Monthly Archives: August 2016

Behind the Book: Stepping In, Stepping Out: Creating Stepfamily Rhythm

By Bethany Bray August 30, 2016

It can take anywhere from four to seven years for a stepfamily to successfully blend, according to Joshua M. Gold in his book Stepping In, Stepping Out: Creating Stepfamily Rhythm.

The formation of a stepfamily is “uncharted water for everyone,” he says. Not only do parents and children each carry the dynamics and histories from their previous family arrangements but also face a myriad of societal stereotypes that often paint stepfamilies as dysfunctional.

“What must become clear to clinicians is that the old myths of the stepfamily drastically interfere with effective clinical understanding and therapeutic assistance to these family constellations,” writes Gold, an American Counseling Association member and professor in the counselor education program at the University of South Carolina. “Therefore, clinicians must educate themselves beyond comparisons with nuclear families to truly appreciate the unique strengths and challenges in working with a family system whose numbers are predicted to become the dominant family form in the United States in the 21st century.”

Gold is a stepparent himself and says that his “lived experience” contributes to his professional focus on stepfamily dynamics. He is also a member of the International Association of Marriage and Family Counselors, a division of the American Counseling Association, and is a contributing editorial board member of IAMFC’s journal, The Family Journal.

CT Online recently contacted Gold for a Q+A about his new book, which is published by the American Counseling Association.

In your opinion, what makes professional counselors a good fit to work with stepfamilies?

To my mind, there are several facets to being a good fit to support stepfamilies. I believe that a foundation in systems thinking is a critical part of family intervention. Each family member brings unique resources to counseling to help the family function more successfully, and the clinician must have the orientation and skills to facilitate their emergence. Implicit in that statement is a focus on a wellness model of stepfamily functioning, which entails understanding the stages of stepfamily evolution, a capacity to legitimize stepfamily struggle within a developmental, rather than pathological, context and a deep appreciation for the characteristics and dynamics of stepfamily life.

In addition, a strong clinician would be able to recognize external family members whose input is critical to stepfamily progress and be sufficiently adept to invite the stepfamily to encourage their participation in whatever mode may be feasible. I also think that sensitive clinicians understand the interaction of ethnicity and sexual orientation with stepfamily life and are prepared to embrace the stepfamily’s experience of self and of the larger society. Clinicians must be prepared in all cases to understand any personal biases or societal misperceptions about stepfamilies that may interfere with the efficacy of their interventions.

Your focus in this book is helping stepfamilies through the use of narrative therapy. Why did you choose that particular method? What makes narrative therapy a good fit for working with stepfamilies?

I believe that any marginalized group in society experiences definition through the social lens of dominant social structures. So, for example, in terms of family functioning, all other family constellations may be compared in membership, roles and perceived success to the nuclear family ideal. This comparison leads to perceptions of deficiency or inherent dysfunction based on oft-repeated, yet perhaps unfounded, social narratives. These perceptions focus attention not on how the family is succeeding but rather on ways in which it fails — if not soon, then sometime in the foreseeable future. This expectation of dysfunction, member unhappiness and marital dissolution may create a self-fulfilling prophecy within the stepfamily.

Narrative therapy seeks to identify and evaluate the validity of these social myths based on the lived experience of the client. By recognizing the negative lens through which the family has viewed itself, members have the opportunity to create more positive expectations of their stepfamily life and then to interact with each other reflective of those expectations.

It’s predicted that the stepfamily constellation will be the most common family form in the U.S. by 2020. Do you think the counseling profession, as a whole, is aware of or ready for this demographic shift?

I believe there is not an area of counseling which has not already felt this shift. For example, any school counselor could recount, just looking at a child’s folder, the new names and addresses added to the roster and the names of new individuals permitted to [interact] with the school on behalf of that child. Any family-focused clinician or mental health professional who conducts a social history of a child presenting in pain would identify the number of stepfamilies in one’s assigned caseload. I also believe that the profession’s commitment to client welfare and provision of ongoing professional development training, in multiple venues, ensure the availability of continual upgrading of clinical skill.

What becomes important, to my thinking, is whether a clinician faced with a stepfamily situation ponders the extent to which that family constellation can be activated to help the individual presenting [with] pain to overcome that life challenge. While stepfamily life may or may not contribute to the presenting issue, I am of the opinion that stepfamily members can contribute to its resolution.

In your experience, do stepfamilies often seek out counseling on their own, or are they more likely to come to counseling in a roundabout way, such as referral from a school counselor?

I believe that family counseling is constantly challenged to expand the focus on counseling from the identified client to the entire family. This therapeutic intent can probably best be accomplished by focusing on assignment of blame or responsibility for current stepfamily dysfunction to identifying potential resources within differing stepfamily relational schema.

This situation of “roundabout counseling” is no different in stepfamilies, except where counselors can provide resources to ongoing stepfamily support communities. Within those peer support systems, counselors can offer psychoeducational interventions on multiple levels: to stepfamilies as a whole, to the marital system, to the stepsibling system, to the involvement of ex-spouses, etc.

In the book, you stress the importance of combating stepfamily myths that members of a family may have. What would you want counselors to know about this? Why are myths a key part of understanding the stepfamily dynamic?

Societal myths influence stepfamily expectations and offer templates for role expectations of differing stepfamily members. However, these myths are imbued within social lore and espoused by social institutions as well as individuals. Therefore, stepfamily members are influenced subtly as to what to expect of others and of themselves within stepfamily roles.

From a clinical orientation, cognitive behavioral counseling, in general, speaks to the function of beliefs, thoughts and assumptions as precursors to action. From that perspective, interventions that seek to modify behaviors, such as conflict-resolution skills, step-parenting, marital communication training, etc., are overlooking attention to the attitudes which drive the actions. Narrative therapy encourages clients to identify, evaluate and perhaps reauthor dominant social beliefs in a way that results in more positive views of stepfamilies in general and each role within that family specifically.

More importantly, in a situation where the dominant myths seem to portray family constituents in negative lights, this process introduces the idea that the issue lies not within that individual but rather within the assumptions one holds about the role that person enacts in the stepfamily. By distancing the negative portrayal from a person to a social perception, the client can better author that perception based on real-life experience and interactions with that specific individual.

For example, stepchildren may view a new stepfather as aloof and uncaring, while the stepfather’s intent is to allow the children time and space to warm up to him. In this situation, it is easy to envision the emotional distance between them and the emergence of negative assumptions about each role. However, by transcending these social narratives about the role of “distant” stepfather and “unappreciative stepchildren,” the adult and children can begin to learn about each other’s gifts and capacities in more positive ways.

Do you think stepfamily dynamics receive enough focus in the education and training that people receive before becoming licensed marriage and family therapists? What do you want students and new counselors to be aware of related to working with stepfamilies?

I think that training programs are challenged to provide both generic and client-population-specific knowledge and skills. To my thinking, as clinicians encounter clients with whom they have not had previous experience, they hold a professional obligation to seek the knowledge and skills that have been found to be relevant for that specific client group. It is the purpose of post-graduation supervision to support each new clinician in expanding one’s generic knowledge and skill sets to ensure efficacious treatment of new and diverse client groups. The career-long expectation for professional development is founded in the understanding that any graduate program cannot prepare a clinician for every client situation. [It] must be augmented by individually determined specialized study to meet the clinical needs of one’s client populations.

In terms of preparation to work with stepfamilies, I would want students and new counselors to be aware of the wealth of current professional knowledge, as compared with self-help resources, and to honor that an admission of “not knowing” is not a sign of clinical unreadiness, but rather of receptivity to new learning.

What inspired you to write this book?

The roots of this work can be found in my clinical, personal and scholarly pursuits. I began providing counseling many years ago and was referred to a stepfamily support group to offer a psychoeducational workshop to normalize stepfamily challenges. Through working with stepfamilies as clients, I had recognized how dissimilar their family challenges were to those experienced by nuclear families, and had dedicated myself to learning what was known about stepfamilies in hopes of offering better clinical service.

Even then I intervened from a systemic perspective and saw the symptom bearer as the “voice” of family pain, requiring systemic change to allow the family to become unstuck. However, before I could intervene effectively, I needed to develop conjointly with the family an orientation toward healthy stepfamily functioning.

From personal perspective, I co-created a stepfamily over a decade ago, [composed] of two teen stepdaughters, their mother and a 6-year-old mutual child. That life experience has provided me with a reality-based template through which to evaluate my thinking and relationships as a husband, stepfather and father. That personalized learning has proven invaluable to continually reinforce the maxim that there is a gulf between theory and lived experience, and both are critical components of deeper and more profound understandings.

From a scholarly perspective, I trace my current book to my clinical experiences in my predoctoral days, my doctoral dissertation focusing on stepfamily marriages and then subsequent publications dealing with differing aspects of stepfamily life and growth. Driven by the identified failure rate of stepfamilies, plus the ongoing escalation in their numbers, I wanted to present to the profession what I hoped would be a useable and understandable treatise about how to help these families become more successful.

Finally, I hoped to contribute to the helping professions a guide for clinicians who work with stepfamilies, and for stepfamily members themselves who wish to analyze their unique family strengths and challenges.

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Stepping In, Stepping Out: Creating Stepfamily Rhythm is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222

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Stepfamily statistics

Approximately one-third of all weddings in the United States today create a stepfamily.
It’s predicted that stepfamilies will be the most common family form in the U.S. by the year 2020. An estimated 9,100 new American stepfamilies are created each week.
Thirty-three percent of all Americans are in a stepfamily relationship, including an estimated 10 million stepchildren under the age of 18.
The divorce rate for remarried and stepfamily couples varies but is at least 60 percent. At least two-thirds of stepfamily couples divorce, and divorce occurs more quickly in stepfamilies than first marriages.
About 46 percent of U.S. marriages today are a remarriage for one or both partners, and about 65 percent of remarriages involve children from the prior marriage, thus forming a stepfamily.
Four recent U.S. presidents were members of stepfamilies: Barack Obama, Bill Clinton, Ronald Reagan and Gerald Ford.

Source: Stepping In, Stepping Out: Creating Stepfamily Rhythm

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

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

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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.

Technology Tutor: Thinking about discussing clients online? Think twice

By Rob Reinhardt August 29, 2016

Our work as counselors can be isolating at times. It is important for our professional growth, our work with our clients and our own mental health to seek peer consultation.

The internet has significantly broadened the potential pool of peers with whom we can consult. Counselors are flocking to mailing lists, forums, LinkedIn and Facebook groups to connect and learn from one another. This is a good thing! It comes with some caveats, however, especially when the focus of a discussion is a client issue.

I hope most of us have had the positive experience of taking a client situation to a group of peers and receiving helpful feedback. These discussions might start with a brief case study: “I’m working with a young black male who is in management at his work. He has a history of anxiety that has been exacerbated recently because he feels he is being discriminated against and passed over for promotions despite his excellent performance reviews.”

This likely would be followed by questions from the counseling peer group to learn more about the situation and then a group exploration of how to proceed with the case. It’s nice to think that this discussion could take place with a large number of peers from all over the country — or even the world. Imagine gathering the synthesis of a wide array of different perspectives on this case.

The challenge on the internet is creating this scenario while maintaining client privacy and confidentiality. You’ve likely been informed at some point not to put anything on the internet that you don’t want the whole world to know. In truth, there are some areas and services on the internet that are far more secure than others (for example, electronic health records, banks, etc.). However, such high-level security doesn’t apply in places such as mailing lists and Facebook groups. In considering whether to post something about clients online, I encourage you to use the mnemonic PIT — the place where information falls in and can be discovered by anyone who happens to peer in. PIT stands for Permanence, Identity and Transferability.

Permanence

It’s important to assume that once something is sent across or stored on the internet, it’s there forever. Unless you’re operating on a private server that you have complete control over, presume there are redundant backups and other measures in place to ensure that data aren’t lost. Need a visual example? Head to the Wayback Machine and have a look at what the American Counseling Association website looked like in 1997 (bit.ly/ACAWayBack). And be aware that it is not only websites that are archived like this.

Some of us might think, “Well, if we share minimal data about this client, it won’t matter if it’s permanent.” Consider, however, that this permanence increases the chances that someone may recognize the client through your description because that information has the potential to be read for months and years to come.

Identity

In educational, employment or office settings, you are likely sitting face to face with people you know. Their identities have either previously been verified or can be verified quite easily in the moment.

Now consider online forums. Even those with the most stringent identity-verification procedures are problematic. Yes, there are professional peer groups that ask members to verify their identities and professional licenses, but few of these groups engage in authentication processes. In other words, there is no way to be perfectly sure that everyone in the online group:

Is who they say they are
Is a mental health professional
Subscribes to the same code of ethics and conduct
Agrees to hold all information posted in confidence
Will not make a mistake and share, forward, screenshot or otherwise cause the information posted to be viewed by someone outside of the intended audience (can you say “reading your Facebook news feed while sitting in a coffee shop?”)

That last bullet point is a big one. I don’t know of too many people who have never accidentally hit the “Share,” “Forward” or “Retweet” buttons. Even though some groups (particularly on Facebook) are set up to prevent sharing of posts outside of the group, it isn’t foolproof. And they can’t prevent things such as screen shots, which brings us to the next point.

Transferability

Almost all information posted on the internet can be forwarded or duplicated in some manner. Emails can be forwarded. Replies can be inadvertently sent to the wrong person. Facebook posts can be shared and reshared. And then there are screen shots.

Screen shots make it possible to share any type of content virtually anywhere. A screen shot of an email can be posted on Facebook. A screen shot of a Facebook post can be placed on a webpage. There’s no limit to how far and wide a piece of information can be shared.

Perhaps you’ve seen the posts on Facebook by teachers and parents who want to prove this concept to kids. They post a picture and ask everyone to like and share it so that kids can see how quickly information can travel to thousands — potentially millions — of people. Although this is a deliberate behavior, I encourage you to consider it when deciding whether to post something online.

Additional considerations

When discussing this topic with mental health professionals, their first consideration is often whether someone might recognize the client. They reason that if they leave out identifiers and keep the information general enough, the likelihood of someone positively identifying the client is small.

What I think many neglect to consider is the possibility that the clients themselves may view this information. It’s very difficult to speak generally about clients and not have them recognize themselves, particularly when they already know they are working with the counselor who shared this information.

Not convinced? As an exercise, think about how you would describe a client in a peer support context in a way that would leave that client unidentified. Now give thought to whether the client would recognize himself or herself if you shared those same details.

Psychologist and “Selling the Couch” podcaster Melvin Varghese echoed these sentiments when asked his thoughts on discussing clients online: “When thinking about asking a clinical question in a public forum like a FB [Facebook] community, I run my mind through two steps. First, I ask myself, ‘If my client saw what I just typed, would they feel like their privacy was being violated?’ Second, I ask myself, ‘If the roles were reversed, would I feel like my privacy was being violated?’ If the answer is yes to either question, I either need to make the question more general (i.e., remove anything that could remotely identify a client, from geographic location to age, gender, etc., and/or connect them to me) or leave it to an in-person consult with a colleague or supervisor.”

From a big picture perspective, I also encourage counselors to consider the public perception of mental health professionals. Even if someone can’t recognize a client on the basis of something you’ve written online, how will that person feel knowing that a mental health professional is discussing clients online? Will this change the likelihood of that person seeking help when he or she needs it? How will it change that person’s perception of counselors?

Tamara Suttle, chief inspiration officer at Private Practice From the Inside Out (tamarasuttle.com), hosts her own Facebook group and is a member of others. Although she has strict rules prohibiting the discussion of clients on her Facebook group and website, she knows that others do not. Here’s what Tamara, a member of the American Counseling Association, said about this topic: “I see [and] hear therapists talking about clients on social media almost weekly. It’s tragic really that they don’t realize how damaging this can be [not only] to their clients, but also to a therapist’s own professional reputation. I left one Facebook group for a while because of this very thing. The shocking part is that when therapists were confronted either on the group or privately, many rationalized and attempted to justify their behaviors by stating things like, ‘Therapists need a place to vent too!’ Even more shocking were the numbers of otherwise well-respected therapists who chose to remain silent on the issue.”

Ethics

To reinforce the importance of these points, we need to look at this topic from our ethical framework as counselors. The ACA Code of Ethics states that:

“Counselors protect the confidential information of prospective and current clients.” (Standard B.1.c.)
“Counselors discuss confidential information only in settings in which they can reasonably ensure client privacy.” (Standard B.3.c.)
“Counselors take precautions to ensure the confidentiality of all information transmitted through the use of any medium.” (Standard B.3.e.)
“When consulting with colleagues, counselors do not disclose confidential information that reasonably could lead to the identification of a client … unless they have obtained the prior consent of the person …” (Standard B.7.b.)

As previously noted, case consultation is an import aspect of the work we do as counselors. We typically address this through informed consent, letting clients know that case consultation happens and what the parameters are. It’s important to note the context of those consultations. Most clients are likely to understand and support face-to-face case consultations between licensed professionals within a secure office environment. But will they provide their consent if you inform them that these discussions may take place in Facebook groups? Can you ensure their privacy and confidentiality there?

To be clear, ACA representatives share these concerns, advocating for a strict interpretation of the ethics code. This includes a stance that online group forums do not constitute group supervision or consultation. ACA Chief Professional Officer David Kaplan states, “Professional counselors are ethically mandated to not discuss clients — with or without identifying information or circumstances — in public spaces, to include online spaces.”

Readers interested in exploring this further may want to pick up a copy of Using Technology to Enhance Clinical Supervision by Tony Rousmaniere and Edina Renfro-Michel. The book is published by ACA.

Legality

It is also important that counselors consider the legal implications of anything they share online. In addition to HIPAA (the Health Insurance Portability and Accountability Act), they need to be aware of any applicable privacy laws in their states.

Anne Marie “Nancy” Wheeler, an attorney licensed in Maryland and Washington, D.C., serves as ACA’s risk management consultant. “Discussing clients online can lead to potentially serious risk management and legal problems for counselors,” she warns. “Even when the information is supposedly deidentified, a client who recognizes himself in an online post could file a complaint against the counselor alleging a number of issues, including intentional infliction of emotional distress.”

Now look back at the client example I presented at the beginning of this article. It may have seemed appropriately vague at the time. But having read this article, I encourage you to give some thought to whether you would still post such information anywhere online.

Appropriate discussion

These cautions don’t mean that we have to ignore all the wonderful benefits that can result from connecting and discussing things with peers online. We simply have to give careful thought to our approach. Consider these guidelines.

1) Approach it from a “nonclient” perspective. Using our example, you might ask, “I’d like to hear experiences from those who have worked with people experiencing discrimination. What techniques and interventions have you found to be effective?”

2) When seeking someone to refer to, focus on the counselor’s skills, not the client’s issues. For example, you might say, “I’m looking for a counselor who helps clients with anxiety and also has experience working with clients experiencing discrimination.”

3) Before posting, give consideration to whether any of your clients might think you are talking about them in public and breaking confidentiality, or whether the general public might have a negative or positive view of what you are posting.

4) If you can’t be sure of protecting a client’s privacy and complying with laws and ethics, save the discussion for peer consultation in a secure environment.

As we increasingly lean on technology to carry out our work, it is important that we continue to analyze the risks and make informed decisions according to the priority of protecting our clients and their confidentiality.

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

Letters to the editor:ct@counseling.org

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

From the president: Celebrating and inviting all of us

By Catherine Rowland

Catherine Roland, ACA’s 65th president

Dear Counseling Colleagues,

One of the privileges of serving as American Counseling Association president is the opportunity to create initiatives based on our passions for outreach to the counseling profession and those we serve. I want to take this opportunity to introduce two of my presidential initiatives, or targeted task groups (TTGs).

The first TTG is titled LGBT Adult Life Span Development: Counseling. Each adult life stage of young, midlife and older adulthood will be considered through a developmental lens, or a continuum of counseling and mental health issues, as examined for the lesbian, gay, bisexual and transgender (LGBT) adult population. Through the lens of intersectionality, aspects of identity (to include culture, sexual orientation/identity, minority status, physical ability and gender) will be examined for risk factors in various counseling settings. The TTG will be isolating particular mental health concerns such as low self-esteem, depression, loss of hope, isolation and anger. Each concern may have a unique set of behaviors and perceptions of self attached to it, along with suggested strategies for assisting clients that take into account the person’s stage of life and the associated “tasks” or expectations pertinent to the LGBT adult population.

One example is the issue of self-esteem related to career choice and life satisfaction. We might work in a college counseling center and see a 20-year-old Latino male student who is gay. He may be experiencing isolation related to harassment or bullying that could influence his major, self-confidence and levels of anger or depression. Now shift this same man to midlife and the setting to a community counseling agency. He could present as unable to keep a job and confused about why he has not maintained a satisfying relationship with a man or why he feels suicidal. We have the same person, with similar basic counseling needs throughout the life span and particular counseling strategies that are necessary to help most effectively. But we also have the important addition of the client’s multiple identities and how those identities intersect throughout his life.

The expected culmination or outcome of this TTG will be the creation of a training guide on the intersectionality of counseling LGBT adults within a life span perspective in different counseling settings. This guide will be used in a training institute called Illuminate 2017.

The second TTG is titled Division/Region Partnerships: Focus on Leader Development Toward Diversity. In the spirit of targeted inclusion of various diversities, this group will devise a plan to enhance the “pipeline” to higher level professional leadership at the branch, region and division levels.

To increase communication and advocacy between divisions and regions, this group will explore sponsorships with ACA for sharing activities, growing membership and engaging in broader outreach to new and diverse counselors who may have an interest in leadership. This will be done through mentoring, inviting the participation of newer people who possess the potential and willingness to lead, and assisting these individuals as they begin assuming leadership responsibilities.

As an example, I’ll shine a light on what often happens naturally in any career position. A colleague with whom you work or a graduate student whom you teach or supervise may show special promise or atypical energy or simply ask to help. Does this scenario sound familiar? Right after the ACA Conference, a student or colleague asks how he or she can get involved at the leadership level. The difference we’re looking for is extending an invitation for that person to join you, shadow you or take on some small responsibility. That is one of the most effective ways to tap early leaders and to broaden the inclusivity and diversity of our ranks.

If you have held any type of leadership position in your job or graduate program, recall the exact time when you sensed that you were needed or were being tapped for something that you hadn’t previously assumed you would do. For me, that moment felt awesome, surprising and empowering. That initial bit of encouragement led to me being right here with you.

Many counseling professionals — leaders on multiple levels within ACA — are steering both of these TTGs. I thank all those who agreed to help and trusted me when I asked them to serve. They said yes. And, for a leader, that is the biggest gift: people’s time, energy and commitment.

Very best,

Catherine

croland@thechicagoschool.edu

CEO’s Message: Leaders listen, learn and communicate with compassion

By Richard Yep

Richard Yep, ACA CEO

Care. Compassion. Civility. These three words are among those I use to describe the work of professional counselors and, specifically, members of the American Counseling Association. For nearly three decades, I have witnessed with great humility the strides that many of you have made not just in developing the profession, but also in the amazing work you do with clients and students around the globe. Professional counselors have the training (and the internal fortitude, patience and commitment to help) that allows you to listen — truly listen — to the needs and concerns of those who want to make positive changes in their lives. You facilitate real growth and development in children, adolescents, adults, couples and families striving toward an imagined future that includes hope, acceptance, tolerance and love.

Each morning, I look at the newspaper. Each evening, I attempt to listen to the nightly news. I must admit that, lately, doing so has gotten tougher. Whereas my work allows me to witness the “positivity, hope and courage” (as ACA President Catherine B. Roland is fond of saying) of what the counseling profession does each and every day, the daily news reveals a much different side of society.

Don’t get me wrong. I am no Pollyanna when it comes to either the positive or negative aspects of life in the 21st century. There are various factions, there is terrorism, there is war, there is abject poverty and, let’s face it, there is evil in various forms. The challenge for me is reading about or viewing those who preach intolerance and exclusion yet simultaneously seek the support of all.

People who wish to lead must also be willing to listen, to learn and to acknowledge what they have learned from their life experience. Earlier this summer, ACA conducted its Eighth Annual Institute for Leadership Training. Nearly 140 national, region, division and state counseling leaders came to the Washington, D.C., area to network, gather information about the ethics of the counseling profession and learn about leadership and advocacy. It was an amazing four days, and I am indebted to all who attended.

I sum up the institute with the following words: share, learn, grow. This was an excellent example of the growth, development and implementation of leadership skill building. Even after the many years I have spent with ACA, I still learned new things. To me, listening, learning from others and being thoughtful about how best to move the community forward is a hallmark of the counseling profession and those who will lead us into the next half of the 21st century.

So, as I look at the newspaper and read about those who wish to lead but for some reason speak with churlishness and intolerance, I wonder what their perspective might be on the good work of professional counselors. I believe anyone in a public policy role should be asked for his or her thoughts on the work of the counseling profession. For those who lack understanding, let’s try to educate them about the good work of counselors. For those who already recognize the many contributions that professional counselors make to society, let’s encourage them to continue that support by sharing their thoughts with others.

Here in the United States, we will be facing some key decisions in November when the polls open and we determine who will lead us at the local, county, state and federal levels of government. Regardless of which individuals are elected to serve, let’s all work to ensure that the work of professional counselors — and the importance of their advocacy for millions of individuals each and every day — is understood and supported by those who wish to lead.

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

Be well.

Treating psychogenic nonepileptic seizures

By Jason Wright August 26, 2016

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

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

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

My first case

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

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

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

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

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

Diagnosis

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

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

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

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

Traumatic experiences and treatment options

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

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

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