Monthly Archives: July 2016

Addressing ethical issues in treating client self-injury

By Julia L. Whisenhunt, Nicole Stargell and Caroline Perjessy July 24, 2016

As professional counselors, we enter this field with a desire to understand and help others. There comes a time in every counselor’s career, however, when intellectual understanding is overpowered by the need for empathic understanding. This is particularly true when counselors work with clients who intentionally cut, burn, scratch, hit or otherwise injure themselves.

Jennifer Muehlenkamp and colleagues found that this coping skill, known as nonsuicidal self-injury (SI), may be used by as much as 18 percent of the general population. Furthermore, Laurie Craigen and colleagues found that as many as 39 percent of adolescents may self-injure. It is important to note that SI is separate from socially sanctioned body modification practices (e.g., piercings, tattoos), substance use or physical fighting, which can also seem intentionally harmful but have different underlying purposes.

Purpose of SI

For those who do not purposefully inflict physical harm on themselves, the concept of SI can be both foreign and confusing. As counselors, we need to know that SI works for some people, most often to help them manage intense and often painful emotions. In fact, David Klonsky, a pioneer in SI research, found that emotion regulation is the single most common function of SI. Emotional pain is linked with physiological arousal (e.g., pounding heart, headache), and SI can ease this tension, channel the pain and bring arousal to a bearable level.

Researchers such as Klonsky, Muehlenkamp, Janis Whitlock, Brianna Turner, Alexander Chapman and Brianne Layden have also examined other functions of SI. For example, SI can serve as a method for transforming emotional pain into physical pain, which can be easier to cope with for many people. SI can serve as a way to validate feelings and create a visual representation of the pain within them. Some people who self-injure may do so to cope with feelings of dissociation or depersonalization — to help themselves feel “real” or “alive” again. This is especially relevant for people who feel numb because of depression or trauma. SI can be used to vent anger privately or to channel anger toward the self as a form of punishment.

Finally, although less common, SI can serve as a means of communicating with or influencing others. Despite popular stereotypes, SI is rarely meant to be intentionally manipulative. Most often, clients who self-injure for this reason do so because they do not know more effective ways of communicating their needs and distress. In fact, the majority of clients who self-injure do so in private and are very secretive about it. Admittedly, some people self-injure to either intentionally or unintentionally influence others, but this is not the primary motivation for most clients. Consequently, assuming malicious intent behind SI can be grossly invalidating to clients’ experiences and can severely damage the therapeutic relationship.

Although the motivations for SI are complex and unique for every individual, the lay community has often equated SI with suicide. Whitlock and colleagues found that as many as 60 percent of people who self-injure may experience suicidal thoughts or behaviors. Although SI is a strong predictor of suicide, a large portion of people who self-injure do not struggle with suicide.

Several differences exist between SI and suicide regarding intent, means, frequency, severity, and emotional antecedents and consequences. Researchers such as Chapman and Katherine Dixon-Gordon have found that the emotions experienced prior to and following SI and suicide attempts are largely different. Furthermore, Muehlenkamp and Peter Gutierrez found that people who self-injure are often able to identify more reasons for living than are people who are suicidal. In fact, for some people, SI may serve an anti-suicidal function that is life preserving.

Counselors working with clients who self-injure are likely to encounter some ethical dilemmas regarding safety concerns and duty to warn/protect. With that in mind, we want to discuss some ways for counselors to address common ethical concerns that tend to emerge in this type of work. This list is not comprehensive, however, so counselors should use an established ethical decision-making model and consult or seek supervision as necessary.

Counselor values

Although counselors are trained to nonjudgmentally join with their clients, counselors may have intense reactions to SI. Doreen Fleet and Rita Mintz found that shock, sadness, anger, anxiety, frustration and diminished professional self-confidence are common responses to SI.

It is important to remember that the therapeutic relationship can be damaged beyond repair if clients feel judged. Even if counselors temper their initial reactions and support clients who self-injure, other counselor values can be damaging to the client and the therapeutic relationship. For example, it is unhelpful to assume that every client who uses SI needs to be hospitalized. We will discuss safety assessment later in this article, but counselors should remember that SI and suicidality are not equivalent.

Some counselors might feel that a contract specifying no SI would encourage clients to use healthier coping skills, but that can stem from a counselor’s anxiety surrounding the behavior and can lead to clients feeling judged by the one person who is supposed to be nonjudgmental. Moreover, SI works as a coping skill for some clients, and asking them to give up their most effective coping skill in the absence of other ways of coping can leave them feeling scared and helpless. In addition, nonharming alternative behaviors (e.g., snapping a rubber band, using a red water-soluble marker) may reduce risk, but they are not effective ways of addressing the underlying mental health issues.

Out of concern, some counselors may lecture clients on the dangers of SI and the fear that SI evokes for loved ones. Although psychoeducation can be used very effectively with clients who self-injure (e.g., dangers and wound care), there is a fine line between psychoeducation and lecturing. Many people who use SI experience self-imposed shame and guilt or have it imposed on them by others. Consequently, lecturing clients on the consequences of SI or otherwise attempting to convince clients not to self-injure can be harmful.

Similarly, chastising clients for doing permanent damage to their bodies is also unhelpful because SI is commonly a way for some people to connect with their bodies and find physical and emotional relief. It can also be unhelpful to insist on seeing a client’s wounds. If the client would like to show you his or her wounds, that can be therapeutic in itself. However, we are not medical doctors, and we should refer physical assessments to someone who is properly trained.

Overall, counselors should work toward empathic understanding of SI and reduce stereotypes or countertransference in the relationship. Working with clients who self-injure presents unique considerations for clinicians, who must manage their own reactions and beliefs about SI while simultaneously providing sound therapeutic care. Supervision, consultation and treatment teams are key sources of support and monitoring when working with these clients.

Confidentiality

The issue of confidentiality can be complicated when working with clients who self-injure, especially if those clients are minors. Confidentiality and privacy should be explained clearly in informed consent, which is an ongoing process.

At intake, or when SI is disclosed, counselors should explain techniques and interventions that will be used specifically to address SI. Counselors should also be very clear about the duty to protect and how SI might lead to mandated reporting, such as if the client develops suicidal intentions or if SI results in a major health risk (e.g., large, infected wounds).

If the client is a minor and caregivers are aware of the SI, an open discussion should occur to determine what types of information will be shared (e.g., types of interventions, progress toward goals) and how this will be shared with caregivers (e.g., privately over the phone, after session with the client present). If the caregivers of a minor are not aware that the client is using SI, counselors might need to disclose this information to parents because of the possibility of foreseeable harm. Again, however, it is important for the client to feel empowered throughout the treatment process, especially when the counselor must notify parents or loved ones.

Foreseeable harm and safety planning

Although it is important to temper counselor anxiety and methodically work through the counseling process with clients who self-injure, it is also important to actively monitor and continually assess client suicide risk. Clients sometimes minimize their use of SI, and counselors must astutely tune in to the serious nature of this behavior, understand the possibility of increased harm in the future and put adequate interventions in place.

Relatedly, clients might disclose SI before they are ready to work toward goals related to the behavior. Counselors must explore the paradox between autonomy and nonmaleficence, constantly assessing for the point at which risk outweighs the client’s readiness to change. As mentioned previously, it is generally not helpful to ask clients to stop self-injuring in the absence of other effective coping skills. So, part of this process typically involves diminishing risk while simultaneously enhancing the client’s other strengths and coping skills.

Ongoing formal and informal suicide assessment should be part of the therapeutic process. However, it is critical that counselors do this in a way that is neither assumptive nor judgmental. It is also helpful to develop a safety plan with all clients who self-injure. Clients can
use the safety plan during times of distress, regardless of whether suicidal ideation is present. A major component of providing care to clients who self-injure involves the counselor’s efforts to ensure the appropriateness of services through consistent consultation, supervision and referrals.

Assessment of SI and suicide

Assessment of SI begins at intake. We believe it is important to ask all new clients about their history of intentional SI. There are a number of assessment instruments for SI, some of which screen for SI, some that monitor risk of suicide and some that assess the functions of SI. Examples include Kim Gratz’s Deliberate Self-Harm Inventory, Matthew Nock and colleagues’ Self-Injurious Thoughts and Behaviors Interview, Marsha Linehan and colleagues’ Suicide Attempt Self-Injury Interview, and Catherine Glenn and David Klonsky’s Inventory of Statements About Self-Injury. As is the case with any therapeutic issue, counselors should document their use of established assessment instruments, consultation or supervision, and a reputable decision-making model to uphold proper standards of care.

In consideration of the elevated risk of suicide and the sometimes conflicting feelings about life and living that some clients who self-injure may experience, it is important for professional counselors to use recursive suicide risk assessment practices. Without assuming that clients who self-injure are suicidal, counselors should conduct suicide risk assessments at intake, at periodic intervals and as indicated throughout the therapeutic relationship. Counselors should remember that suicide risk assessment involves more than asking a quick close-ended question. Rather, it should involve use of a reliable and valid instrument and should include dynamic, ongoing discussions about stress, coping and ideas about living.

When working with clients who self-injure, we ask counselors to remain attuned to the risk factors and warning signs of suicide so that they can respond most appropriately if risk elevates. Safety plans (as opposed to no-harm contracts) are an effective way to build the counseling relationship and minimize client risk. At a minimum, safety plans include identification of warning signs, internal coping strategies, positive distractions, people to ask for help, professionals/agencies to ask for help and ways to make the environment safer.

Competence

As professional counselors, we are charged with practicing only within the boundaries of our competence based on education, training, supervised experience, state and national professional credentials, and appropriate professional experience. However, clients who self-injure usually present with multiple treatment issues that are complicated for both novice and seasoned clinicians to conceptualize.

Clients who self-injure often have trauma and abuse histories. Consequently, they can also struggle with eating disorders, poor body image, personality disorders, anxiety, depression and suicidal ideation. Because clients who self-injure may present with complex symptomatology and even acute distress, counselors may doubt their clinical competence and ability to meet the therapeutic demands of this client population.

Efforts to improve feelings of competence can be addressed in a variety of ways. First, we can encourage counselors to remember that the best way to understand clients’ lived experiences is to create a safe context in which clients feel free to share their stories. Counselors can promote clients’ sense of safety by exhibiting humanistic qualities such as unconditional positive regard, which can both strengthen the therapeutic relationship and convey understanding and acceptance of the client.

Next, counselors engaging in ongoing supervision and consultation can improve their clinical skills related to working with this population. Discussing clients who self-injure, in supervision or consultation contexts, provides counselors with new and different perspectives on their work, which can help them modify their treatment planning and clinical interventions. Consultation and supervision also offer counselors opportunities to reflect on how they feel toward their clients. Considering how strongly our value systems shape our work with clients, this is an invaluable exercise.

It is also imperative that counselors who work with this population review the existing literature on SI, seek continuing education on SI and remain current on emerging SI research. Competent counselors should practice treatment strategies that are evidence based and well-grounded in the literature, and access reputable resources, such as those stemming from the International Society for the Study of Self-Injury.

Finally, in situations in which clients are not progressing or a therapeutic impasse cannot be resolved, competent counselors should understand how and when to refer to another provider. Often, when counselors are unable to promote a strong therapeutic alliance or further treatment goals, it is the result of a lack of training or experience that can be remedied through additional training, supervision and consultation.

Evidence-based practices

SI is a complex treatment issue and, for obvious reasons, counselors may feel ill-equipped to effectively intervene when clients self-injure. However, just like with any treatment issue, effective intervention begins with having a safe and nonjudgmental relationship. This is not to say that knowing the complexities of SI and how to intervene appropriately are unimportant. Rather, we hope readers will remember to start with the relationship and use interventions and treatment strategies that are grounded in the literature.

In the next section, we provide a brief introduction to a few therapeutic strategies that have shown promise with clients who self-injure. It is important to note, however, that no specific treatment interventions have proved largely effective for the treatment of SI. So, counselors often rely on theoretically grounded interventions and those proposed by leaders in the field of SI. For a more detailed yet succinct review of evidence-based practices in the treatment of SI, see the ACA Practice Brief on nonsuicidal self-injury by Julia Whisenhunt and Victoria Kress (see counseling.org/knowledge-center/practice-briefs). The practice brief provides references to a number of researchers who have

examined SI intervention. Additionally, we recommend a recent publication by Catherine Glenn, Joseph Franklin and Matthew Nock, who examined the evidence base of SI treatments for youth and rated their effectiveness using the Journal of Clinical Child and Adolescent Psychology standards level system.

Individual interventions: Dialectical behavior therapy (DBT), created by Marsha Linehan, improves emotion regulation skills and intrapersonal awareness by challenging and modifying one’s cognitions, emotions and behaviors. As mentioned earlier, emotion regulation is the single most common function of SI, so learning to regulate emotions in healthier ways can decrease SI behaviors. DBT interventions are most successful when clients feel supported and accepted by their counselors and when counselors believe in their clients’ ability to change. The evidence base on DBT for SI is still limited, and some results are conflicting, but DBT may be useful for managing some of the emotion dysregulation and alexithymic aspects of SI.

Because of the maladaptive and distorted cognition seen in many people who self-injure, cognitive interventions may be well-indicated. Both David Klonsky and Nadja Slee independently suggest that cognitive therapy has been found to be most effective when focusing on the specific SI behavior and on emotion regulation skills. Problem-solving therapy, a type of cognitive therapy, may be effective when combined with cognitive, behavioral and interpersonal interventions. However, Jennifer Muehlenkamp and others have noted that the long-term results are mixed and inconclusive.

Other empirically based treatment approaches focusing on the behavior of SI include behavioral management strategies, functional assessment analysis of SI and means restriction/delay of SI. Klonsky, Muehlenkamp, Stephen Lewis and Barent Walsh provide a nice overview of these interventions in their book Nonsuicidal Self-Injury, which is part of the Advances in Psychotherapy Evidence-Based Practice series. All of these interventions promote the use of learning new behaviors in an effort to reduce the occurrence of SI.

Pioneered by William Miller and Stephen Rollnick, and applied to the treatment of SI by Victoria Kress and Rachel Hoffman, motivational interviewing (MI) is a humanistic-based therapy that can be used to enhance client motivation to change. At its core, MI is a client-centered approach that demands counselor nonjudgment and acknowledges that every client who comes to counseling is at a different place of readiness for change. Although the application of MI to the treatment of SI has not been researched well, counselors may find MI particularly useful for fostering a strong therapeutic alliance and working with clients who may not be willing or ready to cease self-injuring.

Family interventions: Family support can be a protective factor against SI and suicide. As such, family therapy can promote client change and well-being. Family members who engage in therapy can learn how to communicate with their loved ones in ways that are affirming and nonblaming. Counselors can help educate family members on the reasons that their loved ones engage in SI behaviors.

Family therapy can also help counselors explore family dynamics and how those patterns may have influenced clients’ propensity to self-injure. Trauma, abuse, unhealthy communication patterns, inappropriate alliances and other family dynamics can occur in the family of origin and create toxic relationships that are dysfunctional and in need of repair. Counselors can help clients mend these broken relationships, which in turn can potentially decrease the clients’ desire to self-injure. Klonsky and his co-authors provide a brief overview of the support for applying family therapy to the treatment of SI in their book.

Summary

To help ensure a growth-promoting experience and minimize both risk and liability, counselors should keep a number of things in mind when working with clients who self-injure. These include the following:

Monitoring one’s own values when working with clients who self-injure for the purpose of avoiding making the client feel unsafe or creating inappropriate therapeutic conditions
Identifying when and how to make disclosures of confidential information regarding SI
Identifying foreseeable harm regarding severe SI or suicide
Using reliable and valid assessment instruments to identify and monitor SI
Monitoring one’s own competence to treat SI
Using evidence-based therapeutic interventions

Above all else, we hope readers will remember five key points about SI from this article:

1) SI is often used as a coping skill, but it always has a function (and sometimes multiple functions). For most people, that function is emotion regulation. Therefore, identifying the function or functions can help to guide intervention.

2) Treatment that focuses exclusively on stopping the SI behavior fails to address the underlying reasons for the behavior and is not likely to produce long-term change.

3) Counselors’ reactions — both verbal and nonverbal — communicate clear messages to clients who self-injure. If counselors want their clients to feel safe and not judged, counselors should start by identifying their biases regarding SI.

4) Counselors need to be specially educated and trained in how to intervene with clients who self-injure. There are risks and therapeutic pitfalls that can be minimized with adequate understanding of SI.

5) SI and suicide are not equivalent, but counselors should work to monitor suicide risk without assuming that all clients who self-injure are suicidal.

The information provided in this article is not exhaustive, but we hope readers will be stimulated to continue learning about SI so that when (not if) a client presents with SI, they will feel better able to intervene.

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We would like to extend a heartfelt thanks to our friends and colleagues Victoria Kress and Chelsea Zoldan for their contributions to this article.

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

Julia L. Whisenhunt is an assistant professor of counselor education and college student affairs at the University of West Georgia. She is an editorial board member for the Journal of Counselor Leadership & Advocacy and serves Chi Sigma Iota (CSI) International through committee membership. A licensed professional counselor (LPC), national certified counselor (NCC) and certified professional clinical supervisor (CPCS) in Georgia, she specializes in the areas of self-injury, suicide prevention and creative counseling. Contact her at jwhisenh@westga.edu.

Nicole Stargell is an assistant professor in the Department of Educational Leadership and Counseling at the University of North Carolina at Pembroke. She is a member of the CSI International Counselor Community Engagement Committee, the ACA Practice Briefs advisory group and the editorial board for the Counseling Outcome Research & Evaluation journal. She is an LPC, NCC and licensed school counselor.

Caroline Perjessy is an assistant professor of counselor education and college student affairs at the University of West Georgia. An editorial board member of the Association for Specialists in Group Work, she has presented and published on dialectical behavior therapy and postmodern approaches to counselor practice and pedagogy. She is an LPC and CPCS in Georgia.

Letters to the editor: ct@counseling.org

Embracing intuition

By Lynne Shallcross

One meaning of intuition is “something that is known or understood without proof or evidence.” Given that definition, it’s not surprising that objectively studying and measuring a counselor’s intuition can be challenging. But that hasn’t stopped Jesse Fox from trying.

In 2013, as part of research Fox was doing for his dissertation, he set out to observe and track counselor intuition, a concept that he defines as rapid, nonconscious insight into what is going on in a client’s mind or behavior. Fox, an assistant professor in the Department of Pastoral Counseling at Loyola University Maryland, says counselor intuition is a little like breathing — more automatic than it is controlled.

Fox believes counselor intuition can be quantified and observed, and in his research, he aimed to accomplish that by looking at how 44 counseling experts responded to a variety of two-minute client video segments. Four of those counselor experts viewed nearly 40 client video segments, identifying six to 10 directions a counselor could take with each individual client based on what had happened in the corresponding brief video. Then the remaining 40 counselor experts viewed those video segments and rated the possible next steps on a 5-point scale ranging from “strongly agree” to “strongly disagree.”

The result? Fox says intuition was apparent in the way that the counselors leaned collectively toward certain directions to take with each client. “The best way that I could say [it] is that there was substantial common perspective that [the counselors] brought to those sessions,” says Fox, a member of the American Counseling Association who presented a poster session on his research at the 2015 ACA Conference & Expo in Orlando, Florida.

‘Substantial commonality’

Fox, who is in the process of submitting his research for publication, believes his study is the first of its kind to go beyond counselor self-reports in an attempt to look at intuition in a more scientific manner. By looking at the study results and the like-minded way that the counselors responded to the clients in the videos, Fox believes it is possible to “see” counselor intuition taking place. Additionally, he wanted to contribute to the study of intuition a standardized set of scenarios that could be given to any counselor to study his or her intuitive reaction.

In the setting Fox created, the expert counselors had nothing more than the individualized two-minute video segments to go on when making their decisions about what direction a counselor should take with each client. Fox says that setup required the counselors to draw from information they had accumulated across the course of their careers. “They don’t have all the information [about each client],” Fox says. “They just have a two-minute segment, so they have to rely on information they’ve stored long term that they have to access very quickly.”

Ideally, counselors want to have a full session, at minimum, with each client before making any decisions, Fox says. “But in this case, it was a challenging task, and what elicits an expert’s ability is that you give [him or her] something with high challenge and see what happens.”

Despite the standardized nature of the client video segments and the resulting similarity in the counselors’ reactions in Fox’s study, he is careful to point out that he isn’t claiming that no variation exists between counselors after they reach a certain level of experience. “What I am saying is that there certainly does seem to be some substantial commonality that people develop over time that helps to guide them toward good and bad directions to take,” Fox says.

Recognizing patterns

Some of the original research on intuition was done with chess players half a century ago, Fox says. What researchers found was that chess masters “see the board differently,” he says. Whereas novice players might need to think through a decision tree of outcomes, master players instinctively know the right move based on the information they have stored up over past years.

“It takes you time to develop expertise, and what you’re doing during that time is you’re beginning to recognize certain patterns that come up,” Fox says. “So if you took those findings and you applied them to counseling, what’s happening probably is that as people practice therapy, they begin to recognize certain patterns of clients that come to them.” Master counselors, just like master chess players, can identify those similar patterns and make decisions based on what they instinctively see, Fox says.

“Counselor intuition is that little itch at the back of your head, that small voice prompting you to take a risk and to speak [to] a client’s situation that may seem like it’s coming out of left field,” says ACA member W. Bryce Hagedorn, the director of the counselor education program at the University of Central Florida who served as the chair of Fox’s dissertation study on counselor intuition. “Clinically, intuition is born out of experience in the profession, experience with the client and experience with the client’s presenting concerns. It is a way of subconsciously tapping into these realms and making conclusions that may not be directly observed but rather ‘felt.’”

Some counselors report relying on intuition extensively, Hagedorn says, “oftentimes forgoing specific theoretical orientation for the sake of a clinically sound intuitive moment.”

Still, Fox and Hagedorn acknowledge that the use of intuition in counseling is not without controversy. Some critics question intuition’s very existence on the basis of its subjective, self-reported nature. Others maintain that counselors should not rely on intuition because human judgment is flawed and people make mistakes, Fox says.

On the other side, proponents of intuition might argue that in therapy, there is no way of fully removing the human element, Fox says. “In other words, we’re kind of stuck with humans, with human judgment,” he says. “If you can find a way of identifying what makes people experts or intuitive, why not go find out what makes them that way and then try to teach other people how to do it?”

Regarding the use of theory versus intuition in therapy sessions, Fox thinks counselors should strive for a combination of both. Theory gives practitioners a guiding framework from which to work, but counselors should simultaneously seek information that comes from assessments and the counselor’s experience or intuition, he says.

Counselors interested in developing their intuition can work toward greater awareness of their “gut moments,” Fox says. When counselors feel their intuition kick in, they should become conscious, skilled observers and take the time to “unpack” those situations, he suggests. “When you experience intuition, investigate it,” Fox says.

Unfortunately, no shortcut to honing intuition is available, Hagedorn says. “Outside of gaining more experience, interacting with seasoned clinicians, journaling, recording their sessions and seeking supervision, it can be quite challenging to create intuition in the short game,” he says.

Fox offers two book suggestions for counselors looking to develop their intuition: Educating Intuition by Robin M. Hogarth and Intuition: Its Powers and Perils by David G. Myers.

Counselors should avoid going to either extreme on the intuition spectrum, instead shooting for somewhere in the middle, Fox says. If the intuitive, human element is removed entirely, then it’s no longer therapy, he emphasizes. But on the other hand, it wouldn’t be wise for counselors to rely solely on their intuition in every situation, he says. Counselors should always strive to pull from more than one source of information, Fox says, whether that second source is supervision, consultation, assessment or something else.

Hagedorn agrees. “Therein lies the main crux of the problem: knowing when to apply intuition,” he says. “I don’t believe it is an either/or but rather a both/and in the sense [that] intuition and clinically proven assessments and interventions both belong in the therapeutic setting.”

From the trenches

To further explore how and why counselors integrate intuition into their work with clients, Counseling Today asked a handful of leaders in the field to weigh in with their views. Responses have been edited for length and clarity.

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Richard S. Balkin is a professor and assistant chair in the Department of Counseling and Human Development at the University of Louisville and the editor of the Journal of Counseling & Development.

How do you define counselor intuition?

The definition that makes the most sense to me is “knowing without knowing,” and it came from a writer for The New Yorker, Malcolm Gladwell. In other words, you have an understanding about an event, phenomenon or experience without having gone into the reasoning and formal process of learning about the phenomenon, event or experience.

In what ways can intuition help the counseling process?

Intuition is most often aligned with the counseling relationship. When the counselor knows the client, being intuitive may become second nature. With a strong working alliance, the client may feel more comfortable with feedback, even if it is confrontational, due to the trust and the feeling that the counselor understands.

Can counselors hone their intuition?

I view intuition as a function of the relationship. When the client-counselor relationship is strong, the client is apt to take more risks, but so is the counselor. Risk-taking, from the counselor’s perspective, is rarely about trying some new empirically supported treatment, though it can be. Rather, risk-taking from the counselor often involves, “What happens if I say this to the client? Are we at a point where I can be this honest, genuine and even direct?”

How is this developed? I often go back to my nearly 40 years of martial arts training — time on the mat. When you know without knowing, it is often because of the experience in working with clients and trusting yourself as a counselor. [Rhonda] Neswald-Potter, [Shawne] Blackburn and [Jamie] Noel talked about this as professional self-concept [in a 2013 Journal of Humanistic Counseling article], and I think it aptly applies.

Why is the topic of intuition sometimes controversial in counseling?

“Knowing without knowing” flies in the face of the accountability movement and the focus on empirically supported treatments. We know the relationship and intuition are the most important elements in counseling. But these components are difficult to investigate empirically, whereas treatment approaches lend themselves to empirical investigation much more readily. Ultimately, we end up spending more time on elements that affect very little variance in terms of counseling outcomes, as opposed to concepts like intuition, which are tied more closely to the counseling relationship.

How should counselors balance the use of intuition with the use of more objective interventions such as assessments?

Both are needed. We live in an era of accountability and where our ethical code mandates the use of interventions based on rigorous research methodologies. Intuition alone does not suffice, but of course it is a naturally occurring phenomenon within the counseling relationship. There are times when objective assessments provide important and valuable information that the counselor might otherwise miss. However, such assessments are not error-free, and counselors should utilize their subjective insights to complement or confirm what is identified objectively. Objective assessments are a nice check and balance to counselor intuition, but counselor intuition is also a nice check and balance to objective assessment.

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Jeff L. Cochran is a professor of counseling at the University of Tennessee and president of the Association for Humanistic Counseling, a division of ACA. He is also co-author, with Nancy H. Cochran, of the book The Heart of Counseling: Counseling Skills Through Therapeutic Relationships.

How do you define counselor intuition?

I think of counselor intuition as the counselor’s ability to make informed responses in the moment in therapeutic relationships. This can mean hearing a client’s emerging communication and responding to that, even when the counselor is not sure of [the] correct understanding. A counselor does not often have time [to] evaluate what her client is communicating; rather, she has to respond with her hunches.

With that said, there is also a necessary balance. I encourage students and beginning counselors to learn to wait. A first-hunch intuition might not be right. It’s best to have the hunch, realize it and set it aside. Then see if it persists [and] continues to feel right.

Does intuition take time to develop?

Beginning counselors often understandably hold back, at times too much, in [the] therapeutic relationship, which can make one hard to connect with. I work with beginning students to listen to recordings of sessions. I ask them to state their first impressions of how they might have responded, then evaluate how that in-the-moment response might have worked.

Can counselors hone their intuition?

Counselor intuition comes from within and from without. I think each counselor works from her own “n of 1” example for understanding the world. I’m OK with that as long as the counselor’s view of self and the world is continuing to develop through open self-reflection, through listening well to her or his thought patterns, and attending to and finding meaning in feelings. Self-reflection can inform a counselor’s intuition well if the counselor’s experience is considered through working toward unconditional positive self-regard, allowing her to see her experience most closely to what it really is, and [self-reflection] can tell her about self, others, the world and persons in relationships.

And, importantly, counselor intuition is developed through study. Through initial graduate study and ongoing life as a scholar, counselors study a range of counseling theories, with each carrying its own view of human nature, how we develop, what drives our problems and how we make significant life changes. Each counselor becomes [an] expert in one to a few theories and knowledgeable of others. And each counselor becomes [an] expert in the populations of persons that they serve and the problems commonly faced by those persons. So, when the counselor has to make decisions of how to respond in sessions, based on her hunches of what is going on with the person of her client, her intuition is informed by the meaning she has made of her own life experiences and by what she is continually learning as a scholar [and through] human nature and change.

Why is the topic of intuition sometimes controversial in counseling?

Counseling is research based, but it is not a science. We can know the factors of [the] therapeutic relationship that predict positive counseling outcomes. But we also want to think of counseling as a definitive science, where the only answers needed are to the question, “What techniques lead to what outcomes for what populations with what problems?” But the work is actually much more subtle than that. It’s all about the relationship, and there are many unknowns that we have to feel our way through with intuition.

Is intuition important for clients too?

Often, what clients get out of counseling is self-awareness, regaining trust in the value [of] listening to one’s own experience, which can be thought of as intuition. Many of the clients I served had given up their view of self in favor of how others see them or how they imagine that others see them. Many of the clients I served had come to doubt their own experience.

But helping them rediscover and respect the intuition of their own experience didn’t usually come from the obvious route of pointing out that need. In hindsight, it was the counseling process — me following what I hear in my client’s self-expression and responding as a person in the moment, informed by years [of] scholarship and careful self-reflection — that led us both to my client’s newfound intuition and trust in self.

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Lori A. Russell-Chapin is a professor of counseling at Bradley University and co-director of the Center for Collaborative Brain Research. She also facilitates ACA’s Neurocounseling
Interest Network.

How do you define counselor intuition?

I believe there are four major factors that allow counselors to have intuition: early personal attachment, counseling experience, the vagus nerve and the default mode network (DMN) in
the brain.

Secure, early attachment will allow the counselor to be safe enough to trust the counseling relationship, and thus easily build therapeutic rapport. Once that is accomplished, psychological resonance will occur more often, and the client and the counselor will together solve problems easier with both “heads” offering solutions.

If a counselor does trust his or her judgment and intuition, the longer counseling is practiced, the stronger this intuition becomes.

The vagus nerve is the 10th cranial nerve and the longest nerve in the body. This nerve begins at the base of the medulla oblongata and ends at the abdomen. The vagus nerve takes in so much information from so many sources and senses, it was named from the word “vagabond,” as it wanders throughout the body. This [nerve] offers the counselor, and the client for that matter, invaluable and rich communication about many possible thoughts, senses and emotions.

The DMN in the brain consists of the posterior cingulate, precuneus, cerebellar tonsils, bilateral temporoparietal junction, medial prefrontal, bilateral superior frontal, inferior temporal and parahippocampus. This network has many functions, but one of the main functions is to allow us to introspect and retrospect. If we are relatively healthy and regulated, the DMN helps us understand the world of self and others. This network helps us to mind-wander and create better understandings about our clients from this wandering and being “offline” for a while.

Can counselors hone their intuition?

Counselors can hone their intuition by understanding there is top-down and bottom-up communication in the body. The brain informs the body — top-down — and the body informs the brain — bottom-up. These electrical and chemical impulses send messages about the world around us. Understanding that our physiology gives us those hunches or intuitive feelings may allow counselors to be more in tune with those emotions and sensations. Counselors have to listen to their brains and bodies.

Can you share an anecdote about intuition in your work as a counselor?

Recently, a student supervisee did not show up for a very important meeting pertaining to his future. The student supervisee was typically very punctual. I waited patiently for over 20 minutes. After I returned back to the university, something just didn’t feel right. I listened to my intuition, my body and years of counseling. I began calling around and could not get in touch with this person. I finally called the campus police and asked them to begin a search. Finally, the person was located and had overdosed. Because of my intuition and working with other available resources, a life was saved.

Why is the topic of intuition sometimes controversial in counseling?

Many helping professionals believe intuition is just a soft science, much like the old days of counseling. Today we know that counseling is not a soft science, as counseling does change the function and structure of the brain. The advances in EEGs (electroencephalograms) and brain scans have demonstrated those changes. Now that we also understand the function of the vagus nerve and the DMN, the implications to social connectedness and our social brain, it may not need to be as controversial.

How should counselors balance the use of intuition with the use of more objective interventions such as assessments?

Assessment and intuition need not be in competition with one another. Both are necessary to a complete evaluation of the client’s needs. Quantitative and qualitative measures, whether that be in the form of self-reports, standardized tests or physiological impulses, are all essential to successful outcomes and efficacious counseling treatment.

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Jeffrey Kottler is a professor of counseling at California State University, Fullerton, and the author of several books that explore the counselor’s experiences with intuition, including On Being a Therapist, On Being a Master Therapist and The Therapist in the Real World.

How do you define counselor intuition?

One way to think about intuition is that it represents internalized experience. It’s a shortcut to solving problems, selecting courses of action or interpreting the world or one’s own experience based [on] cognitive templates that are developed over time. It is an ethereal or mysterious phenomenon precisely because words can’t really touch what it feels like.

How is intuition important in the counseling process?

Intuition is a felt sense, an inkling, sometimes felt in the body, sometimes in the heart or mind, that represents one possible interpretation of events or experience. As such, it is a hypothesis that is usually subject to testing and confirmation. I sense that a client is uncomfortable with what is transpiring in the moment, but if I stop and try to explain how and why I know this, I feel at a loss. Observable behavior is not yet apparent, except on a preconscious level. Such initial thoughts and feelings, if not supported with some other evidence, can indeed be problematic, or even dangerous. Calibrating one’s intuitive powers comes with systematic experimentation, making the sense more attuned and accurate after processing honest feedback.

In what ways can intuition help the counseling process?

Intuition sometimes leads to breakthroughs in ways nothing else can touch. Our field has traditionally been dominated by older, white, male theorists who worship logic, rationality, empirical verification and objective data. Of course, this is critical for scientific advancement. But in actual practice, we also rely on hunches, inklings, images and internal feelings that sometimes offer clues that would be inaccessible any other way. Likewise, if these feelings are based on personal biases, distortions, exaggerations or one’s own needs, then counseling can become self-indulgent and not in the client’s best interests.

Can counselors hone their intuition?

Intuitive powers are developed over time, with reflective experience, systematic assessment of accuracy and explorations into alternative domains that bypass mere language. The difference between beginners and veterans is that those new to the profession haven’t yet accumulated sufficient experience to know whether their feelings or hunches are targeted or appropriate yet. But with practice and commitment, all of us learn to be more responsive to others without needing to explain or interpret how the process actually happened.

Can you share an anecdote about intuition in your work as a counselor?

I was doing trauma work in Nepal after the series of devastating earthquakes that occurred last year. A man in his 80s wanted to talk to me about something that was bothering him. It was explained to me by a relative that although he wasn’t physically injured as so many others were, he was still very anxious. The challenge was that he was escorted into my “office” — a schoolroom that was one of the rare buildings still standing — and didn’t speak a word of English.

My Nepali language skills are feeble, and my translator left to help treat another patient. So we just sat there and stared at one another for a few minutes until I felt this really strong energy between us. I couldn’t get the idea out of my head that he wanted to hold my hands. Now it’s entirely possible that this was my feeling rather than his, but I nevertheless reached out to hold his gnarled hands in my hands. We just sat like that staring into one another’s eyes and holding hands. He kept talking to me, telling his story, and I kept nodding even though I could only understand a few words he was saying.

When the session was over, we stood up and hugged one another. He wouldn’t let go. I have no idea what actually happened between us, but it felt miraculous. When I have intuitive experiences like this, I deliberately try not to explain what happened. I learned from shamans long ago that sometimes when you make sense of experiences, you destroy their magic.

Why is the topic of intuition sometimes controversial in counseling?

I don’t agree that it is controversial. I just think it is misunderstood. Intuition is simply a thought, feeling, image, sensation or hypothesis that isn’t — yet — supported by more tangible evidence. It is just a starting point that must be checked out. It is ill-advised when people trust their intuition without assessing the accuracy or combining it with standards of care.

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Catharina Chang is a professor at Georgia State University and the president of the Association for Multicultural Counseling and Development, a division of ACA.

How do you define counselor intuition?

Counselor intuition is the counselor’s ability to connect with her client and to understand her client at a level deeper than the spoken words. Counselor intuition guides the counselor to act in a certain direction with her client. Counselor intuition can assist counselors in case conceptualization as well as helping the counselor decide how to move forward with the counseling process.

Can counselors hone their intuition?

I believe you either have intuition or not, but if you do have intuition, you can further develop your intuition. Some have asked whether counseling is a science or an art, and it’s both. Effective counselors understand the science behind good clinical skills, while respecting that the art of counseling is also important. Intuition is a part of the art of counseling. One’s intuition, I believe, comes out of your past experiences and knowledge, so it can be developed and fine-tuned. Counselor intuition allows the counselor to bring herself into the counseling process.

Why is the topic of intuition sometimes controversial in counseling?

From a legal and ethical standpoint, we want to be able to quantify everything, and intuition is something that can’t be quantified — which is why it’s important to follow your hunches/gut/intuition but be able to also back up that hunch with specific details.

How should counselors balance the use of intuition with the use of more objective interventions such as assessments?

Both are important to be an effective counselor. Intuition helps us know when and where to probe deeper, thus assisting us to gain more concrete information.

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To contact the individuals interviewed for this article, email:

Richard S. Balkin at richard.balkin@louisville.edu
Catharina Chang at cychang@gsu.edu
Jeff L. Cochran at jcochr11@utk.edu
Jesse Fox at jfox1@loyola.edu
W. Bryce Hagedorn at Bryce.Hagedorn@ucf.edu
Lori A. Russell-Chapin at lar@fsmail.bradley.edu

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Lynne Shallcross, a former associate editor and senior writer at Counseling Today, works for Kaiser Health News as a web producer. Contact her at lshallcross@gmail.com.

Letters to the editor: ct@counseling.org

Reconsidering ADHD

By Laurie Meyers July 20, 2016

The stereotypical image of attention-deficit/hyperactivity disorder (ADHD) is the raucous little boy who can’t sit still in the classroom and is a discipline problem at home. But counselors who commonly work with ADHD know that it can also manifest as a young girl who is seemingly always in her own world or an adult who just can’t seem to get things done and frequently misses deadlines. Even after moving beyond the stereotypes, however, ADHD isn’t necessarily easy to spot, especially because the disorder can mimic the symptoms of mental health conditions such as depression, anxiety and schizophrenia.

Once viewed strictly as a behavioral problem, ADHD is now considered by many experts to also be a neurological and cognitive disorder that starts in childhood and presents lifelong challenges for those who have it. Although much remains to be discovered about ADHD, researchers believe that the problem lies with an impairment in the brain’s executive function that causes inattention, hyperactivity and impulsivity. In the past, ADHD was divided into two types, but the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders delineates three types of ADHD: inattentive type, hyperactive/impulsive type and combined type (a mix of symptoms from both the inattentive and the hyperactive/impulsive types). Although typically diagnosed in childhood, ADHD can go undetected until a person reaches adulthood. The difficulties adults with ADHD confront may look different than the difficulties children with the disorder face. For example, instead of failing to complete homework, adults may have problems with missing deadlines at work or forgetting appointments. Regardless, the root cause of those challenges and many of the strategies that are used to adapt and cope are the same for children and adults, according to counselors who work with ADHD.

The professional counselors interviewed for this article say that a number of interventions, including time-management strategies, cognitive behavior therapy and, if needed, prescription medications, can be helpful for those with ADHD. But they also emphasize that one of the most important things practitioners can do is to explain to clients why they experience the difficulties they do. Before showing up in a counselor’s office, many of these clients have come to believe (or have been told by others) that they are dumb, lazy or even mentally unstable.

Childhood challenges

Those who read the comic strip The Family Circus are likely familiar with the character of Billy, the family’s 7-year-old son, and his “trails,” which are often featured in the larger Sunday comic. The dashed lines in the comic trace Billy’s wanderings as he performs seemingly simple tasks such as going to the mailbox. One of Billy’s typical trails might lead to every room in the house, on and off the furniture and perhaps even around the neighborhood as he stops to investigate everything that draws his attention along the way to the mailbox.

Clay Martin, a national certified counselor who was diagnosed with ADHD as a child, says that Billy and his trails are the perfect example of a child with ADHD. It might take Billy forever to get the mail, but it’s not because he’s misbehaving, Martin says. It’s because he has a faulty filter for sensory input. Children and adults with ADHD may, in essence, have trouble distinguishing the signal from the noise, being unable to focus on one thing in a sea of sensory output, explains Martin, a member of the American Counseling Association.

Unfortunately, Martin adds, the adults in the life of a child with ADHD don’t typically understand this, or at least not initially. Instead, parents often think that their child is being disrespectful, willfully disobedient or just plain defiant, but that is usually not the case, he says. Martin explains that when children with ADHD get in trouble, they often are not even sure of what they have done wrong. That’s because they don’t usually possess a strong sense of time, may have trouble processing information and likely intended to listen to the instructions they were given but were ultimately unable to focus on what the parent, teacher or other adult said, according to Martin. He calls this circumstance “blinking” and acknowledges that it sometimes remains a challenge for him even as an adult. Even though he is intent on listening to a conversation, his mind will suddenly be seized by something else.

When providing counseling, Martin does a number of things to help ensure that he stays focused on his clients. He maintains what he calls a “spartan” work environment with few distractions. He silences his mobile phone and locks it in a cabinet until lunchtime and then again until the end of the workday. He maintains eye contact with clients through the entire session and summarizes their statements immediately rather than letting them “pile up.”

Beth Ann Dague, a licensed professional counselor in Wheeling, West Virginia, says the biggest challenge she faces when working with children with ADHD is often helping parents and teachers better understand the nature of the disorder. “I try to educate them about problems that occur with the prefrontal cortex and that [ADHD] is more than a short attention span and distractibility,” she says. In fact, children (and adults) with ADHD can also struggle with lack of perseverance, impulse control, hyperactivity, chronic lateness, poor time management, disorganization, procrastination, poor judgment, trouble learning from experience, short-term memory problems, and social and test anxiety, notes Dague, a member of ACA who has done advanced training in ADHD work.

When children are grappling with several of those issues simultaneously, academic problems are inevitable unless classroom accommodations are made, Dague asserts. She encourages parents to become their child’s best advocate, ensuring that the child gets all the services that those with ADHD are entitled to under federal law because the disorder is classified as a disability. Parents should push especially hard for an Individualized Education Program (IEP) for their child, she says. Under an IEP, a student with ADHD is given accommodations such as the ability to take tests separately, individual lessons with a teacher or tutor to go over problem material and other classroom modifications. Dague says that ADHD is in many ways a disorder of motivation. For that reason, parents may have to be motivated for their children with ADHD, encouraging them to keep trying and assisting them with homework, she adds.

Martin formerly worked with adolescents as an in-home counselor in Georgia and now counsels the same age group in a substance abuse program as part of the clinical work for his doctoral program at the College of William & Mary in Williamsburg, Virginia. He cautions that parents whose children have ADHD should always consult with the child and consider his or her input. Children with ADHD benefit from having structured schedules, Martin says. So parents might decide that, each day, the child will be allowed to play video games or play outside for an hour after school, but then homework must be completed, the family will eat dinner, the parents will check the child’s work and then the child will get to choose whatever he or she wants to do in the time remaining before bed. Rather than the parents always determining the schedule, Martin encourages what he calls “therapeutic negotiation,” in which the parents agree to try a different schedule arrangement based on the child’s desires. For example, the child might propose doing homework for an hour first, followed by video games for two hours. Before agreeing, the parents and child would reach an understanding that if schoolwork is neglected under the new schedule, the child will resume the original schedule.

Both Martin and Dague say it is important to encourage children with ADHD to find and pursue their passions, and both counselors highly recommend extracurricular activities for these children. These outside interests are significant not just as an outlet for excess energy, but as a place where young people with ADHD can excel and experience success, especially if academics prove challenging to them. Dague talks to parents and children about trying out various sports and other activities at school and also informs them about low-cost programs such as a fine arts institute and music programs in the local area. She urges parents not to let their child simply “give up,” which is common among those with ADHD, Dague says. Instead, parents can encourage their child to try a different activity or to stay in a current program or activity a little while longer in hopes that it will spark the child’s interest.

Extracurricular activities can also teach valuable life skills, Martin notes. He credits participating in drama club in high school with helping him learn social skills, how to communicate with others and how to make friends. It was also a place where he was surrounded by individuals who accepted and supported him.

Dague is particularly in favor of sports or other physical activities for children with ADHD because she believes that movement is helpful for activating their brains. She notes that movement increases blood flow, oxygen and neurotransmitters such as serotonin, norepinephrine and dopamine.

But Dague also likes to teach yoga and diaphragmatic breathing for relaxation to child clients with ADHD. Martin finds meditation personally helpful for focus and stress relief and often suggests that clients with ADHD try it too.

Dague encourages parents to look for cognitive training resources to work on with their children. Among those she mentions are Nintendo’s Brain Age and workbooks that include exercises for increasing attention and focus. She also engages in exercises with clients in her office that are meant to enhance their attention levels. For example, she might play Simon Says, Jenga or checkers with them. Dague says that checkers is particularly difficult for children with ADHD because they are thinking too fast to strategize. In her sessions with these clients, she slows things down and helps them think about what moves they could make to beat her. She also encourages older children with ADHD to try out cooking under parental supervision. She believes that following a recipe step by step can help to increase their focus.

In cases of children with ADHD who are acting out, Dague talks with the child and parents about setting up a behavior plan. For example, the family might pick a week and say that if the child can go consecutive evenings without yelling, stomping, refusing to do homework or engaging in other disruptive behavior, he or she can earn some type of reward. Dague also teaches children with ADHD and behavior issues to visualize a stop sign or stoplight every time they feel themselves getting angry or feel the urge to grab or touch things they aren’t supposed to.

Martin and Dague stress that amid all of the possible tips and techniques for managing a child’s behavior, it is important for counselors to remember that ADHD still carries a stigma and that the struggles these children face can leave a mark.

Dague and those she supervises have used multiple methods in school or in the counseling office to help children with ADHD work on their self-esteem. She says it is common for these children to struggle to identify their positive personal aspects, so counselors in school might use worksheets and ask the children to mark their “good traits” or to write down good things that others have said to them. Dague also likes to have children make a “self-esteem box.” The shoebox, personalized with pictures or drawings on the outside, is used as a place to store positive comments from teachers, parents or peers.

Martin is also familiar with the self-esteem issues that those with ADHD often face. When he sought counseling for himself as an adult, it wasn’t to learn time-management or relaxation techniques. It was to learn self-acceptance. Beginning when Martin was a child, he had wondered why he was so different from everyone else. Over time, with the help of a counselor, he learned that he wasn’t inferior to those who didn’t face the same challenges that he faced. Eventually, he even came to appreciate his differences and, in fact, no longer considers ADHD a disorder but rather a different way of seeing the world. He encourages counselors to let their clients know that ADHD is neither an indictment nor a life sentence. Instead, their unique perspectives and passions might lead them to feats of creativity and accomplishment that many others may only dream of, Martin concludes.

College bound

The transition from high school to college can prove challenging for any adolescent, but that can hold especially true for students with ADHD. Some of these students may have grown reliant in high school on receiving assistance from their parents with remembering deadlines, organizing their assignments and managing their time, says Deborah Ebener, an associate professor and coordinator of counselor education at Florida State University (FSU) in Tallahassee. These students most likely also had an IEP in high school that guaranteed them specific accommodations that may not be available to them in college.

“In addition, [students with ADHD] must deal with changes in how disability services are delivered,” continues Ebener, a certified rehabilitation counselor, national certified counselor and licensed psychologist. “College may be the first time the student is solely responsible for requesting and managing [his or her] own academic accommodations.”

The stakes are high. Research has shown that college students with ADHD generally have poorer academic results and are less likely to graduate than their peers who do not have ADHD. Those who do graduate are likely to take longer than their peers to finish college, says Ebener, a member of ACA. College students with ADHD also tend to have poorer psychosocial and emotional outcomes, higher levels of psychological distress and higher rates of depressive symptoms, says Ebener, noting that the research is borne out by what she has seen in her private practice.

“The existing services that are available to college students with ADHD may not be adequate to help them meet the rigorous academic and psychosocial demands that come with going to college,” says Susan Smedema, who collaborated with Ebener to create a group counseling program for students with ADHD at FSU. “For example, academic support services provided by campus-based disability centers provide students with specific course-related assistance, such as extended testing time, but typically don’t address psychosocial concerns, such as helping them to make friends or navigate the dating scene.”

“Individual counseling addresses psychosocial issues and skill development, but it may be difficult to find a counselor with ADHD expertise, and counseling is often expensive and time-limited,” Smedema continues. “Individual ADHD coaching helps students develop skills and self-confidence, but it is also expensive and does not provide emotional support or address a student’s specific problems. Group counseling, however, is a cost-effective way to help students with ADHD cope more effectively with college life.”

FSU’s student disability resource center asked Ebener to develop group counseling services for college students with disabilities. She created the Coping With ADHD project and, with Smedema, developed it into a service, teaching and research project. Ebener describes the group program as a combination of cognitive behavioral and individual coaching interventions.

“We utilize a psychoeducational approach to coaching the students in such areas as time management, organizational skills, test preparation, problem-solving and goal setting,” she says. “In addition, cognitive behavioral interventions are used to address psychosocial issues related to adaption to their ADHD and other life areas. This psychosocial adaptation to disability component is what makes this intervention unique.”

The group curriculum that Ebener and Smedema created consists of eight 90-minute sessions co-led by two advanced graduate students. Topics include understanding and coping with ADHD symptoms, medication issues (such as dealing with side effects), stress reduction, self-advocacy (including how to ask for accommodations from professors), social skills (dating, in particular, is a very popular topic, Smedema says), goal setting, time management and memory strategies.

“The ultimate goals are to help students minimize their functional limitations, reduce psychological distress, gain social support, develop self-advocacy skills and effectively adjust to college,” says Smedema, who has since left FSU to become an assistant professor of rehabilitation psychology and special education at the University of Wisconsin-Madison. She continues to be a co-investigator with Ebener on the research aspects of what is now called the Disability Counseling Project.

Smedema, a member of ACA, says that each session generally consists of 10 minutes of group member check-in, a 15-minute presentation of content related to the day’s topic, 15 minutes of member response to the presentation, a 10-minute break and 40 minutes of general group process.

The eight sessions are:

1) About my disability: Self-assessment and understanding resources

2) Coping with my disability: Self-monitoring and stress management

3) Career decision-making and exploration: Obtaining and maintaining employment; reducing commitment anxiety and external conflict

4) Awareness of self and environment and learning to work well with others: Self-advocacy and social skills; students with disabilities’ rights and responsibilities

5) Learning to manage myself: Aggressive vs. assertive responses; developing memory skills and effective work habits

6) Who’s in control: Time management; solution-focused/forward thinking

7) How do I remember all of this: Memory strategies (e.g. calendars)

8) Wrapup: Debriefing

The group facilitators use psychoeducation to cover topics such as time management. But for other topics, such as stress reduction, they demonstrate effective techniques (for example, diaphragmatic breathing or progressive muscle relations) and lead the group in performing the exercises.

In the reaction portion of the sessions, students talk about their responses to the presentation topic or the technique being demonstrated. For example, they might discuss questions such as how particular relaxation strategies made them feel, how they might be able to implement the techniques in their lives, what barriers they might encounter in using a particular strategy or technique and what impact they think a particular strategy or technique might have on them overall.

The general group process portion of the sessions allows members to absorb what they’ve learned together while providing one another with emotional support, Smedema says.

“According to our research, students who participate in the group demonstrate significant increases in quality of life and college self-efficacy and significant decreases in psychological distress,” Smedema notes. “These results show incredible promise for the efficacy of this type of intervention in college students with ADHD.”

Recognizing ADHD in adults

Stacey Chadwick Brown, a licensed mental health counselor and private practitioner in Fort Myers, Florida, recently started working with an adult client who had formerly been diagnosed with depression. She told Brown that her anxiety and depression weren’t improving. Some of the woman’s current symptoms, such as trouble focusing and a lack of motivation, resembled depression, but as Brown listened to her story over several sessions, she noticed that the client reported long-term attention problems.

When discussing the client’s lack of motivation, Brown discovered that the woman actually was motivated, but only to do things that she found enjoyable. The client also reported feeling anxiety, which Brown definitely sensed. But Brown still didn’t feel that she was getting the full picture of the client, so she did something that she likes to do with all of her cases (with clients’ permission) — get the perspective of at least one other person in the client’s life.

“I had her roommate come in,” recounts Brown, a member of ACA, “and she said, ‘Did she tell you about how she won’t pay bills on time, gets stuck [pulled in] if she walks by the TV and has trouble getting up in the morning?’”

The client had also tried various exercises for depression and anxiety in the past but never kept up with them. Brown considered the lack of follow-up a red flag that possibly indicated the presence of ADHD.

Brown had also asked the woman to journal (another technique that Brown likes to use with most of her clients). The client showed up at the next session proudly displaying her brand-new journal, complete with an intricate self-portrait but no writing or observations. She had also neglected to complete some homework that Brown had assigned.

When Brown delved into the client’s history, the woman reported that teachers used to tell her parents that they couldn’t get through to her and that she wasn’t listening. She also remembered not liking to do her school assignments. In fact, the client told Brown that sometimes her mother had done her homework for her to keep her out of trouble.

Brown finally talked to the client about the symptoms of ADHD and asked her to think about whether she recognized any of those symptoms in herself. Brown believes that educating adult clients about the possible presence of ADHD is very important. She has asked certain clients to watch TED talks and short videos on ADHD and has also recommended that clients read You Mean I’m Not Lazy, Stupid or Crazy?! a self-help book for adults with ADHD by Kate Kelly and Peggy Ramundo. She also gives certain clients ADHD symptom scales to fill out. “It’s all about education and getting [certain clients] to see if [they] think it applies,” Brown says.

When presenting any client with an ADHD diagnosis, Brown tries to ensure that the person leaves her office understanding that the disorder is neurological, not an implied behavioral or character defect. To help in this understanding, she typically draws a picture of a brain, explaining the importance of dopamine for executive function and how those with ADHD have a shortage of this important neurotransmitter. Brown tells clients that executive function is akin to an administrative assistant who keeps the CEO (the brain) organized. When someone has untreated ADHD, it’s like the administrative assistant is on vacation, making it more difficult for the CEO to function efficiently. Brown also tells her clients that medication can sometimes help with executive function. If they are interested in exploring prescription treatment, she gives them the name of a psychiatrist who specializes in ADHD.

Brown says that providing psychoeducation is particularly important because clients grappling with ADHD often internalize a significant amount of shame. She recalls a recent client who constantly beat herself up and had a distorted self-image because of her struggles with ADHD. “She called herself fat, lazy, unmotivated, and kept comparing herself to her ‘successful’ brother,” Brown says. “She hadn’t noticed what she was doing. I kept count in one session, and she called herself lazy 12 times.”

Brown focused on making the client more aware of her negative self-talk and how to use cognitive reframing to challenge it. She had the woman take note of when she was feeling guilty or blaming herself and then fill out a spreadsheet with three columns: the activating event, its consequence and the resulting behavior. For example, an activating event might be that the client failed to pay her power bill on time. The consequence was that she felt guilty. Brown explained to the client that not paying the power bill was not an event that automatically triggered guilt on its own; instead, there was a negative self-narrative of blame that caused the guilt. And that guilt (the consequence) caused the client to overeat, stay in bed and give up on the rest of the day (resultant behavior).

Brown encourages clients struggling with ADHD to think about how they can change that cycle. For instance, instead of engaging in self-blame, this client could say to herself, “I’m human. I forgot. Next time I will put a reminder on my phone, or maybe not keep the bill by the bedside but on the fridge, or maybe try electronic billing. I’m not a terrible person because I did this,” Brown says.

Reframing can pull clients out of the shame cycle and simultaneously encourage them to become more action oriented by coming up with possible solutions, Brown says. One of her clients is a manager who is accustomed to meeting daily deadlines, but outside of the structure that work provides, she struggles to function efficiently. Brown and the client have discussed how the client functions better when kept to a tight schedule, so they are working together to develop a schedule for all the tasks the client needs to complete in her daily life and assign regular deadlines to those tasks. Brown has also encouraged the client to maintain to-do lists and reward herself in some way for every task she crosses off.

Brown has also suggested ways that the client might strategize to avoid scheduling pitfalls. For example, the client acknowledges getting pulled in to television wherever she is, even if she is out somewhere. She turns it on first thing in the morning and often ends up sidetracked instead of getting things accomplished. Brown has encouraged
her to turn on the radio instead, especially when she knows that she has tasks to complete.

Another area Brown and the client are working on is organization. The client often misplaces things, including in the kitchen, so they have talked about organizing in a simple, systematic way — cereal goes with cereal, soup goes with soup, vegetables go with vegetables and so on.

As she does with any client showing signs of a mental health disorder, Brown has also asked this client to visit her doctor and have bloodwork done to rule out thyroid problems, a hormonal imbalance or other possible medical issues that might be causing or exacerbating the problems she is experiencing.

Like Martin, Brown doesn’t think of ADHD in purely negative terms. Those with ADHD have problems with attention in general, but when they are interested in something, they tend to focus tightly on it and even develop a passion for it that can propel them to greater mastery and success, say Brown and Martin. Both counselors believe that there is joy to be gained from these passions and from the unique way that those with ADHD see the world. Martin says that at times, this alternate worldview can even lead to creative problem-solving that might not be possible without the frame of ADHD.

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To contact the people interviewed for this article, email:

Stacey Chadwick Brown at stacey@staceybrowncounseling.com
Beth Ann Dague at bdague1@comcast.net
Deborah Ebener at debener@fsu.edu
Clay Martin at cmartin51277@gmail.com
Susan Smedema at ssmedema@wisc.edu

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Additional resources

For those who would like to learn more about the topics addressed in this article, the American Counseling Association offers the following resources:

Books and therapeutic games (counseling.org/bookstore)

ADHD Game (therapeutic card set to be used with Dinosaur Game Board, sold separately), Bradley Erford
Group Work and Outreach Plans for College Counselors, edited by Trey Fitch & Jennifer L. Marshall

Webinars (counseling.org/continuing-education/webinars)

“Adult ADHD: Help Your Clients to Thrive if They Have ADHD (or Think They Might), Tim Bilkey

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

“Attention Deficit Hyperactivity Disorder (ADHD): Treating Adults,” John S. Wadsworth & Laura Gallo

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

Letters to the editor: ct@counseling.org

Thriving, not just surviving: Un milagro de Dios

By Kelly M. Whaling July 18, 2016

“Catalina” (pseudonym used to protect the identity of the individual being interviewed) is not your typical medical student. Young, Dominicana and the first generation of her family born in the United States, she shoves her clothes into a washing machine in her apartment complex. Graciously, she answers questions about an epidemic in the Latina community: adolescent suicide.

According to the Centers for Disease Control and Prevention (CDC), in 2013, the United States saw one suicide every 13 minutes. A study conducted by Danice K. Eaton et al. in 2011 found that Latina adolescents attempt suicide at even higher rates than other gender and ethnic groups, with 14 percent of Latinas attempting suicide in a given year. This stands in stark contrast to attempts made by white adolescents (7.7 percent). A 2011 report by the CDC uncovered similar rates, with 20 percent of Latina adolescents reporting a plan to commit suicide and 11.1 percent attempting suicide.

Catalina tells me, “It’s just the nature of being an adolescent, wanting to fit in and being different in all of these ways. I’m not American enough, and I’m not Latina enough. It’s like trying to be one thing or the other, while being neither.”

This is not the first time that perceived differences, peer victimization and sociocultural factors have been linked to hardships in the Latina community. Furthermore, these hardships have been linked to increasingly common suicidal behavior in Latinas. In 2014, Andrea Romero, Lisa Edwards, Sheri Bauman and Marissa Ritter stated that levels of suicidality in the Latina adolescent community were epidemic. When reviewing the statistics, it’s truly a miracle of God (un milagro de Dios) that Catalina is alive — and not just alive, but thriving. Thriving with an education level that reaches far beyond her bachelor’s degree and with pride in her heart when she discusses the adversities that she faced growing up.

While navigating middle school and high school, Catalina contended with homelessness, poverty, the incarceration of a parent, the suicidality of a parent and her feelings of missing family members who had remained in the Dominican Republic. “I felt like my whole life, my way of coping with the bull—- was to put on this extremely tough exterior,” she tells me. “I don’t like to show weakness. It was adaptive because I had to be strong for my family.”

Painting a picture of what strength for her family looked like, and perhaps hinting at familismo as a protective factor against suicidality, Catalina laughs and says, “I feel like that was a lot of my issues growing up — this constant need to be tough and in control and be strong for my family. If people f—– with my sister, I would tell them I’d rip their face off. When I think back, I’m like, ‘Whoa, I was f—— insane.’”

All things considered, it doesn’t sound that “insane” to me. Given Catalina’s circumstances, it sounds adaptive. This was her coping mechanism to deal not only with family problems and problems faced by most adolescents, but also with struggles unique to being a Latina.

In a 2012 study paper, Allyson Nolle, Lauren Gulbas, Jill Kuhlberg and Luis Zayas suggested that a model of risk factors for suicidality in adolescent Latinas includes factors such as familismo, the adolescent’s own emotional vulnerability, acculturative stress, conflicts between the dominant culture and the culture of the family, immigration stress, socioeconomic status and gender roles.

Another possible factor that increases suicide rates in this population: Latina/os are less likely than other ethnic groups to seek mental health care. In 1999, William Vega, Bohdan Kolody, Sergio Aguilar-Gaxiola and Ralph Catalano found that less than 20 percent of U.S.-born Latinos searched for mental health services. That number decreased to 9 percent when specifically considering whether an individual sought care in a mental health care setting as opposed to general practice. Other barriers to receiving services for Latina/os include insurance issues, transportation and stigma.

Thriving, rather than just surviving, indicates that through adversity, individuals are able to better themselves, grow from their experiences and develop adaptively. Although there are unique cultural factors that contribute to Latina adolescent suicidality, there are also unique factors that contribute to Latina thriving, as evidenced in the success of Catalina.

Given that Latina teens are at risk for many mental health challenges, how do they cope? How can we maximize upon this coping? Catalina attributes her own personal thriving over suicidality to an optimistic outlook of her future, including the assumption that she could go to college; familismo, including the sense that she could not take her life because her family needed her; and an acceptance of her cultural identity.

Regarding her cultural identity, Catalina shared, “I don’t have to be either this or that. If I like being or having certain things that, yes, confirm stereotypes, then f— it. That’s just the way it is. I like to shake my ass, and I like salsa and hoop [earrings] and red lipstick. I can get a little hood, but I can also go to college.”

Currently, the National Center for Education Statistics estimates that 15 percent of all undergraduates in the United States are Latinas, a number that rises sharply when looking at regions with high concentrations of Latina/o populations. As suggested through Catalina’s narrative and current social science statistics, there are unique factors that create hardships and mental health issues for Latina adolescents at a disproportionate rate. It is of the utmost importance that counselors focus on culturally relevant, fair and sensitive practices when working with Latinas, especially given their historical rates of college enrollment and barriers to college retention. Thus, those who work with Latina adolescents in any capacity should use culturally relevant coping mechanisms not only to buffer the influence of the hardships that Latinas face, but to encourage thriving among this client population.

Many scholars, including Zayas in 2005, have issued calls for more research to be conducted on Latina suicidality. With levels of suicide in this population rising disproportionately, we must utilize the participants as experts. Future research must be conducted from a communitarian psychology or liberation psychology framework, in which the individuals participating in studies have an active role in the research process. This results in an emancipatory experience for participants and a broader sense of the true and lived experiences of adolescent Latinas facing issues of depression and suicidality.

In addition, it is suggested that participants be invited back to take part in outreach workshops in the community as promotoras (lay community members who receive training in conducting workshops on special topics). This approach engenders more community trust and engagement, and it also increases self-esteem for the promotoras who are survivors of suicide.

In conclusion, it is important to note that whereas a significant amount of research exists on the deficits that can cause Latina adolescents to attempt suicide, a balanced amount of research is needed on the strengths that promote thriving, not just surviving in this community.

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Kelly M. Whaling is a counseling psychology doctoral student in the Department of Counseling, Clinical and School Psychology at the University of California, Santa Barbara. Contact her at kwhaling@education.ucsb.edu.

Issues to consider when changing jobs and terminating client relationships

By Brian Carnahan and Bill Hegarty July 11, 2016

If you are reading this article, you are most likely a licensed mental health professional. So imagine these two scenarios.

The first: You’ve just been offered your dream job. You can start tomorrow, without giving notice at your current job, correct?

The second: What if you are not happy at work? What if you have simply had enough? If you aren’t happy, you can just quit, right? You can pack up your belongings and head out the door to greener pastures.

The answer in both scenarios: Not quite.

Licensed mental health professionals are subject to strict laws, rules, and standards of ethical practice and professional conduct regarding “termination.” Termination refers to ending the therapeutic relationship with a client.

The end of the therapeutic relationship can occur for many reasons. For instance, the therapy has achieved the expected outcomes or the client and therapist agree that the client should seek help elsewhere. Or, in many cases, the therapist is moving on to a different job or career and will no longer be able to serve the same clients.

Unfortunately, some therapists terminate inappropriately. They simply stop coming to work or walk out. This can leave clients in a difficult position. The abrupt termination of services can cause setbacks in client progress. An inappropriate termination can place pressure on remaining staff.

In Ohio where we work, improper termination appears to be more of a problem in agency settings than in private practice. It also occurs more frequently among newly licensed professionals. These licensees are often in their first professional jobs and may find it challenging to adapt to the demands of the work.

One of the main issues that the Ohio Counselor, Social Worker, and Marriage and Family Therapist Board sees regarding improper termination is the failure of licensees to complete all of the required client documentation, including case notes, mandated reports, informed consents and releases of information. When licensees leave an agency or practice without completing their required client documentation, they have compromised the client’s continuity of care. How will the next therapist know what has worked and what has not worked with a specific client?

For example, a client may have shared important experiences with a therapist that informed the direction of the therapy. The client may not trust the new therapist enough yet to repeat that information, and without documentation, the therapeutic relationship and client’s progress could be undermined.

In one case, a licensee promised a client that he would submit documentation prior to a court hearing regarding the client. When the licensee terminated his employment, he didn’t complete the documentation or alert anyone else of the need for the documentation to be forwarded to the court.

Holding a professional license means that you might have to place the needs of others before your own. Therefore, leaving a job or otherwise ending a therapeutic relationship requires planning.

Unfortunately, there are going to be times when licensees and their supervisors just don’t agree on things, and licensees may feel that they can’t stand their job any longer. The key is to think of your clients’ needs.

No matter the reason for termination, licensed mental health professionals must ensure that their clients have notice of the pending end of a therapeutic relationship and are provided with options for continuing treatment. These options might include a referral to another agency or mental health professional or transitioning to a professional in the same agency or practice. The requirement to terminate appropriately ensures that clients who may have significant issues are not harmed by an interruption of service.

Although this article is mainly directed toward individual professionals, those who manage others must also be mindful of their obligations regarding termination. Supervisors who demand that an employee leave immediately, either as the result of a dismissal or in response to a resignation, should recognize that they may be causing an ethical situation by not allowing the therapist to terminate with clients properly.

Additionally, those who manage agencies should consider how the work environment and its expectations may be impacting its employees. Are the expectations and demands such that it is difficult for therapists to work effectively and productively, possibly leading them to walk off the job?

As always, licensees should know the laws and rules of the jurisdiction in which they work. Ignorance of the laws and rules is not a defense if a licensee terminates improperly. Licensing boards publish these regulations online, and training from board staff and continuing education providers is also available.

If you think you need to quit a job, first consult your supervisor (both your work supervisor and training supervisor if you are under training supervision). Together, you may be able to address the issues that are prompting you to consider leaving your job. Even if the problems cannot be resolved, you will have guidance for following your licensing board’s laws and rules and those that your employer might impose.

Once you determine that leaving your job is the best option for you, follow basic employment norms, such as giving notice, maintaining civility and being available to help with any transition needs. Expect to work with your supervisor to create a transition plan. If it is not a proper “plan,” be prepared to update your supervisor on your current work and caseload.

If you are in private practice, you may be working directly with clients to make referrals. To ensure compliance with laws and rules, these referrals should be legitimate referrals to other competent professionals. Directing the client to call his or her insurance company is not sufficient. We suggest exploring additional literature and training regarding communicating with clients about termination in situations in which therapists think they can no longer help or that clients have reached their goals.

Be sure to leave complete case notes. The therapist following you will thank you, and you will be helping to ensure that clients receive the help they need as promptly as possible. Values of professionalism would also suggest that you finish any other required paperwork that will help to facilitate client care. This may include informing collaborating professionals of your transition so that they can adjust accordingly.

For example, if you regularly collaborate with a psychiatrist regarding a client, the psychiatrist should be informed that you will no longer be working with the client. This allows the psychiatrist to adjust his or her treatment of the client if necessary, perhaps changing the frequency of appointments until the client has adjusted to the new therapist. The same could be said of school personnel when working with children. Perhaps the school regularly reached out to you when things were getting out of hand. It would be important for the school to be informed of your departure so that it could make plans accordingly.

Leaving a workplace or ending a professional relationship is never easy. Licensed mental health professionals have unique obligations, based on laws and codes of ethics, to ensure that the needs of their clients are met when the therapist can no longer work with them — no matter the reason. By following the guidance outlined above, therapists can help ensure that they meet their professional obligations while also helping their clients.

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Brian Carnahan is the executive director of the state of Ohio’s Counselor, Social Worker, and Marriage and Family Therapist Board. Contact him at brian.carnahan@cswb.ohio.gov.

Bill Hegarty is deputy director and manager of investigations for Ohio’s Counselor, Social Worker, and Marriage and Family Therapist Board. Contact him at bill.hegarty@cswb.ohio.gov.

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Related reading: For more on the termination of the therapeutic relationship, see Counseling Today‘s recent article “The loss of a meaning relationship”

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.