Monthly Archives: January 2015

The ACA Conference & Expo: Orlando

By Robert L. Smith January 23, 2015

Robert L. Smith, Ph.D., ACA 63rd President

Robert L. Smith, Ph.D., ACA 63rd President

What is happening in Orlando, Florida, March 12-15? It’s the 63rd annual American Counseling Association Conference & Expo. I hope you are planning to be there. If you haven’t made your plans to participate, it’s still not too late. This year’s conference could be one of the best ever with a wide range of content programs, excellent keynote speakers, career enhancement opportunities and serious networking, all in an inviting setting where you can have fun in the sun.

During an earlier time, I was mentored by professors and colleagues who strongly encouraged me to attend and actively participate at state and national conferences. Since the 1970s when I was in graduate school, I have not missed an ACA annual conference. As a new professional, I tried to present as many times as possible at each conference I attended, whether state or national. It wasn’t unusual in those days to present four or five content programs because there were no limits on the number of times you could present. All of the conferences have been memorable for me. I have experienced great debates between the giants in our field, sung along with Albert Ellis and a thousand others to songs such as “Cry, Cry, Cry,” “Poor Me” and “Nobody Loves Me,” and met with colleagues from across the country.

I hope you will be intentional in your plans at the conference as you select from:

  • Attending a number of content and poster sessions covering the most salient topics in our profession
  • Enjoying informal meetings and gatherings with colleagues and friends from across the country
  • Meeting employers who are interested in talking with and hiring counseling practitioners and counselor educators
  • Gaining insight into clinical mental health and suicide issues as presented in a keynote address
  • Examining in depth the importance of the relationship in counseling and why it is considered one of the pillars of the profession
  • Meeting a diverse group of professionals at receptions and between sessions
  • Visiting and relaxing at the expo center while meeting with publishers and other exhibitors
  • Attending division, region, branch and interest group membership and business meetings
  • Going to planned events in Orlando, including at Walt Disney World, Universal Studios, SeaWorld and other recreation venues
  • Attending the First Timer’s Orientation and Reception

The keynote address topics will highlight what we do as professional counselors and emphasize the significance of the relationship in all of our work. Mariel Hemingway, a scintillating presenter, author, actress and wellness advocate, will talk from the heart about mental health and suicide. You do not want to miss her opening keynote. Neither will you want to miss the Saturday keynote on the power of the relationship. This will be a meaningful and fun address by two outstanding speakers, Richard Balkin and Jeffrey Kottler.

The bullet points above are just a few of the options available to you at ACA’s 63rd annual conference. Because there are so many options, you will need to plan wisely. Please be intentional in meeting and collaborating with colleagues and friends, whether it is for work, play or both. I look forward to attending this year’s conference and expo and seeing you in Orlando.

Take care,

Robert L. Smith, Ph.D., NCC

Counseling is a professional relationship that empowers diverse individuals, families and groups to accomplish mental health, wellness, education and career goals.

Hidden in plain sight

By Laurie Meyers

Drunk. Junkie. Loser. These are just some of the ugly labels that get thrown around when people talk about addiction. Labels that reinforce the belief that addiction happens to “other” people — or other counselors’ clients.

Counselors know that addiction is a disease, of course. But it’s a disease with a particularly bad reputation, and many counselors may associate it with resistant clients and low rates of successful treatment. For some counselors, it might even seem easier to avoid working with clients who are Branding-Box-flaskstruggling with addiction. The problem is, that’s not possible.

“I think I’ve heard more often than not [from counseling students], ‘You know, I really don’t want to work with alcoholics and addicts,’” says Ford Brooks, an addictions specialist and counselor educator at Shippensburg University in Pennsylvania. “And I’m thinking, ‘Well, unless you work on the moon, most of your caseload is going to have some impact through [the client’s substance use] or someone else’s use.’”

Gerald Juhnke, an American Counseling Association member who has been involved with addictions counseling since 1995, confirms that thought. “I didn’t really want to go into addictions counseling,” he says. “I mean, who would talk to a counselor whose name is Juhnke? I wanted to go into marriage and family therapy, but what I found is that so many of the couples and families I saw came in with issues related to addiction.”

According to the 2012 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 20.7 million Americans have a substance use disorder. The survey data is based on face-to-face interviews with a representative portion of the population. However, because of the strong stigma attached to acknowledging addiction, many experts believe that estimate is low.

Many of these underreported and undiagnosed cases will end up in counselors’ offices — though not necessarily with addiction as the presenting cause. Myriad issues that bring clients to counseling, such as marital and family discord, problems at work and especially mental health complaints such as depression and anxiety, are frequently connected to substance abuse and addiction.

To genuinely help these clients — who may or may not recognize their substance use problems — counselors of all stripes and specialties need to educate themselves about addiction. This knowledge includes the various types of addiction, how to spot addiction, how to help treat it and when to refer clients for more intense or specialized help.

Counselors should begin by examining their own beliefs about addiction, says Brooks, who was a practicing addictions counselor for 14 years and is the co-author, with Bill McHenry, of A Contemporary Approach to Substance Use Disorders and Addiction Counseling, the second edition of which ACA published this month.

“I want people to be aware of their own biases and preconceived notions about people who use drugs and alcohol,” Brooks explains. “For students, it may be, ‘An alcoholic is my Uncle Joe’ or ‘Drug addicts are worthless and don’t work.’”

Brooks makes a point of discussing with all of his counseling students their perceptions of what addiction is and looks like. “If you have the attitude of ‘I’m better than you’ or you think, ‘Oh, you dope. You shot up drugs and got pregnant and are still using,’ these biases are going to get in the way,” he notes.

To help banish such stereotypes, Brooks has students go to Alcoholics Anonymous and Al-Anon meetings. He says they are almost always surprised by what they see, including that the individuals struggling with alcoholism and addiction seem so “normal.” More than that, the students are often able to recognize reflections of themselves or their families in members of the recovery groups.

Julie Bates, an ACA member and former addictions counselor, would like to see all counselors-in-training given opportunities early on to interact with people who have substance abuse problems. She notes that education and exposure have been shown to reduce stigma.

Even when counselors haven’t been exposed to issues surrounding addiction in training or early in their careers, they can strive to understand the person struggling with these issues, just as they would with any other client.

“We need to train our counselors to be curious — curious about the complexity of addiction,” says Bates, who is now a counselor educator at the University of Wisconsin-Stout, where she teaches classes on addiction. “The ‘why’ questions, such as ‘Why do you use?’ and ‘Why don’t you just stop?’ are not inherently bad questions. In fact, if asked in curiosity and not judgment, [they] are actually exceptionally valuable. We should be very interested and invested in the answers to those questions.”

In fact, asking “why,” along with other questions, has become an essential part of addiction therapy. Counselors and other helping professionals have largely abandoned the confrontational addiction therapy model previously used for decades and exchanged it for more collaborative and client-centered techniques.

New perspectives on addiction

These newer techniques and perspectives on addiction and substance abuse are driven in part by research that has upheld what counselors and other helping professionals have long contended: Addiction is a disease, not a moral failing.

In 2011, after years of research, including an extensive focus on the chemistry and wiring of the brain, the American Society of Addiction Medicine officially defined addiction as a disease of the brain — specifically, a “primary, chronic disease of brain reward, motivation, memory and related circuitry.” Brooks believes this definition, with its emphasis on physical changes that cause behavioral impairment, helps ease some of the stigma attached to addiction and substance abuse disorders.

Of course, in addiction, as with any other mental health disorder, the brain does not hold the full story — not physically, at least. Although addiction has a strong genetic component, psychological, environmental and social factors also play essential roles. Probing these elements is a critical part of addiction therapy and recovery.

When Brooks began working with clients struggling with addiction in the mid-1980s, the recovery field was dominated by helpers who had been formerly addicted themselves. These individuals didn’t necessarily have training in mental health disorders or counseling but instead drew upon their personal experiences in recovery.

This was a seemingly practical approach, based in both the 12-step process and directly confronting clients with their problems by saying things such as, “This is your sixth DUI. Time to make a change!” Brooks says. This approach came from a place of compassion, he notes, but tended to increase defensiveness in a client base that was already on guard and often in denial.

By the late 1980s, treatment was no longer routinely dispensed by formerly addicted helpers in recovery. Instead, it became the realm of counselors and other trained professionals. However, until the past decade or so, the confrontational model still dominated treatment, notes Juhnke, a former president of the International Association of Addictions and Offender Counselors, a division of ACA, and a counselor educator at the University of Texas at San Antonio. Now, in addition to the 12-step process, which many professionals still consider an essential part of recovery, Juhnke, Brooks and other counselors have increasingly been turning to more collaborative, person-centered methods such as motivational interviewing. Brooks and McHenry note in their book that motivational interviewing can be particularly helpful for evaluating the existence and extent of a client’s addiction.

“MI [motivational interviewing] … has the counselor or group work side by side with the client,” Brooks explains. “I’m helping you side by side, versus me sitting across from you telling you all that your disease has done.”

When the counselor and the client collaborate, it allows them not only to identify the problem but also to more clearly understand the triggers, behaviors and negative consequences associated with the addictive behavior, Juhnke notes.

“MI allows me to ask simple questions to help them figure out what might be causing their problems,” he says. For instance, Juhnke might ask the client a question or make a statement such as, “Help me understand what you are doing when you have trouble getting into work in the morning.”

With this process, Juhnke is probing for — and simultaneously opening the client’s eyes to — the addictive behavior that caused a particular negative outcome. This line of questioning might reveal that the client drank several beers before work, allowing Juhnke to call attention to the damage that the client’s overconsumption of alcohol is doing.

In Juhnke’s experience, clients don’t usually come to counseling looking for help with addiction but rather for assistance with work problems, family troubles or some other issue. But if substance abuse is a contributing or precipitating factor to the client’s problems, careful probing through the technique of motivational interviewing can reveal a pattern, he says.

“You might say, ‘Are you using any substances?’” Juhnke explains. “And they might say, ‘Yeah, I’m drinking a little bit.’ And then you ask, ‘How’s that going?’ ‘Well, it’s going pretty good — I have no problems.’ But then, as you begin to talk with them, you find out that it is a problem — that they’re losing money because they drink so much, and they just got terminated from their job because of their drinking on the job or before going into work.”

Even after this revelation, Juhnke doesn’t confront the client. Instead he might say, “Hey, I’m a little confused. You say you’re not having problems with your alcohol consumption, yet you tell me you got terminated from your job [and] that you’re abusive toward your spouse or partner when you drink. Help me understand that.”

Juhnke explains that if he were using the “old school” approach to treatment, he would be in the client’s face, determined to show the person that he or she has an addiction.whatarewetreating

“But with MI, if they don’t admit it, no problem,” he says. “I just keep asking questions, and my goal is to help them gain insight by their answers. And hopefully they’ll begin to realize, ‘Hey, I do have a problem here.’”

Once a client recognizes that he or she has a problem, Juhnke will continue to use motivational interviewing in conjunction with family or couples therapy, if possible, and have the client attend 12-step meetings.

ACA member W.Bryce Hagedorn, an addictions counselor in Orlando, Florida, and an associate professor and coordinator of the Department of Child, Family and Community Sciences at the University of Central Florida, frames his addiction counseling around the Stages of Change Model.

“Research has shown that no matter what kind of change they are seeking,” Hagedorn says, “clients go through six stages: precontemplation, contemplation, planning, action, maintenance and termination.”

Hagedorn tailors his approach according to what stage the client is in. He notes that motivational interviewing is particularly helpful in tackling the denial that is entrenched in the precontemplation and contemplation stages. He also likes to use “heart-centered” therapies such as Gestalt or art therapy in the contemplation stage. He thinks this provides a way for clients to bypass the mental blocks of denial and resistance by connecting directly with their emotions. Once a client reaches the stages of planning, action, maintenance and termination, Hagedorn advises using a behavioral method such as cognitive behavior therapy, dialectical behavior therapy or acceptance and commitment therapy.

Juhnke says motivational interviewing is also particularly effective in helping clients identify circumstances that might trigger an episode of substance abuse or, for those in recovery, a relapse.

“The hard part with addiction is that everyone always thinks that they have their addiction beat,” he says. “I just had a client recently who thought he had his addiction beat. He had been sober for seven years and, suddenly, at the department Christmas party, he has a drink. And then he thinks, ‘Well, I’ve already had one drink and it didn’t hurt me. I bet I could have two.’ And then by the end of the night, he’s got a fifth of vodka down and he’s saying inappropriate things to his boss and subordinates.”

Afterward, the client was embarrassed and ashamed, but Juhnke helped him work through the issue by examining what had happened. He asked the client why he suddenly took a drink after so long in recovery. What specifically was happening when he made that decision? What were the triggers? And how could he learn from that?

“Because in recovery, it’s all about learning from your relapses,” Juhnke emphasizes. “Anyone in recovery is going to have relapses, but it’s learning from each time you relapse, learning what happened. How did that happen? What kind of things can I do to insulate myself from that same situation or having those feelings again?”   

Juhnke finds it is helpful to teach all of his clients — but particularly those battling addiction — the acronym H.A.L.T.: hungry, angry, lonesome, tired. He says these feelings often represent precipitating events for substance abuse, and if clients can learn to recognize those feelings as they’re happening, they can address the situation without reaching for a substance.

Intervening on campus

Addiction treatment isn’t the only thing that has changed in the field; the diagnosis of substance abuse has changed as well. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has combined the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe. As a fact sheet published by the American Psychiatric Association notes, “In DSM-IV, the distinction between abuse and dependence was based on the concept of abuse as a mild or early phase and dependence as the more severe manifestation. In practice, the abuse criteria were sometimes quite severe. The revised substance use disorder, a single diagnosis, will better match the symptoms that patients experience.”

This new diagnosis range fits nicely with what ACA member Rick Gressard is trying to do at the College of William & Mary with the New Leaf Clinic. Gressard and his colleague Sara Scott created the student substance abuse clinic to provide counseling services to students and a place for counselors-in-training to get hands-on experience with addiction treatment. Gressard, Scott and the college view the clinic as playing a crucial role in the prevention of future, more serious substance abuse problems.

New Leaf Clinic operates in conjunction with the Office of Student Affairs and is part of the disciplinary system at the college. The clinic is open to any student who wants to come in voluntarily for counseling, but all students at the college who incur an alcohol or substance use infraction, such as being drunk in public, destroying property, or possessing marijuana or another illicit substance, are required to visit the clinic. Depending on the infraction, the student faces three different levels of intervention, all of which are nonconfrontational, nonjudgmental and focused on harm reduction, Gressard says.

The first level consists of required attendance at a single psychoeducational session. “We take the approach that people are seeking a high from alcohol, and they think more is better,” Gressard says. “But we try to help them see that high levels really bring problems, and you actually don’t feel better but worse.”

The session covers topics such as binge drinking and the increased likelihood that students will experience negative consequences such as being arrested, passing out, getting injured, getting into fights, having a sexual experience they regret, being sexually assaulted or otherwise harmed, or ending up in the hospital because of an overdose the more frequently they engage in the behavior. “It’s become a cliché — college students falling off balconies — but we see a lot of those kinds of accidents,” Gressard says. “These are the kinds of problems we are hoping to help them avoid.”

The second level of intervention consists of two sessions. In the first, students fill out a survey on their patterns of drinking and substance use, receive additional psychoeducation and are asked to track their use over the course of the next week. During the second session, students receive an assessment of their drinking or substance use habits based on the survey they completed in session one. The survey was designed specifically for William & Mary and uses data provided by the school’s students so that respondents can compare their drinking and substance use habits against the habits of peers. The student and the counselor-in-training then discuss the assessment, the student’s feelings about the assessment and any concerns or questions.   

The third level of intervention involves a minimum of six individual sessions. Students at this level also take an initial assessment during the first session. The remaining sessions are dedicated to individual counseling using motivational interviewing.

According to Gressard, the intervention program has been surprisingly successful in reducing harm to students and helping those who are grappling with more serious forms of substance abuse.

Intertwining issues

One of the most substantial complicating factors in addiction treatment is the prevalence of comorbid or co-occurring disorders. According to the SAMHSA survey estimates, out of the more than 20 million Americans with a substance abuse problem and the nearly 44 million Americans who have some form of mental illness, 8.4 million people have both. Many professionals who treat addiction believe the incidence of comorbidity is actually much higher. Brooks thinks the comorbidity rate continues to rise with the field’s increasing awareness of co-occurring disorders. In other words, addiction and other mental health issues have always been intertwined; professionals in the field are just getting better at recognizing it.

In Gressard’s experience, where there is substance abuse, there are often other mental health problems. He notes that the epidemiology has shown that those with substance abuse disorders are twice as likely to have other mental health problems and vice versa.

Hagedorn might peg the rate of comorbidity even higher. He says he rarely sees a client who presents solely with a substance abuse problem such as alcoholism or solely with a mental health disorder such as depression.

“I subscribe to a self-medicating hypothesis, which is something of a chicken-and-egg situation,” says Hagedorn, president of the Association for Spiritual, Ethical and Religious Values in Counseling, a division of ACA. “Are they using substances to medicate mental health concerns? Or is the psychological pain or wounding that is contributing to the mental health disorder also contributing to the substance disorder?”

In the past, substance abuse counseling and mental health counseling were often separated, which meant that clients frequently missed receiving all the treatment they needed. “I think we are doing a real disservice to clients by only treating just what makes the most noise. We tend to listen to what clients say hurts the most and not look for what is underlying the pain,” Hagedorn says.

However, he believes that counselors should not try to address both co-occurring disorders simultaneously. “You don’t start digging into why the client [with addiction] struggles in the first six months,” he asserts. “Don’t dig until you know how the client will cope with this understanding. A lot of clients want to understand why, and some counselors take them there way too early. I have
seen the bad results of understanding why too soon.”

Hagedorn explains his line of thinking with a hypothetical situation. “Say someone comes in and says, ‘I just don’t understand why I keep drinking. I want to know why,’” he says. As the counselor digs, he or she discovers that the client had a neglectful father and feelings of inadequacy. The client suddenly realizes this is why he or she drinks, Hagedorn says, but what then?

“How does the client deal with this without drinking again?” he asks. “You keep clients locked in pain without having [another method] to deal with the pain.”

Hagedorn believes the addiction should be treated first so that when the client experiences the pain of understanding the underlying cause, he or she will have learned not to automatically turn to the addictive substance to cope.

Juhnke takes a different perspective. He thinks that once disorders co-occur, they’re all but inextricable. “It’s kind of like Jell-O,” he says. “You have the granules, and then water is added, and then they’re all just fused together.”

In addition, Juhnke asserts that clients with comorbidity are often experiencing such severe problems that there’s little time to separate disorders and treat them independently.

Brooks agrees that co-occurring disorders must be treated simultaneously. He points out that people with co-occurring disorders sometimes start their substance abuse as a way to self-medicate, so if counselors treat the addiction but not the mental health problem, the cycle will start all over again. Comorbidity greatly increases the chances that a client in recovery will relapse, he asserts. To guard against that, a counselor must consider both disorders at the same time. If the client is on medication, a counselor should be working with a psychiatrist who specializes in both substance abuse and mental health disorders, Brooks notes. Similarly, any treatment program (whether inpatient or outpatient) should specialize in both substance abuse and mental illness, he says.

Juhnke thinks it’s best to double or even triple down on treatments and interventions when it comes to comorbidity. “It’s kind of like a big spider web. The more sticky substance we can put down, the better off the client will be,” he says. “Twelve-step programs once a month, that’s not going to be very helpful. But if we have them doing family counseling, if we have them attending 12-step meetings several times a week and if we’ve got them doing homework related to their panic disorder, putting that all together can be really helpful.”

A different kind of addiction

To complicate the picture even further, addictions don’t always involve substances such as drugs or alcohol. Certain behaviors can become addictive, and equally as problematic, as well. Known as process addictions, these behaviors are most commonly connected to sex, gambling, shopping, exercise, eating, Internet use and, some even speculate, work. Process addictions can cause just as much damage as substances, but the behaviors involve common activities, making them more difficult to recognize. But both substance and process addictions follow similar patterns.

“When people are in pain, they find something to ease it,” says Summer Reiner, an ACA member who researches addiction and serves as an associate professor and school counseling program coordinator at the State University of New York at Brockport. That “something” might be alcohol or a substance, but it could also be a behavior such as sex, gambling or shopping, she explains.

As described in the upcoming book Treatment Strategies for Substance and Process Addictions (published by ACA and available in March), process addictions occur when a person experiences a high from a continued activity or behavior. The person’s pleasure causes a rush that he or she is unable to get from other everyday activities. The DSM-5 has a new section on behavioral addiction, but the only diagnosis included is for gambling. However, Internet gaming is listed in a separate section of the manual that includes diagnoses that need more research. Many addiction researchers and professionals believe that other processes or behaviors such as sex, exercise, shopping, eating and even work also qualify as behavioral or process addictions, despite their omission from the DSM-5.

Juhnke says process addictions often co-occur with substance addictions and are actually a harder type of addiction to treat. The traditional addiction treatment model is based on abstinence. However, this approach will not work with people who have process addictions, Juhnke notes. After all, people naturally need to eat, work, exercise, buy things and have sex. So treatment for most process disorders needs to focus on finding a balance between use and abuse.

“With sex [addiction], it isn’t about abstinence for life,” Hagedorn says, citing an example. “It’s how to have a healthy sexual relationship [and] have sex be a connecting experience, not sex being an endpoint.”

But what happens when someone’s process addiction is viewed by most others as a positive instead of a negative? That is the question Reiner asked herself when she started researching work addiction.

“[Work addiction] is something that is rewarded in society and is not seen as a problem,” she says. “You make more money, are professionally rewarded, and when you work hard, your employer and co-workers benefit.”

People with work addictions are often admired by their peers, so the behavior actually receives positive reinforcement, unlike most addictions, says Reiner, the author of a chapter on work addiction in Treatment Strategies for Substance and Process Addictions.

The family of someone with a work addiction is also more likely to make excuses, Reiner notes. “If you had an alcohol addiction and didn’t come to a family party, that would be bad, but people see work as OK,” she notes.

But like any other form of addiction, overwork will eventually result in negative consequences, Reiner says, so counselors should listen carefully for clues indicating that the client’s approach to work is causing problems. For example, clients might mention that their spouse complains that they work too much or brag that they work 60 hours a week.

The client’s co-workers may also start to notice negative consequences, Reiner says. For instance, people with work addictions are happy to do the extra work but often resent that others aren’t putting in those 60 hours or working weekends. Over time, it becomes difficult to work with someone like that, she notes.

In addition, all of the work will eventually take its toll on the person with the addiction because it’s often impossible to sustain that level of performance. Instead, the client is likely to develop health problems or experience total burnout, Reiner concludes.

Recovery from work addiction, as with other process addictions, is about moderation — learning to work, not overwork. “You need to be able to say, ‘OK, I’m going to leave work at 8, and I’m not going to bring my laptop home,’” Reiner says.

Clients with process addictions also need to find other outlets, says Juhnke. “It never works when you just try to remove something,” he says. “If you take one [substance or behavior] away, they will move to another. You want to not just create a void by removal, but help people find out what brings them joy, makes them happy, and fill their lives with that.”

Knowing your limits

“I think counselors should know that they will work with addiction,” Bates says. “Counselors should know that their own perceptions of what addiction is and what it is not may be one of the biggest impediments to providing successful treatment.” She urges counselors at all stages and in all practice settings to work through any biases with education, supervision, additional training and even personal counseling as needed.

Other experienced addictions counselors echo those comments, saying all practitioners should seek more education, training and supervision in this area because the limited courses on addiction in a typical graduate program aren’t sufficient to teach counselors all they need to know. Equally important is that counselors who don’t specialize in addictions treatment know when to ask for help because there inevitably will be times when they feel out of their depth or simply aren’t qualified to provide what a client struggling with addiction needs.

After all, these experts point out, experienced addictions counselors don’t go it alone either. They send clients to 12-step programs, collaborate with or refer to other professionals such as psychiatrists who specialize in substance abuse and mental health disorders and, in some cases, arrange for clients to enter an inpatient or outpatient clinic.

Brooks advises practitioners to make a habit of meeting regularly with peers and more experienced professionals. These meetings can be helpful not only for counselors in session, but also for their own state of mind, especially given the stressful and sometimes tragic circumstances that can accompany working with this client population.

“There is a higher incidence of mortality in this population,” Brooks explains. “So you will have more clients pass away.”

Clients dealing with addiction are also more likely to call in crisis, and that can take a toll, Brooks notes. Talking and sharing with other counselors who have navigated similar circumstances is an essential part of self-care.

But Bates doesn’t want one truth to get lost in all the potential challenges of engaging in addiction work: “Counselors should know that clients with addiction are tremendously resilient people and that they deserve a lot of respect for their efforts to make such a major life change.”


To contact the individuals interviewed for this article, email:

Julie Bates at

Ford Brooks at

Rick Gressard at

W. Bryce Hagedorn at

Gerald Juhnke at

Summer Reiner at


Laurie Meyers is the senior writer for Counseling Today. Contact her at

Letters to the editor:

It’s all about the relationship: Q+A with Richard Balkin and Jeffrey Kottler

By Bethany Bray January 22, 2015

Relationships are the heart of counseling.

No matter how the profession grows and changes, relationships will remain central to the good that counselors do in their clients’ lives. And counselors should never lose sight of that fact, say Jeffrey Kottler and Richard Balkin.

The duo will deliver the Saturday keynote address at the American Counseling Association 2015 Conference & Expo in Orlando, Florida, being held March 12-15.

Although they each have a different background and style – Balkin is a researcher and professor at the University of Louisville and the editor of the Journal of Counseling & Development, while Kottler, a prolific author, splits his time between California State University in Fullerton and Nepal, where he founded a nonprofit — they both specialize in relationally based counseling.

Counseling Today caught up with Balkin and Kottler to discuss the importance of relationships in counseling and to get a preview of what they’ll be talking about in their conference keynote.


(Left to right) Richard Balkin and Jeffrey Kottler


Q+A: Richard Balkin and Jeffrey Kottler


You both specialize in relationally based counseling. Talk about how you came to focus on this area. Why does it interest you?

JK: I’ve always found, both as a client and a counselor, as a student and a teacher, as a reader and an author, and as a supervisor and a supervisee, that it was particular kinds of relationships that most inspired and mentored me. Certainly content, theories, research and skills are all crucial pieces of any therapeutic encounter, but at their core is an alliance that has been mutually negotiated in such a way that the work not only is achieved but also maintained over time.

RB: A big part of my research is examining counseling outcomes with adolescents in crisis. I am interested in what is effective with this population. As I have focused on the goals adolescents need to meet in order to work through crises, the question of how counselors can help their clients work to meet their goals is an obvious extension of this research. This is where I believe the relationship between the counselor and client is extremely important. As other mental health professions have focused so much on specific techniques, I believe the counseling profession needs to make a shift from evidence-based techniques to client-centered outcomes. I hope to expand on this concept in the keynote.


What’s your favorite thing about the ACA Conference? What are you looking forward to at the 2015 Orlando conference?

JK: Of course it’s all about relationships! As much as I enjoy learning about new ideas and cutting-edge research in programs, I most yearn for ongoing contact with friends and colleagues who I have known for decades and yet only get the chance to see briefly each year. Although I dutifully and systematically study the program guide and book myself to attend topics that interest me, it seems that along the way I almost always run into someone interesting or engaging and I end up learning far more in these informal conversations. A conference to me is primarily about making and sustaining personal connections, and that has always been my priority.

RB: At this point in my career, I really enjoy the service component to the counseling profession and ACA. Many of the projects and groups I work with, such as the editorial board for the Journal of Counseling & Development, ACA’s Council of Editors or the ACA Publications Committee, include counseling professionals I have known for years, and it is a joy to work with so many wonderful people. I think it is great that we can work together to continually move the counseling profession toward service, enrichment and growth.

I always enjoy reconnecting with friends and colleagues. I think so much of how I experience ACA affects me as much on a personal level as a professional level. I enjoy the opportunity to participate in ACA at various levels, such as mentoring my students and introducing them to many of the scholars they have been reading about, or engaging in conversations that stimulate how I communicate and teach about counseling. And, honestly, I am excited about participating in the keynote with Jeffrey. I think it is fun to present on topics that provide passion for what I do and communicate that passion at a broad level.


The title of your keynote is “The Power of Relationships in Counseling and the Counselor’s Life.” Why do you feel it is important to talk to counselors about this topic? What will counselors learn?

JK: I think there is way too much attention on techniques, interventions and skills without exploring more deeply what empowers them. There has always been a disconnect between what counselors think makes the most difference in their sessions and what clients report was most helpful to them.

RB: As a journal editor, I get inundated with research and concepts across the counseling profession. I think this keynote is an opportunity to bring us back to the core values of counseling and where we excel as professional counselors. I am hoping counselors walk away with an increased sense of appreciation for what we do and how we do it.


From your perspective, how can counselors make relationship-building a priority with clients?

JK: In part it is about deep faith in the power of relationships to capitalize on and intensify anything else that we do in sessions. On one level it seems pretty strange that a conversation once each week or so can really make much of a difference. When I try to explain what counseling is all about to indigenous healers around the world, they often laugh hysterically at the absurdity of what we do, believing that talking about problems would [not] do much good without the other sorts of rituals, constructive actions and deep relationship that is so much a part of their work.

RB: At the heart of training in counseling is the core conditions, and I think regardless of one’s theoretical orientation or approach to counseling, focus on demonstrating empathy, congruence and unconditional positive regard (is important). However, I often tell my students, “You cannot be an advocate for your clients until you are an advocate for yourself.” So, implementing these concepts in our relationships plays an important role as well.


What is new and fresh in this area? What might counselors be overlooking?

JK: What is new and fresh strikes me as familiar from the good ol’ days: a renewed respect for the power of the [therapeutic] alliance to strengthen almost any intervention or evidence-based technique. My own primary interest focuses on how the stories we share with clients, as well as the way we listen and honor our clients’ stories, become the leverage for lasting influence and persuasion. Ask clients, supervisees, students or readers what they remember from a helping encounter, including this interaction, and they will frequently report a particular story, self-disclosure, metaphor or tale that stuck with them. I work a lot with young children in remote regions of Nepal, and when they ask me what it is that I do for my work, I tell them that I’m a storyteller. They nod their heads in complete understanding because that is what elders and healers and helpers do in most parts of the world.

RB: As I look at the current research in this area, I find there are a number of elements a counselor simply may have limited to no influence [on], such as past history, the presence of immediate support and family history. However, one element that counselors can direct is the working alliance, which is perhaps the most essential component of the factors that counselors can influence.


Please talk about how you two came to know each other and what made you decide to collaborate on a conference keynote. How do your two different styles as counselors complement each other?

JK: It was a shotgun marriage, arranged according to the deeper wisdom of ACA President Robert Smith, who felt our contrasting styles and interests would lend greater wisdom and breadth of experience to the subject.

RB: Jeffrey is right. It was a shotgun marriage, but one I am honored to be a part of.





Jeffrey Kottler and Richard Balkin will deliver the keynote address on Saturday, March 14 at 9 a.m. at the ACA 2015 Conference & Expo in Orlando.


Kottler will do a book signing afterward from 10-11 a.m. His most recent books are Stories We’ve Heard, Stories We’ve Told: Life-Changing Narratives in Therapy and Everyday Life and On Being a Master Therapist: Practicing What We Preach.


For more information or to register for the ACA Conference in Orlando, visit




About the speakers

Jeffrey Kottler is a professor of counseling at California State University, Fullerton and a visiting professor at the University of St. Thomas in Houston. He is also the founder of Empower Nepali Girls, an organization that develops mentoring and supportive relationships with children at greatest risk of being forced into early marriage or sex slavery. Kottler is the author of more than 80 books, many of them about the power of relationships in helping and healing.

Richard Balkin is a professor and program coordinator for counselor education and supervision and school counseling at the University of Louisville. He is also the editor of ACA’s Journal of Counseling & Development. His primary research interests include counseling outcomes and counseling adolescents as well as cultural differences in counseling. He co-authored The Theory and Practice of Assessment in Counseling with Gerald Juhnke and is a past president of the Association for Assessment and Research in Counseling.






Bethany Bray is a staff writer for Counseling Today. Contact her at


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook:


The connection between ADHD, speech delays, motor skill delays, sensory processing disorders and sleep issues

By Donna Mac January 16, 2015

To ensure the overall well-being of child clients with attention-deficit/hyperactivity disorder (ADHD), counselors frequently work in combination with other service providers such as speech therapists, physical therapists, occupational therapists and sleep specialists. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), many children with ADHD have also ADHD2experienced speech delays, gross motor delays and fine motor delays. In addition, many clients with ADHD showcase sensory issues or have a comorbid sensory processing disorder. Many children with ADHD seemingly also struggle to settle down at night, especially when parents are trying to get them into bed.

What is the connection between ADHD and these other deficits? If we take a look at the structural and chemical makeup of the ADHD brain, we find similarities with these other areas. First, let’s take a look at what an ADHD brain can look like:

  • There can be a smaller frontal lobe with less blood flow to it. This is where the executive functions exist: planning, organization, task initiation, task completion, time estimation, time management, self-regulation, social behavior, short-term memory, working memory, motivation, impulse control, intentionality, purposefulness and the ability to transition effectively. A smaller frontal lobe will lead to emotional immaturity.
  • The overall cerebral volume is usually smaller as well.
  • The neurotransmitter systems of dopamine and norepinephrine are affected. People with ADHD do not produce enough, retain enough or transport these neurotransmitters efficiently through the brain. MRI studies show that this inefficiency can be due to less white matter and more grey matter in the brains of clients with ADHD, which slows transportation. Dopamine is the main “focus neurotransmitter,” heavily associated with the frontal lobe and the executive functions, in addition to being the “feel good” neurotransmitter. It is also heavily linked to the limbic system, which contributes to people with ADHD reacting in a manner that is disproportionate to the event, either positively or negatively. Norepinephrine is involved in focusing on tasks a person considers to be either boring or challenging. In addition, it plays a role in sleep.
  • These clients can have a smaller caudate nucleus with less blood flow to it. The caudate is heavily innervated by dopamine neurons, and it plays an important role in learning, memory, social behavior, voluntary movement and sleep.
  • Electroencephalograms (EEGs) have shown that people with ADHD have more slow waves (theta waves) present than the general population when they are in an “awake state.” The increase in slow waves is especially pronounced during reading and listening tasks, causing people to lose focus, daydream or become drowsy.

All of this simply means that the ADHD brain is less mature and has less activity than a neurotypical brain. It is important to note that a doctor will not order an EEG or MRI either to diagnose or rule out ADHD because these findings are not indicative only of ADHD. In fact, many other issues present this way, including the following.

Speech delays: As stated earlier, the frontal lobe plays a key role in ADHD, but it also plays a role in speech production. There is a significant distinction between those with ADHD who have had speech and language delays versus the general population. It is also important to understand that children with speech and language delays typically have attention spans commiserate to where they are developmentally with language. For instance, if a 7-year-old speaks at a 4-year-old level, the child’s attention span may be that of a 4-year-old. This does not mean the child has ADHD. In addition, the child with a speech delay might find it challenging to communicate needs appropriately, so the child may begin to act out, have tantrums or melt down, much as a child with ADHD might demonstrate. Therefore, if a child has a speech and language delay, a thorough investigation needs to be conducted to determine whether the child’s “ADHD types of struggles” (of both attention and behavior) are related to the language delay, or if, in fact, the child also has ADHD.

If a child does have both ADHD and a speech delay, a physical therapist can make recommendations to the speech therapist concerning how to use specific large-body movements during speech therapy sessions. This will bring blood and glucose to the frontal lobe of the brain. This can be beneficial for speech production and will help the child with ADHD to feel more emotionally regulated.

Another speech issue connected with ADHD is speaking too quickly. This will sound almost as if the child’s speech is slurred. This can be due to the cognitive impulsivity related to ADHD. It can be addressed in a psychotherapy session or a speech session by having the child draw slow, wavy lines as the child speaks.

Motor skill delays: The ADHD brain processes slower than a neurotypical brain because of the transportation difficulties with the neurotransmitters and also because of the increase in slow wave (theta wave) movement. Interestingly enough, researchers find that about half of all children with developmental gross motor coordination disorders actually suffer from varying degrees of ADHD.

Why? Possibly because slower brain processing speed is also manifested in motor skill deficiencies. These motor delays are helped by physical therapists. However, there are other techniques used as well because there are activities that can help speed processing in the brain, such as balance-based activities. Physical therapists and occupational therapists tend to work together to incorporate balance-based activities with both motor skill delays and ADHD because the act of balancing the body actually requires the use of both hemispheres of the brain. In turn, this speeds processing, increases focus and decreases impulsivity.

Other extracurricular activities such as gymnastics, yoga and martial arts involve balance and practicing controlled movement, which are crucial for both ADHD and motor skill deficiencies. Some children with ADHD will have difficulty with fine motor issues such as buttoning clothing or tying shoes, and occupational therapists can help with those concerns as well.ADHD1

Sensory processing disorders: Reward-deficiency syndrome is when the brain is asking for more dopamine. This can be witnessed in the hyperactive response of those with ADHD when they “sensory seek” (spinning around and around, for example) or “novelty seek” (such as hanging over a two-story banister). Dopamine also limits and selects the sensory information that arrives to the frontal lobe, which is one reason that children with ADHD show these sensory issues. In addition, there is a less developed frontal lobe in cases of ADHD. This poses a “double whammy” because both dopamine and frontal lobe issues are involved with sensory concerns as well.

An actual sensory processing disorder occurs when a person has difficulty with the way the brain senses, organizes and utilizes sensory input. This results in unexpected outcomes of movement, emotions, attention and adaptive behaviors. It is as if the brain is using unexpected information on the way in, so, naturally, the unexpected emotions and behaviors come out, which can create further stress and anxiety for the person. Some people with ADHD will have certain sensory concerns without having a full-blown sensory processing disorder, but other people will have both ADHD and a sensory processing disorder. Occupational therapists are skilled at helping children with these issues.

Sleep issues: Children with actual sleep disorders or inconsistent sleep patterns will showcase symptoms similar to ADHD such as irritability, less developed social skills, attention difficulties, memory impairment, lower academic output, increased internalizing and externalizing of problems, not complying with requests and aggression. Because of this particular symptomology, it is crucial to rule out a sleep disorder before diagnosing ADHD.

Can a person have both ADHD and difficulty sleeping? Yes, but not always. A study was published in The New York Times in which researchers focused on children with comorbid diagnoses of ADHD and a sleep disorder. A year after surgeries or treatments for the sleep disorders, only half of the children retained their ADHD diagnosis, meaning that the other half had been misdiagnosed with ADHD; it was only the sleep disorder causing their symptoms.

It’s important to note that “trouble sleeping” was once a symptom qualifier to secure an ADHD diagnosis. The symptom was removed from the DSM in 1987, but the issue can still occur with some people. Remember that the caudate nucleus and norepinephrine are involved in both ADHD and in sleep, which is one reason people may struggle to sleep some nights. Most children with ADHD tend to have difficulty settling down at night and getting into bed because of their hyperactivity and impulsivity, which can spike in the evening hours. But once in bed and calmed down, children with ADHD can usually fall asleep in a time frame that is considered “within normal limits.” Many children with ADHD tend to wake quickly and experience an accelerated start to their day.



Donna Mac has worked professionally with ADHD for 15 years as a teacher, a YMCA director and currently as a licensed clinical professional counselor in a therapeutic day school. She is also the mother of twins diagnosed with ADHD at age 3. She has published a book titled Toddlers & ADHD, available on,, and at her website:


All I really need to know I learned in practicum

By Sandy Boone January 12, 2015

The following article was inspired by Robert Fulghum’s All I Really Need to Know I Learned in Kindergarten.


BooksAppleSchoolAll I really need to know I learned in practicum. Practicum was just the beginning of a rewarding career that includes lifetime learning, giving of self, acceptance when a client is not progressing as I would like and priceless glimpses of what can be accomplished when one is open to change. During practicum, I learned my professional and personal truths and the ideas upon which I intend to base my career.


I learned that individuals intuitively know when you are invested and that it is something you simply cannot fake. My favorite moment in practicum came when a client looked at me with tear-stained cheeks and said, “Thank you for caring about me — really caring about me. I don’t think I’ve ever had that with anyone but my family. Unfortunately, there are many within my family who do not care like you do.” It was hard to believe that in just four short sessions, we were able to break through barriers of distrust and begin to heal the hurts of disappointment.

I learned that verbal abuse can cut much deeper than anything physical. I never believed the adage “sticks and stones may break my bones, but words will never hurt me.” But I do not think I have ever experienced such defeat radiating from an individual as I did recently. In our session, I said to a client, “Tell me one good thing about yourself.” My client replied, “Nothing. I can’t see anything good about me.” She then began to sob. This was my least favorite moment in practicum. It was the result of a lifetime of poor communication and devaluing that had put her in such a deep, dark place — a place I prayed never to lead anyone to. This experience will reverberate with me forever.

I learned that even when someone is really trying to get better, the beast of mental illness can sometimes be too strong to overcome, despite the best efforts of the client or those around them. The client that challenged me the most had seven previous inpatient hospitalizations and 10 previous suicide attempts, three of which occurred while she was hospitalized. For the first four sessions, I knew that my client desired to get better. She wanted to do whatever was necessary. My supervisor, the client and I had talked through suicide ideation for two hours on a Friday afternoon. There appeared to be a turnaround, and work was definitely being done at every session. And then it happened. Two weeks after the Friday talk, the client received a phone call from her primary care physician indicating that there might be a major problem with her liver. No one was home except for the client’s sister. The client thought it would be easier to end her life than to risk being diagnosed with yet another chronic illness. She attempted to overdose on her insulin and found herself admitted to a local psychiatric hospital. In that moment, her fear was too much to bear alone, and she panicked. She fell back into the trap of what she had always done and tried to end her life. Although I was definitely disappointed, I was not surprised. The enormity of her mental illness was at times overwhelming for me. It was certainly reasonable for her to be overwhelmed and to feel like she could not face one more thing.

I learned that counseling is definitely an art and, with practice and opportunity, even the most difficult tasks can be eventually mastered. In the words of Philip Clarke, “Your reflections are your strongest skill. Stop impeding them.” In practicum, this truth finally settled in my mind. I do possess strong reflections, and utilization of them can lead to powerful growth opportunities for clients. For many clients, reflections represent the only time in their lives that they know they have been heard. Just as Dr. Clarke previously had assured me, most of the time my reflections were strong, spot on and succinct. During reflections, I “shared space” with my client and was able to relay immediacy.

I learned not to make assumptions based on what I have researched or read in a book. In my first class, I wrote a paper on borderline personality disorder (BPD). Upon completing the paper, I decided I wouldn’t want to work with that population of clients because therapy is rarely successful and the clients’ self-sabotaging behaviors are emotionally draining for the helping professional. During practicum, however, my caseload was flooded with BPD. Although clients with BPD are challenging and self-sabotaging, it is possible to facilitate improvements, even though they may be minimal. If I am able to make a difference in only one person, then that is one life that I helped to make better. Helping to make life better was one of the reasons I chose counseling. I found that I do want to learn more about this population and that I should not be “afraid” to work with these clients. Rather, I should proceed with caution and accept the challenge.

I learned that every counseling theory has salient points that resonate with me. Prior to practicum, I thought that I would primarily focus on dialectical behavior therapy and solution-focused orientations. Although I do still identify more closely with these two approaches, I am thankful for my knowledge of varying theories. Sometimes existentialism or systems theory are more congruent with what my client needs. I have to be open to what works for the client.

I learned that becoming an “expert” in a given client population is achieved by doing research, observing others who work with that population and reviewing everything that you can get your hands on. I still desire to work with adoptive families. I still desire to work predominantly with the age group I first anticipated — ages 15 to 30. Becoming an “expert” does not always mean there is a certification to obtain. It is important to follow your passion.

I learned it is OK not to have a rigid plan and to go where the client needs to go. I must confess, I have been known to be a “control freak.” Although I still do not believe it is wise to move forward with reckless abandon, it is OK to “roll with it” and be open to working on whatever the client finds important that day. It is OK if the perception of the interpersonal relationship between a client and a loved one is not objective because it is the client’s truth. His or her feelings are never wrong. Although reframing is imperative in many situations, the goal of counseling is life improvement. I have always been a “truth seeker,” and I do not advocate on behalf of misconceptions and untruths. I do not do well with lies. But a client’s truth is not a lie — it is a perception. This growing edge can be applied in my personal life as well. I have gained perspective on what is important in life and how blessed I truly am. I am willing to accept the truths of those I love, although their truths don’t necessarily align with my perception. I acknowledge that I will make mistakes, both professionally and personally, and that is part of “being real.”


I am certain that I will continue to learn in the semesters to come and even when I am a licensed counselor. However, these are the current truths upon which I will grow. These are things that will allow me to earn the privilege of meeting someone where they are and join them on their personal journey.



Sandy Boone is currently pursuing a master’s degree in counseling from Wake Forest University, which she anticipates completing in December 2015. She previously worked as a clinical research coordinator for more than 14 years. Contact her at