Monthly Archives: March 2016

From the president: Impressions of a traveler

By Thelma Duffey March 29, 2016

Thelma Duffey, ACA’s 64th president

Greetings, fellow counselors! As I prepare for the American Counseling Association Conference in Montréal (being held in partnership with the Canadian Counselling and Psychotherapy Association) and reflect on what I was doing this time last year, I am amazed. What a tremendous year this continues to be. I feel such pride in our profession and have such great hopes for its future.

Counselors are doing wonderful work in the world, and I have an opportunity, through my travels, to experience some of this work firsthand. I’d like to chronicle here some of my experiences thus far in 2016 so we can celebrate and shed light on some of the great things our colleagues are doing throughout the country.

This past January was particularly cold in many parts of the country, but that wasn’t the case at Rollins College in Winter Park, Florida. In fact, the sun was shining as the school’s students engaged in creative learning activities in a “master therapist” series that provided cutting-edge opportunities for professional skill building. It was such an honor to spend time with these students and their amazing faculty. I left glorious Winter Park with a deep appreciation for the faculty’s investment in instilling pride, confidence and a strong sense of professional identity among the students. What a terrific way to start the year.

Days later, I braved an East Coast blizzard to attend a reception at the White House to recognize the national School Counselor of the Year. Our school counselors do such important work, and to have this acknowledged by our nation’s first lady, Michelle Obama, was a rich and truly memorable experience.

From there, I flew to Boise for the Idaho Counseling Association (ICA) conference. Late January brings a bit more than a chill in the air to Idaho, but the reception and camaraderie that ICA members afforded me was heartwarming, and the conference itself was action packed, productive and a whole lot of fun. ICA knocked it out of the park and held a wonderful conference.

Next stop? Dallas. I traveled to my home state of Texas, where ACA partnered with the Human Rights Campaign for this year’s Time to Thrive Conference. There are few words to express the power of this experience. I left feeling deep hope for a future that includes safety, pride and connectedness for the hundreds of participating lesbian, gay, bisexual, transgender and questioning youth. I also left feeling grateful that ACA CEO Richard Yep and staff continue to find ways to promote this important ACA mission through advocacy and collaborations such as Time to Thrive.

The trip from Dallas to my hometown of San Antonio was a quick one. And that’s a good thing because I was home long enough only to pack a suitcase before I was “On the Road Again.” This time, the destination was the Windy City of Chicago. Meeting with students and faculty at Northern Illinois University (NIU) was a terrific experience. The counseling department at NIU is deeply invested in creating a training experience that will help students develop the qualities of truly great counselors. On top of that, I was literally swept off my feet on what proved to be an especially windy day.

Following Chicago, the song “Double Shot” by the Swingin’ Medallions (a beach music group from South Carolina) ran through my head as I traveled to Hilton Head for the South Carolina Counseling Association (SCCA) Conference. The conference theme, “All In: Educating, Supporting and Advocating for All Counselors,” perfectly aligned with my presidential initiative for this year on professional advocacy. Hilton Head was everything I needed after my busy travel schedule. Sharing time with my gracious and dedicated SCCA colleagues while enjoying some good old-fashioned Southern comfort was nothing short of rejuvenating.

Counselors are doing wonderful things in the world, and I appreciate the opportunity to share some of my impressions of these great works with you. Next stop, Montréal! All aboard!

All my best,

CEO’s Message: Let’s make this one all about you

By Richard Yep

Richard Yep, ACA CEO

You work hard, and the collective efforts of the counseling profession benefit millions of children, adolescents, adults, couples, families and communities each and every day. Although your work may not get reported on CNN or in The New York Times, the impact of professional counseling cannot be denied. You make the world a better place, and that is not hyperbole; it is fact.

Because of the amazing work of professional counselors, ACA set out many years ago to find a way to raise public awareness of what you do. From that desire was born Counseling Awareness Month. Please note that it is not a day or a week but an entire month! Given all there is to tell about the importance of counseling and the work of our members, we wanted a full month. We know you are busy and that you give 100 percent to your clients and students, so asking you to share your story or to support efforts to increase the public’s knowledge about counseling may at first seem to be asking too much. Our hope is that you will recognize the benefit of celebrating Counseling Awareness Month, but rather than doing it alone, that groups can come together at local, state and regional levels to let the public know of your great work.

To make it easier, ACA has developed information, suggestions and tips for how you can participate in Counseling Awareness Month. Simply go to counseling.org/about-us/counseling-awareness-month-2016 to find the special resources we have developed just for you. Over the years, many of you have established your own events to celebrate Counseling Awareness Month, and I hope even more groups of counselors will do that this year. Let’s make the 2016 Counseling Awareness Month the best ever.

I realize professional counselors do not typically seek the limelight for the work they do, but please know that the ACA staff and volunteer leadership deeply appreciate the work of our members. I hope that being a member of the ACA family will come to mean more to you than just receiving Counseling Today, buying books that we publish, attending our conference or knowing that we advocate for the profession at the state and federal levels of government. Yes, we provide all of those things (and more), but we want ACA to be your professional home because you feel that we look out for you as a practicing professional. We provide a way for you to network and interact with your peers. We provide consultation about your career, ethics and practice issues. Our mission is to be your professional partner and a supporter of the good work you do.

We also want to be the place you turn to when communicating with your peers. You may have noticed that our online community, ACA Connect, underwent some extensive changes and was recently relaunched based on the input and comments you shared with us. Although the previous version was good and did serve as a community place where members could interact, your suggestions helped us to make some substantial improvements. This is yet another way we are trying to improve ACA as your professional home.

So, as we kick off Counseling Awareness Month, I want to personally congratulate all of you for the service you provide to so many people. When I hear stories of your work, I am in awe of what you do, and I am humbled by your efforts to advocate for and serve your clients and students.
Job well done.

As always, I look forward to your comments, questions and thoughts. Feel free to call me at 800.347.6647 ext. 231 or email me at ryep@counseling.org. You can also follow me on Twitter: @RichYep.

Be well.

Don’t use the ‘t’ word and five other tips for counselor advocacy

By Kevin Doyle

After 30 years in the counseling profession, I have arrived at the conclusion that we counselors are sometimes our own worst enemies. When a unified voice could be the key to advancing our profession — such as with current efforts to expand reimbursement for counselors’ services under Medicare, initiatives to standardize our licensing standards and outreach to get more counselors hired to positions within the Department of Veterans Affairs — we at times seem to be fighting our own internal battles instead.

How, then, can the individual counselor do his or her part to advance the profession that we all love? In the spirit of helping the counseling profession achieve the status that 40 years of licensure would indicate, I’d like to offer six concrete, yet relatively simple, suggestions.

First, as my students would corroborate, I have a visceral resistance to using what I call the “t” word: therapist. Although probably well-meaning in most instances, when counselors use this word, they miss opportunities to use an even better one: counselor. The same principle exists for use of the word therapy when counseling could be used.

In our culture, most people do not know the differences between counselors, social workers, psychologists and even psychiatrists. Each time that we call ourselves by the correct name (counselor), we are taking advantage of an opportunity to educate the public about our profession — to help with our own branding, if you will. Similarly, each time that we use therapist or therapy, we are missing out on that same opportunity and in a small way contributing to the ongoing diminution of our professional identity. When referring to a multidisciplinary group of helping professionals, using therapy or therapists is, of course, appropriate.

A second concrete action that each of us can take is to refer to other counselors. Obviously, our primary obligation is to our clients, and if the appropriate and best referral is to a helping professional in one of our sister professions, then so be it. But in making referrals, we are afforded another opportunity to help our profession advance, so we should include professional counselors as often as possible when we refer.

In my hometown of Charlottesville, Virginia, several licensed professional counselors got together a few years ago and formed a loosely organized group. We meet monthly for informal support and discussion and engage in quarterly trainings together for required continuing education. But in addition, we have also established an active professional network that has allowed us to learn more about the expertise of local counselors, which has greatly enhanced our ability to make appropriate referrals. Rarely does a week go by without a member of our group posting a message to our distribution list asking for help in identifying a fellow counselor to work with a particular type of client. Referring to other counselors, when appropriate, is one of the best ways that each of us can support our profession.

My third suggestion relates to the electronic age in which we currently operate. We must not underestimate the power of the Internet. Unfortunately, many counselors in our community do not have websites, so the referral process I outlined above is often complicated by the fact that most clients want to read about the person they were referred to before pursuing services with that professional. Because of that, we may be forced to refer to a professional from another discipline who does maintain a website. Lest counselors be discouraged by expense, several low-cost or even free web-design templates are available (for example, see weebly.com, wix.com and web.com). Using these or other templates, the main cost involves purchasing the domain name and hosting the site, which is typically quite affordable (often less than $100 per year). In addition to generating referrals for your practice, having a website helps to solidify the presence of counselors on the Internet and further legitimizes our profession in the eyes of the public.

A fourth step in advocating for our profession induces fear in some counselors and may not be for everyone: talking to the media. Local newspapers, radio stations and television outlets are on a continuous quest for fresh content related to issues of the day. Some counselors routinely turn these requests down (I know, because they refer the media to me), missing another chance to educate the public about themselves and the profession.

Dealing with the media can be tricky, of course, but simply discussing what our profession does can be a valuable public service and an opportunity to teach about what counselors do. Commenting on particular cases or specific clients would be problematic and even potentially unethical, but participating in an interview on a particular issue, such as a counseling approach, what counselors do or a topic of interest to the local community, could be entirely appropriate and valuable. American Counseling Association staff members are available for consultation on talking to the media as well.

Getting to know your state and local legislators is a fifth way for counselors to engage in advocacy for the profession. State legislatures vary greatly, but most are composed of part-time legislators who spend much of their time in their local communities. These legislators are almost always extremely open to meeting with constituents (another word for voters!). Waiting until an issue is in front of the legislature to visit with your elected representative is often too late. By that time, whatever opposition exists may have already made its position known, meaning you may be up against a formidable adversary in a politically charged environment. A better approach is to proactively establish a relationship with local legislators. This can be done by inviting them to visit the program where you work, introducing them to other counselors, considering honoring them for work they may have done that is helpful to your clients or considering making a campaign contribution. Any or all of these steps can make a real difference when counselors in your state legitimately need the help of the legislator on a particular issue.

If you are uncomfortable or overwhelmed with the idea of visiting your local legislator, think about going as a group. Several counselors, perhaps with different specialties, can attend a meeting together, allowing the elected official to learn from multiple perspectives on a single visit and maximizing the effectiveness of your time. Remember, legislators are people just like us.

Finally, a sixth suggestion relates to the all-important governing bodies that oversee the practices of many of us: state licensure boards. Early in my career, my role in state professional associations led me to attend numerous meetings of our state board of counseling. Not only was this necessary and valuable as it related to the issues under consideration, but it also contributed to my interest in serving on the board and eventually resulted in my appointment to this position in my home state of Virginia. Before my appointment, while attending the meetings and advocating for things that weren’t necessarily in line with the board’s thinking at the time, I received a wonderful compliment when one of the board members said to me, “We don’t always agree with what you have to say, but we appreciate the way you conduct yourself.”

Opportunities to advocate for the profession frequently present themselves, and we need to take advantage of them, whether our audience is the general public or our fellow counselors. Attending a meeting of your state counseling board is an easy step; most boards must meet in open session, and their activities are matters of public record. Public comment is usually received at the beginning of each meeting, not just when controversial items are being debated. These are free, easy opportunities for counselors to speak in a public way about issues of importance to the profession. Serving on such a board is also a very valuable way to engage in advocacy on behalf of the profession.

Clearly, there are numerous ways for counselors to engage in advocacy. Each of us should be able to identify a few ways to get involved, either based on the suggestions in this article or by staying alert to other advocacy opportunities. Whether it involves the somewhat tongue-in-cheek avoidance of the “t” word or the more substantial activity of attending a state counseling board meeting, each counselor is presented with daily opportunities to engage in the activity of advocacy.

To this counselor at least, it seems that we earn the right to express our displeasure only when we actively engage in advocacy. Not doing so contributes to some of the obstacles we currently face in attaining the respect and consideration that the counseling profession both needs and deserves.

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Kevin Doyle, a licensed professional counselor and licensed substance abuse treatment practitioner, is an assistant professor and co-coordinator of the counselor education program in the College of Education and Human Services at Longwood University in Virginia. Contact him at doyleks@longwood.edu.

Letters to the editor: ct@counseling.org

All things connect: The integration of mindfulness, cinema and psychotherapy

By Bronwyn Robertson

Barely able to breathe, a young man battling a panic attack hesitantly enters the group room and makes his way to an empty chair. He and a dozen others “check in” and are then guided through a simple, calming breathing exercise. The lights are dimmed and the group members are asked to focus their attention on the flickering images and pulsating sounds coming from a screen in front of them. Transfixed by these moving images and sounds, the young man’s anxiety begins fading away. He is no longer in the throes of a panic attack.

Seated next to him is a middle-aged woman who has been struggling with racing thoughts and rumination. She, too, is becoming engrossed in this experience, her thoughts slowing down as she shifts her attention to what is unfolding on the screen before her. She settles into a restful state.

The group sits together, sharing this experience, for 45 minutes. Afterward, they together process what they have just experienced. All report being in better moods, much calmer and more reflective than when they first entered the room. All the group members readily agree to explore their experiences in their journals during the upcoming week and then return to share their reflections with the group.

What these group members share a week later is both unexpected and remarkable. They bring journals filled with prose, poetry and sketches. One group member struggling with an addiction shares that focusing on this homework prevented him from relapsing. A few others note that they were inspired to make major life changes during the past week, letting go of unhealthy relationships and circumstances, and even embarking on new careers. Some report having been freed of creative blocks and now being able to paint, write or compose music for the first time in months — or years. All attribute their enhanced awareness and healthy changes to the experience of sitting together in a room and collectively focusing on the same moving images and sounds.

The group didn’t experience some new, groundbreaking therapeutic technology during those 45 minutes in a darkened room. Members viewed “all things,” an episode of The X-Files television series.

The therapeutic power of cinema

From full-length feature films to episodes of TV shows, cinema engages individuals like few other mediums. Leading researchers studying the neuroscience of cinema, via the emerging field of neurocinematics, have found that when groups of people view evocative, “well-directed” cinema together, they become collectively engaged through a phenomenon known as neural synchrony. Neuroimaging studies show that the activation of specific areas of their brains and their brain wave patterns actually become synchronized.

According to neuroscientists, the human brain is wired to connect with and be activated by cinema. The iconic Swedish filmmaker Ingmar Bergman suggested that this connection might be even deeper: “No art passes our conscience the way film does, and goes directly to our feelings, deep down into the dark rooms of our souls.”

X-Files image copyright of Fox

Cinema can be a powerful, transformative catalyst. As a licensed professional counselor, I have found that the therapeutic use of this catalyst, otherwise known as cinematherapy, can be profoundly effective with even the most troubled or resistant clients. While integrating cinematherapy within an experiential, mindfulness-oriented approach, I have used everything from The Wizard of Oz to The X-Files with more than 1,000 clients in individual and group therapy — with remarkable results.

Simply defined, cinematherapy is an expressive, sensory-based therapy that uses movies, TV show episodes, videos and animation as therapeutic tools for growth and healing. The clinical use of cinema has been found to enhance the therapeutic process on many levels, including strengthening the therapeutic alliance and increasing overall engagement in clients who are “difficult to-reach.” As noted by Joshua Cohen, co-editor of Video and Filmmaking as Psychotherapy: Research and Practice, cinema has been used as a healing tool since its inception “because creating and watching a film often can speak directly to the human soul.” What makes this medium therapeutic, he writes, is its use “with therapeutic intent within the safe environment of therapy with credentialed and trained therapists.” Cinematherapy moves beyond talk therapy “by appealing to clients’ visual, auditory and other senses” and offers “opportunities for self-discovery that are not found through words alone,” according to Cohen.

Neuroscientist Uri Hasson, a pioneer in neurocinematics, similarly notes that the multisensory, multilayered complexity of cinema provides viewers with an experience “that evolves over time, grabbing their attention and triggering a sequence of perceptual, cognitive and emotional processes.”

Evidenced-based therapy

Research spanning more than four decades has shown that cinematherapy is effective with many populations in multiple settings, ranging from outpatient to residential treatment, psychiatric hospitals to nursing homes. Cohen and his co-authors reference numerous studies in their book, including a pilot study dating back to the 1980s which found that the use of videos with 17- to 19-year-olds who had dropped out of high school resulted in enhancing their self-worth and self-esteem. More recently, Michael Powell, Rebecca Newgent and Sang Lee found the use of The Lord of the Rings film trilogy effective in the treatment of depression in adolescents.

Several notable international studies published in 2014 explored the use of cinematherapy within different cultures, settings and age groups. A Korean study by H.G. Kim noted the positive effects of a cinematherapy-based “group reminiscence program” on managing depression in nursing home residents. An Iranian study of “vulnerable women” receiving treatment from nongovernmental social service clinics in Tehran found cinematherapy effective in increasing self-esteem. Research from the University of Bucharest in Romania by Sorina Dumtrache concluded that group cinematherapy is effective in decreasing anxiety in young adults.

Cinema selection: Therapeutic resonance and relevance

Cinema must resonate deeply, on multiple levels, with clients for it to be effective therapeutically. The individual’s age, developmental level and relationship with the cinema selection are all crucial factors. As Cohen has noted, “Movies can help clients achieve insights if the movies are strategically selected for relevance to the client’s interests and needs in treatment.”

To meet the unique needs of my clients, I have to give careful consideration to cinema selection. My clients, ranging in age from 3 to their late 70s, have come from diverse backgrounds and have struggled with varying challenges, including anxiety, addiction, depression, domestic violence, grief, panic disorder, social phobia, body dysmorphia, eating disorders and trauma. The selections I use are based on the specific needs, strengths, challenges and aspirations of each individual.

For instance, I have found the films 28 Days, When a Man Loves a Woman and Flight to be particularly useful in helping adults with substance use disorders break through the denial of their addiction and gain a better awareness of the impact it has had on their lives and the lives of their loved ones. While doing a skills-based group on prevention of sexual exploitation for young women with intellectual disability, I discovered that all of the participants were avid fans of Buffy the Vampire Slayer, so I used an episode of the TV show to help them explore the risks of alcohol and drug use. I have also used the favorite cartoons of children in residential treatment in therapeutic exercises to enhance self-regulation and healthy attachment.

When carefully integrated within the therapeutic process, cinema has powerful healing potential. The iconic film The Wizard of Oz and the fantasy drama What Dreams May Come have long served as powerful catalysts of personal healing for my clients. With the help of these movies, they have explored core concepts of mindfulness such as resilience, compassion, acceptance and being present within oneself. Barnet Bain, the producer of What Dreams May Come, has noted that both cinema and psychotherapy use “the power of stories to heal.” An advocate of integrative body psychotherapy, he believes that we all “take refuge” and find healing in transformational stories. “In my view,” Bain explained during a brief interview with me at the Illuminate Film Festival in 2015, “any story that can lead one home to integration in the embodied present, that is a therapeutic story.”

It is through the integration of mindfulness-oriented practices and cinematherapy that I have seen the most profound changes in my clients. In group therapy, for example, I integrate mindfulness-oriented exercises before and/or after viewing cinematic selections, followed by in-depth processing of the cinematic experience. I also assign homework that includes practicing and applying mindfulness skills, watching “prescribed” cinema, journaling and engaging in other expressive exercises. Follow-up sessions explore cinematic experiences via group discussion and experiential exercises, including role-play and writing or rewriting one’s own script. Countless clients have reported that this integrative approach has helped them make life-changing progress.

Mindfulness, resonance and synchronicity

In my work, the therapeutic power of integrative, mindfulness-oriented cinematherapy was perhaps best exemplified by the impact that “all things” had on my clients. Unlike more typical episodes of the sometimes scary sci-fi show The X-Files, “all things” features no monsters, aliens or government conspiracies. Instead, it examines paths to personal transformation and investigates concepts of the mind-body connection, spirituality and synchronicity.

More than a decade ago, I was challenged with introducing mindfulness and mind-body healing concepts to clients who were court ordered for treatment because of substance use, domestic violence or related convictions. At the time, mindfulness was not yet mainstream, and very few of the people referred to me had any prior exposure to its concepts or practices. They were coming to group therapy to avoid incarceration, loss of their driver’s license or removal of their children from the home. These were individuals most in need of having simple, powerful, mindfulness-based skills and concepts to better manage their lives. I needed a means through which I could introduce these concepts in a nonthreatening, entertaining and effective manner.

Initially, I showed only those segments and sequences of the “all things” episode that best illustrated core concepts of mindfulness and mind-body healing, including slowing down, paying attention, acceptance, self-compassion and the impact of toxic emotions on health and well-being. Clients were so moved by these evocative clips that they routinely requested to view the episode in its entirety.

Coincidentally, the 45-minute episode fit very well within groups that ran 90 minutes to two hours, allowing us time to engage in mindfulness-oriented exercises before or after the viewing and time to process the experience as a group and discuss homework assignments. I have now used “all things” in its entirety with more than 1,000 clients in both individual and group therapy.

Over the years, I have used the episode in dozens of different groups focusing on everything from stress management to trauma recovery. These groups have varied from eight- to 16-week structured, skills-based groups to less structured, ongoing groups for individuals with chronic mental health needs. In nearly every instance, at least one group member has reported experiencing some sort of breakthrough or making some sort of positive life-altering change after viewing “all things.” In some groups, every member reported experiencing a significant impact. Many group members have noted that the episode’s images and themes resonated with them on a deeply personal level. In fact, numerous clients have contacted me months or even years after completing treatment and shared that the experience of viewing this episode, in a therapeutic context, played a significant role in their recovery and personal growth.

Having watched so many clients view “all things,” I have noted what moves and soothes them within this episode. Letting go of shame and guilt, seeking meaning in life experiences and “seeing the reasons why all things happen” are themes within the episode that resonate universally with clients. Grief, loss, shame, abandonment and exploitation are among the more personal themes that have emerged and brought tears to the eyes of many clients after watching “all things.” The episode became the means through which those clients could safely identify and begin to process their painful experiences.

The use of “all things” in group therapy has had yet another surprising effect. I found that clients become much calmer and more reflective immediately after viewing the episode. In dozens of cases, I have observed clients shift out of highly anxious or agitated states while watching the episode. As a result, they were better able to reflect on and process their reactions after viewing it.

The way “all things” was directed and filmed seems to have contributed to this effect. Pulsating chimes, dripping water, ticking clocks and tapping pencils set the rhythm, while slow-motion sequences and extreme close-ups focus viewers’ attention. Shots of a window shade toggle undulating back and forth, circulating fans, spinning wheels, flowing curtains, swinging signs and even the main character swaying back and forth while having a mystical experience in a Buddhist temple serve to grasp and direct the gaze of viewers.

I suspect that these cinematic devices are partly what produce an immediate calming effect on my clients, quite possibly inducing a state of mindfulness. They may even contribute to client “breakthroughs.” As if they were some form of cinematic eye movement desensitization and reprocessing, could the audio and visual techniques used in “all things” produce bilateral stimulation of the brain and subsequently enhance adaptive information processing and alleviation of affective distress?

Synchronicity, neural synchrony and interconnection

Neurocinematic research may well explain some of the therapeutic power of “all things.” The episode’s cinematic and thematic complexity, along with its well-directed and evocative sequences, are what neuroscientists have found to contribute most to interspectator neural synchrony, or the synchronization of brain activation and brain wave patterns across viewers. Intersubject correlation (ISC) measures the collective engagement of a group of viewers via neural synchrony. As researchers Kaisu Lankinen, Jukka Saari and Ritta Hari noted in 2014, emotional film clips enhance ISC. Likewise, “a well-directed movie,” in contrast to one that is loosely structured, strengthens ISC.

According to Hasson, a research scientist and lead author of an article titled “Neurocinematics: The Neuroscience of Film,” the concept of ISC is relatively straightforward and simple. “In cinema,” Hasson and his co-authors write, “some films (or films’ segments) lead most viewers through a similar sequence of perceptual, emotional and cognitive states. Such a tight grip on viewers’ minds will be reflected in the similarity of the brain activity (high ISC) across most viewers. By contrast, other films exert (either intentionally or unintentionally) less control over viewers’ responses during movie watching (e.g., less control of viewers’ emotions or thoughts). Throughout the years filmmakers have developed an arsenal of cinematic devices (e.g., montage, continuity editing, close-up) to direct viewers’ minds during movie watching. These techniques, which constitute the formal structure and aesthetics of any given cinematic text, determine how viewers respond to the film.”

When I inquired whether inducing bilateral brain stimulation and synchronized brain activity in viewers was intentional or intuitive, Gillian Anderson, the writer, director and star of the “all things” episode, indicated that it was the latter. She explained, via personal note, that she “had no idea” that those cinematic techniques could produce such “amazing” effects. As she has noted in previous interviews, the writing and directing of the episode was a “deeply personal” endeavor and an exploration of her own deeply held belief that “we are all connected.”

No stranger to counseling and psychotherapy, Anderson has both professional and personal connections to the field. She is currently penning a self-help book and has recently published the second in a trilogy of novels featuring a child psychiatrist as the main character. Personally, she began therapy at age 14 and credits it with keeping her “sane and alive.” She has been a strong supporter of counseling and psychotherapy ever since.

Anderson believes that cinema, like therapy, has powerful healing potential. “Any film that has a message that teaches people about themselves, that teaches people how to get out of a place where they are stuck and get on with their lives and get on with being a productive human being, is important,” she said. “Films are instruments to teach people, and they can affect people in profound and in life-changing ways.”

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Note: My use of all films, television episodes, film segments and videos in group and individual therapy was done via “fair use” with no copyright infringement intended.

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Bronwyn Robertson, a licensed professional counselor, has lectured and published internationally on the integration of mindfulness in counseling and psychotherapy. She specializes in the treatment of anxiety, depression and trauma-related disorders. Contact her at Bronwyn@BronwynRobertsonLPC.com.

Letters to the editor: ct@counseling.org

Getting unstuck

By David Flack March 28, 2016

Andrew never knew his father. At age 4, he witnessed the death of his mother from an overdose. She was heroin dependent, and they were living in a car at the time. After her death, Andrew entered the foster care system. Between the ages of 4 and 15, he experienced more than a dozen different placements. Not surprisingly, with each move, his behavior became increasingly problematic.

At age 9, Andrew started drinking alcohol. By age 11, he was using alcohol and marijuana regularly. He discovered meth as a 13-year-old and went to inpatient care for the first time. He ran away after four days. When he was 15, he ran from the group home where he was living.

When Andrew entered treatment at age 16, he was on probation and had just moved into a transitional living program after several months on the streets. When he started treatment, he met the criteria for multiple substance use disorders. He also had pre-existing mental health diagnoses that included posttraumatic stress disorder (PTSD), attention-deficit/hyperactivity disorder, conduct disorder and major depressive disorder. At that time, Andrew said he had no interest in stopping his substance use because “that’s not a problem for me.”

In his treatment journal, Andrew wrote, “Lots of times I feel like I’m living in some kind of black hole. I’m alone, but not really, because everything’s there, because I just can’t escape it no matter what I try. It’s black there, because that’s what black holes are, right? But black is really all the colors at once, every single one of them. And that’s too many damned colors if you ask me.”

Understanding the stuckness

Very few teenagers enter substance abuse treatment by choice. They show up due to legal mandates, school requirements, family pressure or other external reasons. Often they see treatment as the least bad choice — only slightly better than detention, suspension or homelessness. Like Andrew, these teens often appear unwilling or unable to do things differently, even though their current behaviors are clearly causing problems. In other words, they’re stuck.

I propose that our primary task as counselors is to help these teens get unstuck — not behave better, fulfill mandates or even stop using substances. We can hope those other things happen. I certainly do. However, it seems to me that those changes can occur only when an individual gets unstuck.

When helping teens get unstuck, we need to maintain a developmental perspective as counselors. Various developmental models exist, with most including a progression of stages that individuals move through, and each stage featuring specific tasks to be accomplished. The primary stage-specific tasks for adolescence are generally considered to be developing identity and establishing autonomy. As part of establishing autonomy, it is normal for adolescents to question, rebel against and ultimately reject the plans of authority figures, including the most well-intended plans of professional helpers.

Sometimes, those well-intended plans lead to reactance, which is a tendency to resist influences perceived as a threat to one’s autonomy. Many adolescent treatment programs are designed in ways likely to exacerbate reactance. We tell adolescents what, when, why and how. In residential programs, we restrict personal items. In wilderness programs, we often take away everything. Then we wonder why participants are unsuccessful. Worse, we blame them — declaring them in denial, resistant to treatment, unwilling to engage or simply noncompliant. Instead of helping, we’ve increased their stuckness.

Reactance can be exacerbated by what I think of as developmental debt. Most developmental theories state that if a person doesn’t successfully complete the tasks for a specific stage, then he or she remains in that stage. It seems to me that this might not be accurate. Instead, sociocultural and biological factors keep pushing individuals forward, even when tasks at another stage are unresolved or only partially completed.

With every push forward, an individual becomes less likely to complete the next stage. This leads to an ever-growing developmental debt. Much like with a credit card that’s never fully paid off, the person not only will always have a balance due, but he or she will get further behind each month.

With this developmental perspective in mind, I propose five strategies for fostering change with teenagers who have co-occurring disorders. Inspired by motivational interviewing, stages of change, narrative approaches and existential psychotherapy, I have found these strategies useful for helping this population to overcome rigid thinking, get unstuck and start moving forward.

Slow down

Traditionally, drug treatment programs have assumed that anyone entering services is ready to get and stay clean. This simply isn’t true. Change is a process, not an event. When we slow down, we’re able to help participants move through that process. Developed by James Prochaska, John Norcross and Carlo DiClemente, the stages of change is an evidence-based transtheoretical model that identifies five steps in the process of change:

Precontemplation: The person doesn’t believe he or she has any problems related to the target behavior, so the person sees no reason to make changes. To help participants in this stage, we can focus on building a therapeutic alliance, validate the participant’s lack of desire to change and provide objective information.
Contemplation: The person is considering the possibility that a problem might exist but hasn’t yet decided if change is necessary. To help participants in this stage, we can explore the pros and cons of continuing to use substances, gently identify contradictions, help make links between substance use and mental health challenges, and provide opportunities to imagine or experience alternatives.
Preparation: The person has identified a problem related to the target behavior and is deciding what to do next. To help participants in this stage, we can encourage small initial steps or experiments, continue to explore and solidify motivation for change, and help eliminate obstacles to change.
Action: The person has decided to change the target behavior, has developed a plan and is now putting that plan into action. To help participants in this stage, we can explore ways to implement change, provide support, build self-efficacy and remain solution focused.
Maintenance: When the new behavior has become habit, the person has entered this stage. I propose that six months of sobriety is a good milestone for this. To help participants in this stage, we can provide ongoing support, continue to explore real or perceived obstacles and foster resiliency.

In addition to these five stages, there’s Recycle, which occurs when a participant reverts to behaviors from an earlier stage. When a participant recycles, many helpers blame the person’s lack of skills, situational factors or unwillingness to change. Extenuating circumstances may certainly be present, but it seems to me that recycles occur because we push participants into the action stage too quickly. As such, recycles are potent reminders that we should slow down and revisit earlier stages, looking for unfinished or overlooked business.

Identify their motivators

Teens often enter services believing that they’re free of problems or that their only problem is something external. It may not seem like success to some, but the change process has begun when teens report treatment as the least bad option, state that their only problem is that others think there’s a problem or make similar comments. These may not be the motivators we desire for participants, but change requires meeting them where they are at, not where we want them to be.

We can help clients discover and deepen their motivators by using the “Five R’s” from William Miller and Stephen Rollnick’s motivational interviewing:

Relevance: Why is change important?
Risks: What are the risks of changing? What are the risks of not changing?
Rewards: What will you gain from change?
Roadblocks: What are the obstacles to change?
Repetition: Review these elements at each session.

Sometimes, to help participants solidify their motivators for change, we need to assist them in developing problem-recognition skills. We can do this by exploring what defines a problem; nurturing mindfulness; and creating an inclusive, nonjudgmental treatment environment.

Approaches from narrative therapy can also be helpful. Teens with co-occurring disorders typically enter treatment with problem-saturated stories. These tales of stuckness have become the defining stories for their lives. Help them discover new stories and further increase problem-recognition skills by:

Externalizing the problem: Instead of “having” a problem or “being” a problem, assist participants to view problems as existing outside themselves. This helps remove pressures rooted in blame, shame and defensiveness. Take
this even further by encouraging participants to think of problems as characters in their stories.
Seeking exceptions: We build and sustain problem-saturated stories by ignoring times when the problem wasn’t in control. Seeking exceptions involves assisting participants to discover those ignored times. These exceptions hold
the keys to change, so explore them in great detail.
Reauthoring stories: Once exceptions have been discovered, participants can start reauthoring their problem-saturated stories. Reauthoring gives them the opportunity to create new, more empowering stories with plots that focus on moving forward.

Some teenagers are so stuck that they’re unable to identify any exceptions to their problem-saturated stories. In these cases, it can be useful for counselors to add a fourth approach to those cited previously: creating exceptions. One way for these teens to break the cycle of stuckness is to try something new. I’ve had participants explore belly dancing, glass blowing, rock climbing, rugby, hand drumming and much more.

Expect ambivalence

As I’ve noted, the change process has begun when a teen’s thinking moves from “I don’t have a problem” to “My only problem is that other people think there’s a problem.” When this occurs, the participant has moved into the contemplation stage of change. This stage is about ambivalence, which can be defined as simultaneously believing two seemingly contradictory ideas.

Ambivalence is common for all teenagers, who desire the privileges of adulthood while retaining the comforts of childhood. In the case of substance-using teens, there is often another, more complex layer — wanting to fix their problem while continuing to use. Andrew described this ambivalence well: “Using has really messed up my life, but I don’t think I’ll ever stop. When I’m high, the bad feelings go away. I don’t think about the past, and I don’t care about the future. For a little while, my brain shuts up and I can pretend everything’s OK.”

Some professional helpers focus solely on the reasons to stop using, perhaps believing that any discussion about the possible benefits of drug use will be seen as an endorsement. This simply isn’t true. Helping youth such as Andrew get unstuck requires a sincere, nonjudgmental exploration of both the pros and the cons of substance use. Here are a few other ideas for resolving ambivalence:

Normalize the process. Change is hard. It conflicts with deeply ingrained behavioral patterns and neural pathways. It requires us to ignore the stories we tell about who and what we are. It requires us to face the unknown. Because change is hard, we’d rather stick to the known, even when it is not effective or useful anymore. Helping participants realize that ambivalence is common can be essential to helping them get unstuck.
Explore the risks of changing. High-risk behavior is common in the lives of many teens with co-occurring disorders. Paradoxically, these teens are often risk avoidant. As Prochaska, Norcross and DiClemente noted in 1994, change “threatens our very identity and asks us to relinquish our way of being.” This is dangerous stuff for anyone, but for stuck teens, it can feel especially risky. Helping them make lasting change requires exploring the risks involved.
Foster self-efficacy. Albert Bandura wrote that self-efficacy is “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations.” In other words, it is a person’s belief in his or her ability to succeed. Teens with low self-efficacy avoid challenging tasks, focus on negative outcomes and quickly lose confidence in their ability to be successful. They have very little interest in attempting to change.
Disrupt rigid thinking habits. Teens with co-occurring disorders typically exhibit all-or-nothing thinking, catastrophize, deny having problems and blame others. These rigid thinking patterns reinforce their ambivalence. Resolving ambivalence requires them to think between the extremes. Traditional cognitive behavioral approaches identify these thinking patterns as irrational, erroneous and maladaptive. I prefer the term thinking habits, because habits can be changed.
Address existential concerns. Irvin Yalom identified four “givens” that define an existential perspective to psychotherapy: death, meaninglessness, freedom and isolation. Professional helpers sometimes shy away from these existential concerns, especially when working with adolescents. However, these givens are very much present in the lives of teens and can contribute significantly to both stuckness and ambivalence. Acknowledge these givens and explore them with participants.

Become trauma-informed

The Substance Abuse and Mental Health Services Administration defines trauma-informed care as “an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives.” Trauma-informed care includes the use of carefully developed approaches that reduce the likelihood of retraumatizing participants while integrating safety, trustworthiness, choice, collaboration and connection into all interactions.

Studies show that as many as 75 percent of teens in treatment for substance use disorders have experienced some form of traumatic stress. This occurs when an individual is exposed to a potentially traumatizing event or situation that overwhelms his or her ability to cope. Traumatic stress can be caused by a one-time experience or complex trauma, which can be defined as the experience of multiple traumatic events. Traumatic stress can lead to PTSD, a severe anxiety disorder that develops after exposure to traumatic stress. PTSD is a clinical diagnosis that requires the presence of specific symptoms, such as nightmares about the traumatic event, avoidance of stimuli associated with the event, increased arousal and hypervigilance. Regardless of whether they meet the diagnostic threshold for PTSD, teen trauma survivors often exhibit the following:

Hyperarousal: Survivors can become extremely vigilant about their surroundings and often experience high levels of anxiety, which leads to sleep problems, trouble concentrating, feeling constantly on guard or being easily startled.
Intrusion: Memories, flashbacks, and nightmares can continue long after the original traumatic exposure. Additionally, survivors sometimes unintentionally reenact aspects of the trauma. For example, teen survivors often engage in highly risky behaviors.
Constriction: Attempts to avoid intrusion frequently result in survivors withdrawing from the world both physically and emotionally. Agoraphobia, substance use, limited social interactions and dissociation are a few examples of constriction.

When an individual has both a substance use disorder and traumatic stress, we usually assume that the trauma led to using the substance. However, substance use often leads to trauma exposure — or further exposure. In addition, pre-existing mental health challenges and a variety of other factors can increase the likelihood of trauma exposure. Whether trauma leads to drug use, drug use leads to trauma or a more complex scenario is present, substance-abusing survivors often find themselves perpetually stuck.

Even though risky behavior is evident in the lives of most substance-abusing teens, and especially those with trauma histories, these youth are frequently risk adverse, with their risky behaviors serving as ineffective attempts to avoid risk or distractions from their past trauma. Some adolescent survivors are so obsessed with safety that they resort to substances and other maladaptive methods in an effort to find it. Still other teens lead lives so constricted that they barely participate in life. According to Judith Herman, in all these cases, trauma has “cast the victim into a state of existential crisis” in which all choices likely lead to even further stuckness.

Create connectedness

Edward Hallowell wrote that connectedness “is a sense of being a part of something larger than oneself. It is a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone. … Connectedness is my word for the force that urges us to ally, to affiliate, to enter into mutual relationships, to take strength and to grow through cooperative behavior.”

For teens with co-occurring disorders, this sense of connectedness is typically missing. I believe that isolation exacerbates all life problems, so I strongly propose that the first step toward ensuring a valuable therapeutic experience is helping participants move toward increased connectedness. In clinical settings, we can focus on two types of connectedness: group cohesion and therapeutic alliance.

Group cohesion: It seems to me that groups should be part of the treatment plan for any teen with co-occurring disorders. That said, for change to happen in groups, a strong sense of cohesion is essential. We can help achieve group cohesion by remembering this simple formula: Cohesion = Shared Fun + Safety.

When working in groups, it is essential that we create safe spaces. This includes physical, emotional and social safety. We can create a sense of safety by modeling what we expect. That means being consistent and reliable, treating participants and co-facilitators in a welcoming manner and ensuring that groups are fully inclusive.

Some treatment approaches seem to assume that participants are fragile, hopelessly damaged or completely dysregulated. Fun activities and laughter have no place is such approaches. That’s a shame. Shared fun activities build connectedness between group members and provide valuable opportunities to practice interpersonal skills. In addition, the use of fun and games helps alter negative preconceived notions of treatment, provides entry points for less verbal participants and helps teens reauthor their stories to include a world where laughter is the norm.

Therapeutic alliance: Numerous studies show that a strong therapeutic alliance is the most important indicator of positive outcomes when working with teens. When we take time to foster a strong alliance by genuinely embracing our participants’ real motivators, we stop being an adversary and become an ally. This allows us to gently challenge the ambivalence, thinking habits and other roadblocks that keep participants stuck.

Edward Bordin wrote that a strong therapeutic alliance is composed of three elements: a positive bond between the therapist and participant, agreement regarding the tasks of treatment and agreement about the goals of treatment. In other words, there is congruence between the participant and the therapist. It seems to me that there also exists a need for transparency. Here are a few ideas for this:

Explain what you’re doing as a counselor. Take time to explain the theory behind your therapeutic approaches. In addition, explain to the teen what you hope to achieve by asking a particular question or assigning a specific homework task. This not only increases transparency but also improves buy-in.
Remember that relationships are reciprocal. We expect participants to be honest. They should get the same from us. Don’t disclose excessive amounts of personal information, but do answer questions that have been sincerely asked. Be genuine and model openness.
Use concurrent documentation. Before ending individual sessions, write your progress note. Then have the participant read the progress note and write his or her own summary of the session. This may seem a bit clumsy at first, but in my experience, most participants quickly embrace the process.

Addiction as an attachment disorder

Substance abuse specialists familiar with attachment theory invariably report an inverse relationship between substance use disorders and healthy interpersonal attachments. In traditional treatment, unhealthy interpersonal attachments are generally considered the result of addiction. There is no doubt that heavy substance abuse is likely to exert a negative influence on relationships. However, there is mounting evidence that insecure attachment styles are risk factors for problematic substance use.

There are two basic concepts that are important for us to consider. First, if we don’t have opportunities to observe caregivers engaging in effective emotional regulation, we may resort to substances in an effort to manage uncomfortable feelings. Second, if we don’t connect to other people in meaningful, emotionally satisfying ways, we will find something else to fill that void.

Andrew referred to this void as a black hole made of all colors and tried to fill it with alcohol, drugs and significant acting-out behaviors. Other teens try to fill their voids with gangs, gambling, food, sex or video games. When we slow down and meet participants where they are at, we are able to help them get unstuck and start the change process so that they can see all the colors, not just black.

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

David Flack is a licensed mental health counselor, chemical dependency professional and child mental health specialist. He lives in the Seattle area and has worked for the past dozen years exclusively with teenagers who have co-occurring disorders. He has special interests in the comorbidity of substance use and trauma in adolescents, the use of experiential learning in clinical settings and the unique challenges faced by LGBTQ teens. Contact him at david@davidflack.com.

Letters to the editor: ct@counseling.org