelling practitioners to confront a confounding yet essential dilemma: Are counselors seeing the pervasive, persistent traits of true personality disorder, or are they applying outdated norms and expectations?

“The problem is, I think we’re trying to say that these things [personality disorders] are acceptable because we’re seeing them in everybody, and there doesn’t seem to be a choice because it’s in such alarming numbers,” says Morgan Brooks, an ACA member who is an associate professor and director of the clinical mental health program at Niagara University. “It’s one of the things that confounds this issue. Should we be excluding this [behavior] as a disorder, or should we be accepting [that] this might be the normal behavior now?”

If the trend has been obvious, its causes have proved harder to pin down. Prevailing wisdom gives the apparent surge in personality disorders a generational genesis — a seeming groundswell of millennials disproportionately beset by narcissistic, histrionic and borderline tendencies.

A fact sheet from the American Psychiatric Association (APA) describes personality disorders this way: “Personality disorders are associated with ways of thinking and felling about oneself and others that significantly and adversely affect how an individual functions in many aspects of life. They fall within 10 distinct types: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, antisocial personality disorder, borderline personality disorder, histrionic personality disorder, narcissistic personality disorder, avoidant personality disorder, dependent personality disorder and obsessive-compulsive personality disorder.”

Counselors may come across any of these disorders in their work with clients, but certain personality disorders seem more commonplace. For example, individuals with narcissistic personality disorder are obsessed with overblown notions of self-worth. Those with histrionic tendencies display impulsive and emotive behavior that seeks to attract attention. Clients with borderline personality disorder lack a sense of self and engage in intense but unstable relationships. They often have a history of sexual abuse or other childhood trauma.

The professional literature remains relatively scant regarding the surge, leaving academics and mental health practitioners to construe anecdotal accounts as to how and why so many signs of personality disorder are flooding their offices and classrooms.

“We all have theories about why this is happening,” Brooks says, “but it’s a lot harder to test those theories because there aren’t really assessments [available]. You have to really create surveys and somehow validate them.”

Millennials maligned

A popular school of thought hinges on the millennial generation’s endemic sense of entitlement that, taken to an extreme, burgeons into full-fledged traits of a personality disorder.

The advent and explosion of social media — Facebook, Twitter and the like — has also drawn scorn for its impact on the way children and teens invest their formative years online, often at the expense of engaging in genuine, real-world relationships.

Some trace the personality disorders phenomenon to a generation of parents who heaped excessive and disproportionate praise on their children — leading to deluded notions of grandeur and self-worth — and “helicopter parents” who hover over their children’s lives well into early adulthood, exerting an undue influence that stifles maturation.

Much of that line of thought builds off of the “emerging adulthood” theory that Jeffrey Arnett laid out a decade ago, in which people in their late teens and early 20s languish through a period of frequent career changes, extended education and nonmarital cohabitation. It is a period, Arnett explains, defined by instability, identity exploration and being self-focused.

The theory has gained wide acceptance among mental health professionals of every ilk, some of whom see emerging adulthood as a foundation from which personality disorders too easily spring forth.

Arnett warns that such reasoning can be overblown, citing research that shows a marked decrease in depressive symptoms and increase in self-esteem over the span from late teens to mid-20s. But he does acknowledge that emerging adulthood is a particularly vulnerable time that can pose serious developmental challenges.

Whatever their root, personality disorders are being repeatedly, and tragically, brought into the public eye as laypeople and media pundits speculate (or, conversely, refute speculation) about the purported mental health of the perpetrators of some of our nation’s worst mass shootings: Virginia Tech, Sandy Hook Elementary School, Fort Hood, Aurora, Colo., and, most recently, at the Washington Navy Yard.

Gap in the data

Brooks and four colleagues at Niagara University have tried to give shape to the nebulous phenomenon in a study of a random sampling of students, the results of which were published earlier this year. Brooks expected to see a high prevalence of personality disorders, but what the study exposed, she says, was “absolutely staggering.”

During her graduate school internship in the late 1990s, the issues Brooks counseled college students on typically amounted to little more than dorm-room disputes, homesickness or a need for career advice. Only on rare occasions did she see full-blown, clinical-level instances of personality disorder.

That all changed around the middle of the first decade of the new millennium, when Brooks was working in Niagara University’s counseling center.

“It was incredible. It was all of a sudden. It was just a marked shift,” she says. “There was nobody coming in and saying they were homesick. There was nobody who just had a roommate problem. Nearly everyone — I would say nearly 90 percent of people — walked in already suspecting they had a disorder, or already having a name for a disorder that they’d been given by a previous therapist, or were continuing therapy from high school, if not further back than that.”

The surge of students on medication was so pronounced, she says, that the university hired a psychiatric nurse practitioner to keep up with the demand.

“They were coming to campus with these issues already, with the diagnoses, on the medications,” Brooks says. “There were real and serious issues going on.”

To quantify the explosion of personality disorders, Brooks and her Niagara colleagues screened 351 voluntary participants at the 2,700-student school.

With a 1 percent to 3 percent threshold thought to be the norm, the study unearthed an “unprecedented prevalence” for the 10 kinds of Axis II diagnoses laid out in the DSM-IV, with the most striking figures coming for histrionic personality disorder and narcissistic personality disorder, at 29.6 percent and 21.1 percent, respectively.

Even more distressing, the study — published in the International Journal of Education and Culture — found no significant statistical difference in the prevalence of eight of the Axis II disorders between clinical participants and those who had never been in a therapeutic setting. The data offer a startling indication, Brooks and her co-authors write, that personality disorders may be vastly more widespread among college populations than previously suspected.

“We’re seeing this across the board,” Brooks says. “If you’re on a college campus, you hear this stuff from everybody. We are all seeing these things and all wondering, ‘How are these people going to succeed in life?’ So it surprises me that more people aren’t looking at this, to be honest.”

A mother’s legacy

The 13-year-old girl who sat in Beckwith’s Palm Beach office that day in 2009 bore all the hallmarks of borderline personality disorder: A childhood defined by a tumultuous home life. Arguments, screaming, name-calling, a litany of self-destructive behavior and emotions that would get the best of her. Promiscuity, self-mutilation and declarations of a desire to kill herself. An inability to maintain friendships and a constant craving for a boyfriend to make herself whole. On top of that, Beckwith suspected the girl had been exposed to domestic violence.

The client’s careening behavior reached its breaking point when her parents caught her in bed with an 18-year-old and decided to bring her in for counseling.

Those borderline traits, as well as a history of depressive episodes, revealed themselves before the first session was complete. And over three ensuing years of counseling sessions and therapy, the case emerged as perhaps the most extreme instance of borderline personality disorder Beckwith has ever seen. “It was right out of the textbook,” she says. “Every symptom was there.”

The cause traced quickly and clearly to the girl’s mother, who from one moment to the next vacillated between smothering affection and “annihilating rage,” Beckwith says, while also showing jealousy over the daughter’s relationship with her father. The mother would insist that the daughter get help, then would turn around and undermine Beckwith’s efforts to provide that help.

“Mom would tell her, ‘I would have been better off without you. I want you out of my life.’ And the next minute she’d be hugging her and crying, ‘Oh, I love you,’” Beckwith says. “The daughter was totally, totally abandoned emotionally. She was rebellious and would constantly seek attention and love from just about anybody else. You could see how much the daughter was just trying to get mom’s love and support, and how much mom just could not come out of her own needs.”

Beckwith turned to the 2002 book Understanding the Borderline Mother by Christine Ann Lawson and conducted weekly sessions of trauma outcome process therapy with the girl. Sessions focused on the girl’s hypersensitivity and the cascading physical reactions — quickening heart rate, anger-induced blackouts and various anxieties — that were triggered anytime her mother flew into a rage. As a result of those episodes, the girl’s emotions would get mixed up, conflated and confounded into a sort of numbness and sense of disassociation, Beckwith says.

Much of Beckwith’s work was aimed at helping the girl empathize, understand boundaries, socialize better and grasp societal norms, and forge and maintain healthy relationships. Beckwith provided her with a sampling of psychoeducational literature to take home, which the girl had to make copies of and sneak into her backpack to conceal from her undermining mother.

“What was amazing is, I sat down with [the girl], I took it right out of the DSM and explained to her what a borderline personality is,” Beckwith says. “And when I pointed it out, it’s like a light went off in the daughter’s head, and it started making sense to her.”

Over time, the girl’s appearance started to soften. Her wardrobe featured more pastels. She grew more relaxed, centered and self-assured. She was coming into her own, emotionally, academically and socially, Beckwith says. She cultivated positive friendships and even started dating in what Beckwith saw was a healthy way. She was flourishing as an artist and began looking to apply to colleges.

More than two years into therapy, as the girl neared her 16th birthday, she started talking about seeking emancipation to free herself from the toxic relationship with her mother. She showed Beckwith an intricate budget laying out the income from her two jobs and the cost of rent, food and expenses. Beckwith knew the girl was no longer simply acting out; she was becoming stronger and who she needed to be.

“I was afraid to say to myself, ‘Could she be getting better? Could she actually be getting healthier?’” Beckwith says. “But things really were falling into place.”

It was, for Beckwith, one of the most personally rewarding cases of her career. The success she experienced is in stark contrast to what many counselors face when working with clients who have personality disorders — particularly borderline personality disorder. This population of clients can be notoriously difficult to treat. “They just suck your emotions dry,” Beckwith says.

Not  ‘doomed forever’ 

Counselor burnout was part of why Marsha Linehan devised dialectical behavior therapy (DBT) 30 years ago, a landmark shift that made headway in treating some of the most intransigent disorders and dysfunctions. With its central tenet of a perpetual exchange between acceptance and change, DBT has become the standard-bearer for treating borderline personality disorder.

The technique proved particularly apt for Cheryl Hamilton’s work at a community mental health agency in Columbus, Ohio, and in her counseling of juvenile clients in the local county court system. Over the course of six years — until Hamilton went on maternity leave this past spring — more than half of her client caseload showed traits or had a full diagnosis of borderline personality disorder.

Hamilton’s tact adhered as closely as possible to the archetypical DBT model, with its specific targets, hierarchy and modes of service delivery: individual psychotherapy, group skills training, phone consultations and a team consultation.

The community mental health center where Hamilton worked asked clients to commit to DBT therapy for a year. Therapeutic work in the initial stages included group sessions to develop the client’s skills in mindfulness, emotional regulation, distress tolerance and interpersonal effectiveness.

What makes DBT effective, for both client and counselor, is its explicit structure, says Hamilton, a member of ACA. “I found that when other counselors referred clients to me, the clients felt like they had been in so much chaos in their [previous] therapy if they weren’t using a structured model,” she says. “With DBT, you know what the target is. There are no surprises. I knew where we were going [and] they knew where we were going. It kept us moving instead of being stuck. Compared with not using DBT, it always felt like there was movement and progress and a goal. What it does is get them to apply those skills so they can decrease their emotional suffering and all that chaos.”

Many of Hamilton’s clients would come directly from a hospital after a suicide attempt or some other self-destructive behavior. Originally developed to treat clients with a history of parasuicide attempts, DBT is one of the few treatments empirically proved to achieve significant improvement.

“Unfortunately, I’ve had a lot of clients who would meet criteria [even] after treatment for borderline,” Hamilton says. “But I’ve also had a lot of clients who wouldn’t. Some of the traits of that personality might still be there — some of that vulnerability, some of that emotional intensity — but not necessarily meeting diagnostic criteria. So, I definitely think there’s hope that someone isn’t doomed forever to have the disorder.”

In his work with students at Hiram College, a liberal arts school outside Cleveland, Kevin Feisthamel has developed a style that folds in elements of DBT with a handful of other techniques. The director of counseling, health and disability services at Hiram, Feisthamel places emphasis on having clients improve their situational self-awareness and mindfulness of all their senses. Sometimes, he asks clients to keep a journal detailing specific behaviors. He also integrates elements of positive psychology and motivational interviewing techniques along the lines of the Stage of Change model conceived by James Prochaska and Carlo DiClemente.

Meditative therapies have been of particular interest lately to Feisthamel, a member of ACA. “I know it’s relatively new here in the Western world, but all the research I’ve seen regarding meditation has been very positive, even with personality disorders,” he says.

Millennials struggling with personality disorders tend to lack any deep emotional attachment, Feisthamel says, but because of their relative youth, they are also generally less entrenched in their disorder and thus more able to internalize and implement change.

“Those habits can be changed, which is important for students to hear, because so often they don’t think there’s any change that can come,” Feisthamel says. “It’s about making them aware of, ‘Now you’re not 10 years old anymore. You had no choice when you were 10, but now you’re a grown adult, and here are some choices you can make for yourself.’ With the young kids of today, having them feel comfortable and safe — to be able to talk about specific issues in their life and how to function better on a daily basis — a huge part of that is working on it with them together. That client-counselor relationship is the No. 1 predictor of change in all the research, and forming that relationship is huge.”

A line in the sand

Beckwith sets the case of her teenage client with borderline personality disorder squarely within the context of the unsettling rise of personality dysfunction she is seeing both as a counselor and as an adjunct professor. She says her classrooms are rife with students who feel disproportionately privileged and who think that because they’ve paid tuition, they are owed an easy A and deferential treatment. “So many young people these days, they feel so entitled that when they don’t get what they need, they simply cannot handle it,” Beckwith says.

The seeming deluge of personality disorders has called their very definition into question, prompting leaders in the field to reevaluate how mental health professionals face the issue. During development of the DSM-5, proposals were made to eliminate several categories of personality disorder. This proposal was ultimately voted down, and the same 10 personality disorders from the DSM-IV were retained. However, an alternative hybrid dimensional-categorical model for diagnosis is included in Section III of the DSM-5.

As detailed in a personality disorders fact sheet published by APA, “The [Personality Disorders] Work Group’s first revision represented a significantly different approach to diagnosis. It attempted to break down the concise models of personality disorders, which sometimes are too rigid to fit patients’ symptoms, and replaced them with a trait-specific method. Using this model, clinicians would have determined if their patients had a personality disorder by looking at the traits suggested by their symptoms and ranking each trait by severity.

“As evidenced by the field’s reaction, this new model was too complex for clinical practice. … The result was reflected in a second proposal, a hybrid model that included evaluation of impairments in personality functioning (how an individual typically experiences himself or herself as well as others) plus five broad areas of pathological personality traits. Although this hybrid proposal was not accepted for DSM-5’s main manual, it is included in Section III for further study. … APA hopes that inclusion of the new methodology … will encourage research that might support this model in the diagnosis and care of patients, as well as contribute to greater understanding of the causes and treatments of personality disorders.”

Ideally, that hybrid alternative will push mental health professionals to think of personality disorder less in black-and-white terms and more in nuanced shades of gray, says Feisthamel, who presented a standing-room-only session on understanding personality disorders in the DSM-5 at the ACA Conference in Cincinnati this past March.

Having had time now to delve into the since-published DSM-5 and consider its approach to personality disorders in greater depth, Feisthamel has found merit in some of its suggestions. Perhaps the greatest positive, he says, is that the alternative model in the DSM-5 suggests breaking out the characteristics of personality disorder so that practitioners can document a collection of traits “instead of giving that full-blown diagnosis of personality disorder.” And instead of the “not otherwise specified” designation that Feisthamel says too easily became a catchall under the DSM-IV, the “Trait Specified” diagnosis encourages practitioners to pick and choose facets of disorder.

It’s a framework that jibes well with Feisthamel’s approach to counseling undergraduates and in teaching future mental health professionals to be more guarded and judicious before doling out a diagnosis. “We’re always very cautious of assigning the [old] Axis II disorders — especially the personality disorders — because it is a lifelong punishment,” he says. “Those are labels for life.”

The prevalence of personality disorders at Hiram doesn’t seem as dire to Feisthamel as the reports he hears from some of his peers on other college campuses. He has seen the surge of personality disorders firsthand, however, especially when he worked in community mental health centers earlier in his career, where he says prevalence rates were as high as 85 or 90 percent.

“It’s a big change in the culture of our country,” he says. “I do think there is a change in people’s behaviors and individuals being raised where you do have those people feeling entitled. There are a lot more people in need and who need that access [to counseling].”

Feisthamel believes some of the apparent increase is due to the public’s growing comfort with talking about mental health issues. He points to Hiram’s chapter of Active Minds, a student-run nonprofit that advocates for mental health awareness. The organization focuses its efforts on establishing a more open dialogue that educates students and encourages them to seek help when needed. Since incorporating 10 years ago at the University of Pennsylvania, Active Minds has spread to more than 400 schools nationwide.

“I think we’re doing a good job of decreasing the stigma,” Feisthamel says. “I find myself being on a college campus where individuals are more knowledgeable about seeking services, which I think is excellent. So maybe it’s that more people are aware of the signs and symptoms and they are getting in for treatment at that moment.”

Just as understanding of the autism spectrum has evolved within the mental health fields and the public at large, Feisthamel says, counselors need to adapt their definition of “personality disorders” to keep pace with shifting cultural norms.

But at some point, Brooks says, mental health practitioners must be mindful to stand their ground about what constitutes a willingness to be flexible versus what constitutes clearly delineated personality disorders.

“These are not adaptive skills,” she says. “No matter what generation you’re in, or what time, if you can’t have a face-to-face conversation, if you can’t sit down for an interview without rolling your eyes or crossing your legs or looking bored, or you can’t get to class on time — or you don’t bother to come at all — no matter who you are and whoever your boss is, I can’t imagine anybody is going to be able to keep a job or a healthy relationship. Maybe we will all adapt to that, but that to me would be a very sad world. What would happen to us if everybody just didn’t show up to work, to school, or know how to function in a relationship? We’d completely fall apart. And I think we’re moving more and more in that direction.”

 

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To contact the individuals interviewed for this article, email:

 

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Letters to the editorct@counseling.org

 

 

Forging ahead to college

Amy L. Cook

StudentAccording to the U.S. Department of Education, African American and Latino students drop out of school more frequently and have lower high school graduation rates than do their White non-Latino counterparts. There are many reasons for this achievement gap, including failing and under-resourced schools, students residing in unsafe and/or poor neighborhoods, acculturation challenges, limited English language acquisition, racism, and familial and socioeconomic barriers. For example, African American and Latino students are more likely to attend schools that offer few opportunities to take Advanced Placement courses, and these students are less likely to take SAT preparation courses. According to the Department of Education, only approximately 13 percent of African American and Latino students took the SAT in 2008. Given that 90 percent of four-year colleges and universities use the SAT as an important criterion in selecting first-year incoming students, African American and Latino students are at a significant disadvantage compared with their White peers.

College affordability is another issue that restricts African American and Latino students’ access to higher education. Immigrant students who are undocumented cannot apply for federal financial aid, although the Deferred Action for Childhood Arrivals (DACA) program that went into effect in August 2012 has resulted in some states permitting DACA recipients to pay in-state tuition instead of international rates of tuition.

English language learners continue to be the fastest-growing population within U.S. schools. According to the U.S. Census Bureau, the projected Hispanic school-age population (ages 5-19) is estimated to reach more than 20.1 million by 2025, up from 13.8 million in 2010. The projected African American school-age population is expected to reach 9.9 million by 2025, up from 9.4 million in 2010. Given the growing Latino and African American populations and the widening achievement gap, educators must engage in a unified effort for change. School counselors, given their unique position of serving as a counselor, consultant and advocate to and on behalf of students, can take a leadership role in this effort.

Federal No Child Left Behind (NCLB) legislation was enacted in 2002 with the goal of every child being “proficient” by June 2014; however, significant gaps in academic achievement persist. The economic benefits of completing high school and attaining a higher education, both for individuals and for society as a whole, are important and cannot be ignored. According to the Bureau of Labor Statistics, the 2012 median average weekly earnings for individuals 25 and older with no high school diploma were $471. A high school diploma increased median average weekly earnings to $652, while the median weekly earnings for individuals holding a bachelor’s degree were $1,066.

Unemployment rates follow a similar path. The 2012 unemployment rate for individuals 25 and older who did not possess a high school diploma was 12.4 percent; for individuals with a bachelor’s degree, the unemployment rate was 4.5 percent. In addition, according to the Georgetown University Center on Education and the Workforce, individuals without any college education were more likely to lose their job during the economic recession, and economic recovery has been significantly weaker for individuals without a college education. Consequently, closing the achievement gap and promoting college access are social justice issues that require all educators and policymakers to take immediate action.

Understanding the school counselor’s role

In thinking about how to best promote academic success among African American and Latino students, it is important to understand the school counselor’s role and areas of possible intervention. The National Standards for School Counseling Programs published by the American School Counselor Association (ASCA), a division of the American Counseling Association, was the first national initiative to define the role of the school counselor in ensuring equal student access to comprehensive school counseling programs. The national standards also served as the impetus to develop the ASCA National Model, which helped further clarify the role of the school counselor concerning program foundation, service delivery, management and accountability. 

A principal aspect of service delivery includes working with parents and families and providing consultation to school personnel. School counselors are also held accountable for demonstrating that their interventions contribute to academic achievement among all students, with an emphasis on advocating for social justice through closing the achievement gap for low-income and minority students. Moreover, in 2002, the Education Trust implemented the National School Counselor Training Initiative. This set a clear role for the school counselor as a leader within the school community charged with collaborating with all school community members, including students, teachers, administrators, parents, families and community members, in promoting academic achievement.

The National Office for School Counselor Advocacy (NOSCA), through the College Board, also defines the role of the school counselor as a leader in advocating for student achievement and implementing schoolwide reform. This includes:

1) Achieving academic success and working with students and other stakeholders to develop future career plans

2) Supporting social justice for all students

3) Encouraging schoolwide change to benefit students

4) Developing a school environment that encourages academic achievement

5) Developing outcomes-based interventions with quantifiable objectives to measure academic success

6) Celebrating student differences and valuing uniqueness

7) Maintaining continuing education with a focus on multicultural advancement

The leadership and advocacy roles that school counselors are now charged with in terms of implementing comprehensive school counseling programs put these counselors at the forefront in promoting academic achievement and college readiness among African American and Latino students.

College and career planning

College and career planning are major areas of focus for middle school and high school counselors. School counselors, in collaboration with teachers, can set high expectations for all students and prepare them for rigorous course work. School counselors can also work with administrators to implement an open policy regarding taking Advanced Placement courses. They should provide support to all students who have an interest in taking advanced courses, being careful not to discourage access based on perceived limitations, even if available spots are limited.

In addition, failure should not be accepted. School counselors can take the initiative and collaborate with teachers to provide support with academic work, such as implementing a homework club and reinforcing positive efforts to complete work. Given that so few African American and Latino students take the SAT test and perform well, school counselors can offer SAT prep courses in collaboration with teachers and outside volunteers. School counselors also should explore which colleges and universities accept the ACT college entrance examination in place of the SAT. The SAT and ACT are quite different in their composition, and encouraging students to take the ACT in addition to or in place of the SAT may be beneficial because some students score significantly higher on one versus the other.

In addition to prepping students for college entrance examinations, school counselors are actively involved in exploring ways for students to finance their higher education. When providing financial aid workshops, it is important for school counselors to consider the financial barriers encountered by many African American and Latino students, especially those who are undocumented. These students’ parents may not be aware of the recent DACA program. Because DACA recipients are now eligible to pay in-state tuition in many states (though not all), providing community-based referrals concerning immigration likely would be helpful.

School counselors still need to explore other means for immigrant students to finance their education because they are not eligible to apply for financial aid, even if they become DACA recipients. Other options include attending community college, where in-state tuition rates are low, and then transferring to a four-year institution. Even though these students cannot apply for federal financial aid, they should still be encouraged to fill out the Free Application for Federal Student Aid form because colleges use this form to determine eligibility for private aid. Furthermore, together with students, school counselors can explore options for scholarships through websites such as fastweb.com, finaid.org, collegeboard.org, careerinfonet.org and edupass.org.

Culturally sensitive interventions

To reach at-risk students, school counselors first need to build strong connections with them and form relationships that are based on trust and respect. Respecting these students and facilitating a caring climate will aid in efforts to build the level of student responsibility and maintain high expectations.

School counselors need to enforce healthy and consistent boundaries and set appropriate and consistent limits both inside and outside the classroom. Often, school counselors feel uncomfortable when it comes to setting limits and “disciplining.” However, when limits are communicated in a respectful, caring manner and implemented consistently, with the understanding that educators hold the highest expectations, students — particularly at-risk students — are more likely to respond positively. On the other hand, raising your voice in response to a child’s yelling or behaving in ways that fuel angry responses serves only to perpetuate negative behaviors.

When engaging in discussions with at-risk students, school counselors should emphasize students’ strengths and build on their previous successes rather than focus on problem areas. The use of solution-focused counseling, which centers on working with students to generate solutions by following a strengths-based approach, can help struggling students identify previous successes in their lives and apply that learning to overcome present-day challenges. (For more information on solution-focused counseling, refer to the work of Gerald Sklare, Linda Metcalf and the Institute for Solution-Focused Therapy.)

Sometimes, after numerous attempts to motivate a student, a school counselor might feel discouraged and decide to shift efforts to other, more responsive, students. During these moments, it is helpful to remember that even the smallest changes can have a ripple effect and, in time, the student will build upon what he or she has learned through future interactions with educators. It is also beneficial to reach out to a trusted colleague who can help provide support and assist in preventing burnout. Working toward closing the achievement gap requires steadfast dedication and unified efforts on the part of all school stakeholders.

When engaging in discussions and activities with students and parents, school counselors need to ensure they are implementing culturally sensitive interventions. Individualized instruction and outreach to students on the part of teachers and counselors is necessary, albeit time-consuming. School counselors can consult with teachers to provide support in differentiating their curriculum so that it reaches all students, while also ensuring that it is culturally relevant.

High-achieving students often receive the educational resources necessary to access higher education regardless of whether they also receive support from their families or other outside sources. On the other hand, students of color often receive insufficient support from educators but may describe their parents or extended families as offering a strong foundation of support. However, because many parents have limited experience with higher education requirements, particularly if they did not attend college themselves, school counselors should bridge the potential information gap and provide African American and Latino students with adequate preparation for higher education. School counselors can also engage in various activities and serve as liaisons to encourage a greater sense of connection between the school and community.

Family and community partnerships and involvement

Increasing parental involvement is frequently identified as a challenging process for school counselors. The perception that the school is a place where educators teach children without interfacing with parents and caretakers arguably leaves some students without a personal advocate for academic achievement. It is important to recognize that some parents are unaware of the right to push for academic placement that is aligned with their child’s educational and career goals. Consequently, the student may miss out on particular academic opportunities that are critical for accessing higher education. 

School counselors need to be able to forge connections between parents/caretakers and the school. One possible way to engage parents, particularly when families are new to the school, is to encourage connections between newcomers and other more settled families that have lived in the United States for a few years. These students and families can receive support from one another during the adjustment phase and simultaneously feel connected to the school.

In addition, bilingual (and, preferably, bicultural) school counselors are integral to supporting Latino students’ academic development and achievement. School counselors should engage in continuing education around multicultural counseling and working with a diverse student population. Forming collaborative relationships with community volunteers who represent the diverse cultural backgrounds of the students in the school is an excellent way to strengthen students’ connections within the community. This concomitantly provides students opportunities to engage with professionals from similar cultural backgrounds.

Being aware of resources in the community and partnering with community-based organizations can help to address resource-based needs. For example, a college or university in the area might be interested in partnering to bring additional resources into the school. This partnership might offer high-achieving students, including those for whom English is not their first language, the opportunity to take college courses. A Latino literature or language course taught in Spanish at the college might be of interest to high school students. The opportunity to take a college-level course could help to engage students, while simultaneously preparing them for the academic rigor associated with college course work. Properly utilizing community resources is an essential component of implementing a comprehensive school counseling program.

Fostering collaboration and enhancing school climate


School counselors can examine current structures that are in place to involve parents in the school. Rather than recreating an entirely new program, school counselors should build upon the positive aspects of existing parental programs. By focusing on the inherent strengths of existing programs and recognizing the current efforts of school personnel, school counselors are more likely to be viewed as being collaborative and more likely to achieve better results. On the other hand, teachers and other school personnel may perceive the implementation of new projects as too time-consuming. 

Regarding collaboration among school personnel, school counselors can track students’ academic progress both during and subsequent to counseling interventions and then share the results with teachers and staff. Through this process, school counselors can become cognizant of specific interventions that contribute to academic success among African American and Latino students.

In terms of meeting the needs of Latino students, school counselors can build awareness of the role of bilingual programs so English language learners will have equal access to academic opportunities. Schools should provide information to their teachers and other personnel regarding the bilingual program placement process and how students acquire biliteracy. Maintaining consistent and relevant data that teachers can use to monitor the academic progress of English language learners is also helpful. Given that school counselors typically are involved in student placement and data collection, they should assume a central collaborative role in sharing information among teachers and other school personnel across all academic disciplines, including mathematics, social studies and the sciences.

Relatedly, ESL (English as a second language) students are often isolated from mainstream students, with the exception of in physical education and select elective classes. In addition, ESL students typically are not considered for placement in gifted and talented education classes. Consequently, school counselors should consult and collaborate with ESL teachers to decrease the isolation of ESL students, while simultaneously providing opportunities for these students to participate in rigorous course work.

It is essential to connect with all teachers, staff, parents, families and students to publicly define the school counselor’s role in the school building. All students, in particular African American and Latino students, may not understand when it is appropriate to reach out to the school counselor. Depending on their cultural background, students may also feel a sense of shame or discomfort in speaking with the school counselor for reasons other than academic concerns. They may also view their counselor as someone who only works with students when they excel or, on the contrary, when they have major academic deficiencies. Explicitly defining the role of the school counselor directly with students and families is essential when working with diverse student populations.

School counselors need to foster a school climate that is inclusive. African American and Latino students may experience feeling excluded by their peers on the basis of English language knowledge and/or skin color. This can happen even with students from within their same cultural group. As such, it is critical to provide counseling interventions that address both intragroup and intercultural relationships to improve school climate and promote positive relationships within and across student populations. In addition, school counseling interventions should focus on developing African American and Latino students’ sense of empowerment, self-confidence and cultural pride.

Conclusion

African American and Latino students are less likely to enter college and more likely to drop out of school than are their White peers. Because of this, educators and school personnel, including school counselors, have identified an urgent need to close the achievement and opportunity gaps. In keeping with the National Standards for School Counseling Programs and the Transforming School Counselor Initiative (for more information, refer to the Education Trust at edtrust.org), school counselors promote student academic achievement and college and career readiness through school and community collaboration with all key stakeholders. School counselors advocate for equal access to educational opportunities and should achieve this through the use of culturally sensitive interventions that respect diversity and communication differences. They also need to be knowledgeable of community-based resources and stay current with legislative changes that affect access to higher education.

School counselors should emphasize the importance of creating a school learning community in which teachers, staff, parents, students and community partners work together to promote academic opportunities. Implementing a comprehensive school counseling program that is equal and complementary to the school curriculum is necessary to promote the development and academic excellence of African American and Latino students.

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

Amy L. Cook is an assistant professor in the Department of Counseling and School Psychology at the University of Massachusetts Boston. She has worked in urban schools and mental health agencies with Latino students, clients and families. Contact her at amy.cook@umb.edu.

Letters to the editor: ct@counseling.org