Monthly Archives: June 2018

The lingering influence of attachment

By Laurie Meyers June 25, 2018

A few years ago, American Counseling Association member Lisa Bennett took a trip to Southeast Asia. While there, she thought it would be fun to visit an elephant sanctuary where sick and injured animals had been sent to heal. What she saw fascinated her. The elephants engaged in attachment behavior.

Among herds, young elephants are raised not just by their mothers but by an older female who has already had babies and “retired,” moving on to another tribe. These older females return to their original herd, however, to serve as nannies to the young elephants. Bennett noticed that the nanny elephants seemed to be teaching the mother elephants how to connect with their calves.

“Nannies will literally push the mother toward the calf when the calf is in need and will model to the mother the actions to take to secure the calf’s safety and security,” Bennett says. The calves still viewed the mothers as their primary attachment figures but also displayed an attachment to the nanny elephants.

Of course, as a professor and director of clinical mental health counseling at Gonzaga University in Washington state, Bennett knows that attachment theory has even bigger ramifications for counselors and the clients they serve. All humans are born with the need for engagement with and responsiveness from other humans, says Bennett, who studies and gives presentations on attachment theory. People need to be touched, to be stimulated, to feel safe and to believe that someone — usually their primary caregiver or caregivers — will provide things for them. In other words, people need to be “attached.” If children don’t feel as if they have reliable attachment figures — a source for stability and safety — they are more likely to experience anxiety and have difficulties trusting others and forming relationships, Bennett says.

Bennett recently took a group of students from various programs, including clinical mental health, marriage and family therapy, and school counseling, to a wildlife park containing elephants. She wanted them to observe attachment in action in the animal kingdom and apply what they saw to human behavior.

Interestingly, Bennett’s group also observed that elephants can transfer their attachments to humans. In the park, there was no way for retired females to return to their old herds. As a result, there were no elephant nanny figures. However, whenever the human trainer appeared, the calves responded to him as if he were a nanny. Bennett believes that because human attachment is analogous to that of other animals, the elephants’ consistent attachment to a nanny figure showed that secondary attachment figures play an essential role in well-being.

Attachment theory is derived from the combined work of John Bowlby, a British child psychologist and psychiatrist, and Mary Ainsworth, a Canadian psychologist. The theory posits that infants have an instinctual survival-based need to form an emotional bond with a primary caregiver. This attachment provides a sense of safety and security. If children receive consistent attention and support from a caregiver, they are more likely to develop a “secure” attachment style. Children who do not receive consistent attention and support develop insecure — avoidant or anxious — attachment styles. Attachment style affects a person’s sense of self and shapes his or her ability to regulate emotions and form relationships.

Bennett notes that neurological research shows that humans are wired to make attachments, but these connections need to be reinforced, optimally between birth and age 2. However, children can become attached at an older age if they receive the right care and connection, she says. In addition, if a primary caregiver does not cultivate attachment in a child, another caregiver can provide that crucial link by responding to the child’s emotional and physical needs with “connection and delight,” Bennett says.

As children develop, they form a working model of the world and themselves, Bennett says. Children who have secure attachments tend to believe that they are lovable and likable and that other people are safe and kind and will meet their needs, she explains. Children whose needs are not being met generally develop one of two beliefs about themselves and the world. Those who have formed an avoidant style of attachment often believe that they are OK but that the world and the people in it are bad. Children who have developed an anxious style of attachment usually think that other people are generally benign but that they themselves are bad or unlovable, Bennett explains.

ACA member Joel Lane previously worked with children, adolescents and young adults and now supervises counseling trainees who work with this same population. He says that attachment issues often play a significant role in clients’ presenting concerns, either as the primary difficulty or as a complicating factor. With children and adolescents, much of Lane’s work consisted of helping these clients and their parents or caregivers understand one another’s needs better.

Attachment styles — and the interpersonal behaviors they engender — can form a lifelong emotional template. People with secure attachments know they can depend on those to whom they are attached to be available for support and vice versa, says Christina Schnyders, an assistant professor of counseling and human development at Malone University in Ohio and a frequent researcher and presenter on attachment issues. In contrast, anxious attachment creates fear that an attachment figure will not be dependable, she explains. In response to this fear, people with the anxious attachment style can become co-dependent and may also become frustrated or angry because their relational needs are not being met. People with avoidant attachment create distance from others to prevent having to depend on anyone or having anyone depend on them.

Each of these attachment behaviors affects how people function in crucial life areas such as family, peer and romantic relationships, Schnyders says. Attachment style can even influence a person’s career choice and interactions in the workplace.

Leaving the nest

Lane, an assistant professor in the counselor educator department and coordinator of the clinical mental health counseling program at Portland State University, studies attachment, particularly as it relates to the population known as “emerging adults” (those in their late teens to late 20s). Emerging adulthood is a time of tremendous interpersonal transition that usually involves an individual leaving the parental household, forming new friendship groups and getting more attachment needs met by peers — and particularly by romantic partners — rather than by family members or caregivers, he says.

Transferring attachment needs from parents or caregivers to peers is a process that typically begins in a person’s teens, says Schnyders, an ACA member and part-time college counselor at Malone. Parental attachment doesn’t become any less vital at this time; it’s just that peers are placed higher on the attachment hierarchy, she explains. In fact, having a secure attachment to parents or caregivers is critical to adolescents’ ability to make connections with their peers, says Schnyders, a licensed professional clinical counselor formerly in private practice.

“Attachment beliefs inform our sense of self and others, particularly during times of distress,” Lane says. For example, in stressful situations, people with attachment insecurity may believe they are incapable of dealing with the problem, he says. Stress may push those with anxious attachment to rely solely on other people rather than deploying their own problem-solving skills, whereas people with avoidant attachment may believe they cannot count on others to provide emotional support, causing them to withdraw from the support system and creating greater isolation, Lane explains.

In contrast, emerging adults who have formed secure attachments to peers and parents are more resilient and better able to handle changes, both good and bad, Schnyders says.

“Put simply,” Lane says, “attachment plays a major role in understanding our emotional needs and getting those needs met. And in emerging adulthood, it can be especially important since our emotional needs evolve, as do the groups of people whom we hope or expect to meet those needs.”

The question becomes, how can counselors help “fix” an attachment style that may be having a negative impact on multiple aspects of a client’s life?

Lane doesn’t believe it’s a matter of changing clients’ attachment styles. Rather, he says, counselors can help clients better understand and anticipate their attachment needs, which can lead to increased attachment security over time.

“I believe that the counseling relationship provides clients with corrective attachment experiences,” he says. “When we feel heard, seen and understood, insecure attachment beliefs are challenged, and secure attachment beliefs are reinforced. Over time, this can have a powerful impact on how we view ourselves and how we view others. We can also help our clients learn to better understand their attachment needs and communicate those needs to others.”

Schnyders uses psychoeducation to teach clients the differences between secure and insecure attachment. She then uses cognitive behavior therapy to help clients understand how their insecure attachment has created core, irrational beliefs. Schnyders and the client then work together to reframe and restructure these beliefs. This allows clients to acknowledge and address the insecurities and fears that drive their behavior, better enabling them to modify their personal interactions.

Schnyders says that narrative therapy can also be useful, particularly with emerging adults. She guides clients as they create a narrative riddled with problems connected to their attachment style. Once that narrative is constructed, Schnyders and the client work to create an alternative storyline that focuses on elements of secure attachment and talk about how to work toward that story.

Attachment and romantic relationships

“Attachment drives the way we experience ourselves and our significant others,” Bennett says. “It provides a lens for how we see and interpret them.”

There is no consensus on whether attachment styles influence the selection of people’s romantic partners, says Bennett, who works with couples in her private practice. At the same time, she can’t help but noticing the number of anxious and avoidant pairings in her office.

“Put simply, one keeps pushing or nagging at the other to be present, and the other is a great escape artist,” Bennett says. “Both [are] driven by their styles and both [are] really chasing the other off, even though that is not what either one wants.” The doubts and fears that drive such behavior are barriers to real intimacy, she adds.

To help couples identify and break the patterns that are sowing discord, Bennett teaches them about attachment theory and how their individual styles can affect the relationship. She then helps couples develop secure attachment behavior by teaching them how to be more available, accessible and responsive to each other.

Bennett says she often finds that couples don’t know what a nonsexual warm connection looks like, so she teaches them how to greet, touch and talk in nonsexualized ways that express love and care. Vulnerability is also a big issue. Couples need to be willing to be vulnerable with their partners and, conversely, to react gently, she says.

Bennett also frequently works with couples on how to change their “demands” to “requests” and how to respond to each other’s requests with warmth. In addition, relationship partners often need to learn how to apologize to each other, how to talk about their fears and anxieties with each other, how to listen to each other and how to turn to each other for support, Bennett says. Finally, she advises couples to get in the habit of immediately repairing any relationship “ruptures” rather than allowing them to fester and build.

People with attachment issues often have difficulty expressing themselves, which can lead to frustration and misunderstanding. Partly for that reason, Schnyders does a good deal of assertiveness training with couples to improve their communication. Learning to be assertive allows clients to communicate their needs without discounting the feelings of their partners.

When teaching assertive communication, Schnyders instructs clients to use “I” statements such as I want this. I believe this. I need this. In the process, she strives to change the way clients see themselves.

Schnyders tells the story of a 60-something female client with a pattern of insecure attachment. Schnyders had been focusing on self-esteem with the client, encouraging her to believe that she was a person of value and worth. The client was also having problems communicating with her husband, who had a habit of speaking at her rather than to her and treating her dismissively.

One day, the client came in and told Schnyders about a breakthrough. A recent encounter with her husband had devolved, as it usually did, to him speaking disrespectfully to her. All of the sudden, the woman found herself exclaiming to her husband, “You can’t speak to me like that. I am a person with value and worth!”

Her declaration stopped the husband in his tracks and, soon thereafter, their relationship dynamic began to change. With the client standing up for herself and beginning to believe that she was worthy of respect, Schnyders asked her to consider what she needed from her husband. The woman said she wanted to be able to hear and understand his needs without diminishing her own. Schnyders and the client then talked about how she and her husband could work together rather than following their previous pattern, which involved the woman placating him rather than standing up for herself.

Sometimes, just slowing down an interaction can improve communication. In couples and family therapy, rather than letting clients have rapid back-and-forth exchanges, Schnyders will slow the conversation and have participants tell their partners or family members what they need from them. Schnyders will then ask the partners or family members to repeat what they have heard because sometimes conflict arises from an inability to listen to what someone else is saying.

Attaching to a career

Like all areas of life that involve interacting with others, work can sometimes be tricky for those with insecure attachments. As Schnyders explains, if a person doesn’t trust their co-workers and can’t communicate and interact with them effectively, that person’s performance is going to be hampered, perhaps even putting them at risk of losing their job.

But attachment style can also play a role in the job search itself, says Stephen Wright, a professor of applied psychology and counselor education at the University of Northern Colorado. Wright, an ACA member, studies how attachment style affects career choice and decision-making in college students.

When it comes to considering careers, people who are securely attached have an advantage because they are less likely to perceive career barriers, according to Wright. In other words, they have more confidence in their innate strengths and their ability to cope with challenges. Those with secure attachment also are more likely to have a stable support system of people who bolster their confidence and may even have contacts that will assist in the career search, Schnyders says.

In contrast, those with insecure attachment are more likely to perceive many reasons that they will not succeed in a particular career field or in the career search itself, Wright says. These individuals are also less likely to have a support system in place.

That’s one area where professional counselors can come in. Counselors not only serve as a secure base for clients but can also boost their feelings of self-efficacy in various areas, which can diminish the effects of insecure attachment, Wright says.

By providing a strong sense of support, counselors may help insecurely attached clients perceive fewer barriers. Setting and completing specific goals — even small ones, such as researching a new profession — can help strengthen these clients’ sense of accomplishment and confidence, Wright says. If clients have shown interest in a particular career area, helping them learn more about it and explore the various jobs available in the profession can increase their sense of self-efficacy in that area, he says. If clients lack the required skills for a specific job, counselors can assist them in developing a plan to acquire those skills rather than let them perceive their current situation as an insurmountable barrier, Wright says. He also suggests that counselors use career models to assist these clients with decision-making and identifying their job-related strengths and weaknesses.

Recovering from child sexual abuse

Research indicates that people with secure attachment style find it easier to recover from child sexual abuse, says Kristina Nelson, an assistant professor in the Department of Counseling and Educational Psychology at Texas A&M-Corpus Christi who studies and works with survivors of child sexual abuse. Having secure attachment provides these individuals with a safe base from which to explore and process their experiences, leaving them better able to regulate their emotions, she says. The feeling of security from healthy attachment serves as a form of support in and of itself, adds Nelson, who was previously a private practitioner in Florida.

Survivors with insecure attachment styles have typically received inconsistent or limited support throughout their lives, and this leaves them feeling unsure of whom to trust, Nelson says. In addition, they often don’t know how to regulate their emotions or how to begin the process of recovery.

Counselors can offer the support that those with insecure attachment styles have lacked throughout their lives, Nelson says. “Counselors can actually serve as a secure base for a client. [They can] be that consistent presence by providing that constant positive regard, allowing them to explore and make sense of their experiences.”

Counselors can also help these clients learn how to regulate their emotions. Nelson often recommends deep breathing techniques to her clients and adds that some people find meditation helpful. She cautions, however, that because meditation involves closing one’s eyes in a dark room, it may be a trigger for sexual abuse survivors, so counselors should proceed carefully.

Psychoeducation about attachment styles can also help clients gain awareness about why they react the way they do and how they developed their coping mechanisms, Nelson says.

Permanently attached?

So, is everyone stuck with their childhood attachment styles for life? Not necessarily, say Bennett and Lane. Although attachment style is usually pretty stable, there are cases in which it can change.

“The idea here is that we have core perspectives that tend to drive core styles,” Bennett says. “I’d venture that friendships and workplace relationships can have an impact, but our primary home styles are more likely to set the tone.”

“If impacted by social and work settings, we can repair by going home, by changing up friendships, by moving jobs,” she continues. “If stuck in an unhealthy work environment or social setting without recourse or the capacity to go home and mend, it makes sense that we’d alter to a less secure base, sadly.”

This is also true in relationships, Bennett says. For example, if a spouse repeatedly behaves in ways that erode the person’s trust in the spouse or in themselves, then that person’s attachment style can warp into a less secure one, she says.

Lane says there is some evidence that insecure attachments can become more secure throughout adulthood. He believes this may happen as people shift their attachment needs to people of their own choosing rather than the families they were born into or the caretakers they were placed with.

“I think that important interpersonal experiences influence and are influenced by one another,” he says. “When we regularly experience our needs being met as infants, we are more likely to be able to form healthy interpersonal relationships throughout life. However, adverse life and interpersonal experiences can still disrupt our attachment system, especially after multiple significant adverse experiences. The reverse also seems to be true — insecure attachments in childhood decrease the likelihood of healthy attachment relationships later in life. However, when those healthy relationships occur, they can influence our attachment orientations toward being more secure.”

 

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Related reading

To learn more about issues related to attachment, read the following articles previously published in Counseling Today and available on the CT Online website at ct.counseling.org:

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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

 

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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.

The social justice of adoption

By Laurel Shaler June 18, 2018

The adoption journey is not an easy one. After three years and nine months of active pursuit, my husband and I finalized our adoption on Nov. 29, 2017. Through this process, I learned a great deal that has helped me grow as a counselor educator and supervisor. For example, I learned the benefits of being a part of a support group after involvement in several different adoption support groups. Although I have always valued such groups, and facilitated many, the personal experience of being a participant deepened my appreciation of their benefits.

I was also greatly reminded of the beauty and benefit of empathy. When those who supported us during our adoption process were able to put themselves in our place to the point of weeping with us (rather than for us), it was deeply meaningful. We talk and teach empathy as counseling professionals, but when we experience the other side of it, it allows us to more richly understand this critical component of counseling.

But what I learned more than anything is the many aspects of social justice involved in adoption. Merriam-Webster defines this term as meaning “a state or doctrine of egalitarianism.” We wouldn’t accept Wikipedia as a scholarly resource on a research paper, but the way the website expands on the definition of social justice resonates with me: “a concept of fair and just relations between the individual and society.”

So, what does social justice have to do with adoption? Let’s take a brief look at the social justice for the birth parent(s), the adoptive parent(s) and the adopted child(ren).

1) Justice for the birth parent(s). There are at least two categories of birth or biological parents in the adoption process — those who choose to place a child for adoption and those who have their children removed from their care. In both instances, these children should be treated fairly.

For those who have children taken from their home, there is due process that government agencies must abide by. These parents have rights that should be respected.

Likewise, those who are choosing to place a child for adoption have rights. They should be fully informed about the adoption process and should be offered counseling to address the possible short- and long-term impacts. As a matter of social justice, they should be treated as equals — they are still parents who made a plan for their children out of love. This is also the motivation for the adoptive parent(s).

2) Justice for the adoptive parent(s). During the adoption process, adoptive parents should be treated with compassion and empathy. After the adoption is finalized, the adoptive parents should be treated like the parents they are. The word “adoptive” can and should be dropped. The adoption was an action that is now completed.

That certainly doesn’t mean that we should hide or be ashamed of the fact that the child was adopted. Rather, it is something to be celebrated. However, those who are raising children they have adopted should be treated as equal to parents who are raising biological children. Remember, social justice has to do with a fair relationship between individuals and society. This should also be explored for the children who have been adopted.

3) Justice for the adopted child(ren). Children who have been adopted are not adopted by their own choice. Rather, they are adopted because of someone else’s choices. Sometimes those decisions are good (such as the birth mother who recognizes that she is not capable of adequately raising a child, even with significant assistance, and makes an adoption plan). Sometimes those decisions are poor (such as the birth parent who abuses or neglects a child and is not able to meet the requirements to improve his or her parenting skills or meet the needs of the child.)

Regardless, the child who is adopted should be treated like every other child — just as precious and just as wanted. These children should also be provided the opportunity to receive as much information about their backgrounds as is age appropriate, depending on their ability to process and cope with the information.

Additionally, they should be offered counseling if the need should arise. We should not talk about children who have been adopted, but rather to them. Their right to privacy should be respected not only by the helping professionals in their lives, but by everyone who knows about their story. This is a fair relationship between these individuals and society.

 

According to the American Academy of Child and Adolescent Psychiatry, approximately 120,000 children are adopted each year in the United States. Therefore, counselors are sure to encounter individuals who have placed their children for adoption, who have been adopted or who have adopted children in the past. It is important for counselors to understand each of these three components — these human beings — as we work with them. We can learn a lot about social justice by looking at their experiences.

 

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A national certified counselor and licensed social worker, Laurel Shaler is an associate professor at Liberty University, where she serves as the director of the Master of Arts in professional counseling program. Additionally, she writes and speaks on the intersection of faith, culture and emotional well-being. She is the author of Reclaiming Sanity: Hope and Healing for Trauma, Stress and Overwhelming Life Events. Her next book, Relational Reset: Breaking the Habits that Hold You Back, will be released in 2019. Contact her at drlaurelshaler.com.

 

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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.

Stepping into recovery

By James Rose June 13, 2018

After many years of working as an accountant, I decided to enter counseling as a profession in my “retirement” years. After four years in graduate school, including two years of clinical work at an addictions recovery center, I began my new professional career this past January. Here is how it began.

 

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It was my third day as the evening counselor at Ashley Addiction Services. A clinical aide called me and said, “We have a patient here who wants to leave now. He’s calling his girlfriend to get a ride, and he is looking for someone to punch so he can get kicked out. Would you come down?”

The patient was a young man I had met during my training period the prior week. “You look stressed,” I said.

“Of course I’m stressed!” he screamed back.

I coaxed him out of the clinical aide’s office to a quiet place where we could talk. He told me he was on the withdrawal drug Suboxone. He wanted to go out and get high, then quickly get enrolled in another facility so he wouldn’t disappoint his mother.

“Your mother’s opinion is important to you,” I said.

“Of course,” he said.

“What about your dad?” I asked.

“He’s dead,” he told me.

I asked him to tell me more. He had been using for seven years. This was his fourth stay in a recovery facility.

“What happened seven years ago?” I asked.

“Nothing,” he said.

“When did your dad die?” I asked, following a hunch that there might be a link.

“Five years ago,” he said.

No link, I thought.

I had been working in addictions recovery for two and a half years at that point. I spent most of my life as an accountant, working in grants administration at various universities. At age 58, I had a near-fatal heart attack, and during my recovery, I knew that I had to change course in my life. Counseling had always fascinated me, and I had been in and out of therapy myself for about seven years. I made the decision six months after the heart attack to make a major course change in my life and study counseling. I enrolled in the pastoral counseling program at Loyola University Maryland, the same school where I had earned a Master of Business Administration 26 years earlier.

As part of my counselor training, I had worked as an addictions counselor at the Westminster Rescue Mission. I remembered a story about another patient I had worked with there who reminded me of my current patient. I shared that story with my current patient, explaining that my former patient’s parents divorced when he was 5. His dad lived only a few blocks away after the divorce, but he rarely saw his dad. Sometimes his father would tell him he would take him fishing on a Saturday morning, so this young boy would get up early, get dressed, assemble his gear and wait all day at the living room window for his dad to come. His father never came.

My former patient started shooting heroin when he was 18 and continued to do so for the next 24 years. After working with this patient for a year, he said to me, “Until we talked, I never understood the connection between what my father did and my addiction.”

Something in this story seemed to resonate with my current patient. So I asked him again, “What happened seven years ago?”

“That was the year my dad got sick,” he said. “He got diabetes and had to have his foot amputated. He was my rock.”

And then it hit him: the link between his dad’s sickness and death, and his own addictive behavior. He jumped out of his chair, threw his arms around me and shouted, “You just saved my life!”

I breathed a sigh of relief. It was a heady moment for me. We both knew an important bridge had been crossed. We talked a little while longer, then went for a quiet walk outside.

 

An epidemic of loneliness

People talk of the tragedy of the opioid epidemic. And the tragedy is painfully real. One of my patients lost two friends during his first weekend in recovery, and he believed that if he had not come in for help, he too would be dead. Another patient found his best friend dead from the dope he had shared with him. A third patient stood before the entire patient community and told us that he had lost 42 friends to overdoses in one year, and he knew that if he did not come in for help, he might well be next.

And yet from my perspective of working with people in addiction, the opioid epidemic masks a deeper epidemic. The epidemic I see every day is an epidemic of loneliness.

It is so ironic. We have never been more connected. We have cell phones, email and FaceTime. We can meet anyone, anytime, anywhere. The world I live in today reminds me of the futuristic world I saw pictured in science fiction comic books when I was a kid. And yet, rather than being more connected, we seem more distant from each other than ever before.

I believe that we all need a deep sense of connection with other people in our lives. Emotional connection is an essential part of being human.

People in recovery are in a state of inner conflict. They simultaneously want to recover and stop abusing drugs and alcohol, while at the same time they have cravings to continue to use. When they stop using, once they get through the painful physical symptoms of detoxifying, the painful emotions that led them to use in the first place tend to rise to the surface. Often, there is a painful event or painful circumstance in their lives that caused them to use in the first place.

Substance abuse is often a coping strategy, a way of easing pain, and very often it is some painful event that triggered their addiction. Substance abuse serves a function in their lives; it reduces their pain enough to enable them to cope and carry on with their lives. In that way, it is similar to taking a pill to get rid of a headache. Of course, the circumstances are far more drastic.

I asked one user why he used heroin, and he said it was better than committing suicide. It was hard for me to argue with his logic. From his perspective, heroin use had the positive aspect of keeping him alive, of keeping him from killing himself by his own hand. That is part of the reason that it is so hard for people to give up their addiction. It serves the positive function in their lives of keeping them alive, allowing them to continue to function, in spite of their pain. It numbs out their pain, however temporarily.

Unfortunately, in numbing out their pain, it numbs out all of their other emotions as well. This is why it is nearly impossible to have a meaningful relationship with someone who is addicted to a substance. Meaningful relationships require an emotional connection. How can one have a meaningful connection with someone whose emotions are chronically numbed out?

 

Breaking the cycle

The damage of addiction spreads out like the ripples in a pond, far beyond the individual who is addicted, to affect all the other people in that individual’s life — friends, family members, co-workers. Children of parents who are addicted grow up with parents who are emotionally unavailable. These children’s lives are shaped by the experience of emotional unavailability, and so the cycle continues.

Breaking that cycle of emotional absence is at the heart of the work I do. When patients stop using, the emotional pain that led them to use in the first place reemerges, and they often are as unequipped to deal with that pain in the present as they were in the past. As their counselor, I help patients to identify past trauma and try to find a new perspective through which to see it.

One way of looking at emotions is to think of them as predictions of what is about to come. If you enter a house filled with the aroma of freshly baked chocolate cookies, you might find your mouth starting to salivate and your stomach starting to rumble — physical signs that your body is preparing for you to eat something yummy. A sudden scream in the night might make your body straighten, your muscles tense, your eyes widen and your ears perk up — all signs that your body has gone into a high state of alert for possible danger, usually accompanied by a sharp rush of adrenalin to be ready for fight or flight. Again, these are the physical signs of anticipation of and preparation for predicted danger.

Emotional pain evokes different bodily reactions. We may feel a loss of appetite, a heaviness of heart and a wish to isolate. The triggers for emotional pain may be less obvious to a person than is the smell of cookies or a scream in the night, but they are certainly quite real to the person experiencing them. And the pain can be overwhelming.

This is where substance abuse comes into play. Often, emotional pain comes about when a person has lost someone with whom they had an important emotional connection in their life, and that emotional connection has been broken. If a parent has died or moved away, a loved one has betrayed you or a traumatic event such as a rape or murder has occurred, there is no way to undo the event. The pain of such events can be overwhelming.

Drink or drugs can provide a means of easing the pain enough that the suffering person can get on with their lives, but they cannot undo the event. Many people find solace over time and find ways to cope with the pain without resorting to drink or drugs; however, many do not. Because drugs numb the pain without addressing the loss, a person remains stuck within the loss, and so the need for the drug endures.

The damaging paradox of a person who uses drugs to deal with the loss of emotional connection is that drugs eliminate the possibility of creating new emotional connections, which are the very thing the person needs to heal. Drugs numb out all emotions — both the painful and the joyful ones — and without the ability to feel the full range of emotions, any new, real emotional connections are impossible to create.

 

Searching for ‘meaning’

Being with a person in the initial stages of recovery from substance abuse is an awesome experience. As a counselor, I face them in that moment of transition in their life. I know I cannot fix or heal anybody. The thing I can do is to be present with them, offering what guidance and presence I can as I try to help them find healing within themselves.

Often, that is a matter of helping them name and identify those hard emotions that arise within them — the ones that led to substance use in the first place. Once the emotions are identified, then we look for the event or the circumstance in their life that brought that emotion into play. This is the moment when the hard stories come out, the stories of heartache and loss. And then it is a matter of looking at the meaning those stories have had in their lives.

It is the meaning we place on our stories that give them their emotional charge. A child whose parents divorced and whose father moved away might, as a child, believe in some unnamed way that they are worthless. After all, dad delivered the message, in the most obvious way possible, that they were not worth sticking around for. I have known many people struggling with addiction who had just that circumstance in their lives, and that sense of worthlessness was at the root of their addiction.

In this work, we can look at stories like that and change the meaning. The meaning might be that dad was a troubled man. It might be that dad and mom had a bad marriage and their breakup was necessary. It might be that dad had to go away on a job or for military service. By reframing the story, we can change the meaning, and when we change the meaning, the emotions that accompanied that story can change.

This was the case for the young man whose story I shared at the beginning of this article. For him, the meaning of his dad’s sickness and death was that he was losing his rock, and there would be no one there to give him guidance. His story changed to dad was sick and died through no fault of his own, nor by his father’s choice, and now he would have to find his own guidance. In changing the meaning of his story, his emotions changed, and his need to numb out his painful emotions with drugs gradually evaporated.

 

Being present

So, at the heart of my work is the aim of being present with another person so that they can learn to be emotionally present themselves. One of my favorite outcomes was when a patient told me about his 17-year-old daughter. She was the rock of their family, a straight-A student who was always reliable and dependable, emotionally calm and stable.

She came to visit her father a few weeks after he had entered recovery. He told me he could not believe what had happened. His strong, calm and rational daughter had broken down in tears in front of him. I said, “She was emotionally present with you.” After a moment, I asked, “Do you understand why?”

He looked baffled and said, “No.”

I said, “For the first time since she was a little girl, she could sense that you were emotionally present for her, no longer drunk or high, but really right there with her. She felt it, and so she, for the first time in years, was able to be emotionally present with you. That is why she cried.”

My final meeting with the young man whose father had died of diabetes was the night before he completed the program. He told me that he was planning to move back home where he could help his mother. He expected he would be able to go back to work at his job in a restaurant, and he planned to attend school in the fall. I asked what he would study, and he said he was interested in psychology. He said he was thinking of becoming a counselor, which would further motivate him to stay on his path of recovery.

I saw him again the night he finished the program. I was thinking of the years I had spent in grad school — the books I had read, the papers I had written, the checks I wrote and all the time I had invested. And in a moment, it was all worthwhile when he threw his arms around me and said, “Thank you.”

 

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James Rose, a national certified counselor and graduate professional counselor, is a recent graduate of Loyola University Maryland and works in addictions treatment at Ashley Addiction Services. Contact him at jrrose@loyola.edu.

 

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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.

Counseling Connoisseur: Thanatechnology – Grief and loss in a digital world

By Cheryl Fisher June 8, 2018

Thanatechnology: Any kind of technology that can be used to deal with death, dying, grief, loss and illness.

 

Kelly (an alias), an eighth-grader, sits with her friends in the school auditorium as her principal calls out the names of each of her classmates who were killed in the recent shooting. To honor the lives of these young people, the school is hosting a remembrance ceremony. As tears run down her face, Kelly huddles close to her schoolmates and clicks away on her phone posting messages on several social network sites and a memorial site that she and her friends created. A text message pops up from a boy she met on one of the sites. He is a survivor of a school shooting that happened a couple of years ago — he understands.

Tony’s (alias) phone vibrates, rousing him from his slumber. He looks at the clock – it’s 2 a.m. He has to be up for school in just a few hours. He squints, trying to read the alert on his phone. Another teenager has died from drug overdose. He heaves a mournful sigh and turns on the bedside lamp. His phone begins to blow up with social media posts. The deceased didn’t attend his school but is related to his girlfriend’s best friend. Tony attempts to return to sleep, but he keeps thinking about the teenager [and] wondering why it happened.

Without a doubt, the youth of today are often exposed to significant and traumatic losses. Traditionally, we have marked death with rituals such as funerals and memorials and grieved with the support of counseling, faith communities and neighbors. In more recent years, technology has provided additional ways to remember and mourn, such as creating online memorials, seeking distant or virtual grief counseling and connecting with family, friends and even strangers without geographical limitations. It erases time and distance and allows for virtual experiences and expressions that promote a narrative that lives forever.

Digital Presence and Youth

In Dying, Death, and Grief in an Online Universe, researchers Kathleen R. Gilbert and Michael Massimi observe that digital technology can “bring people together for social support, provide information, and offer a venue for conducting grief work such as telling stories or building digital memorials.”

In another section of the book, researcher Carla Sofka writes that young people are even more likely to seek grief support online. Sofka explains that the internet, social media and other digital platforms are where younger generations are most comfortable because they provide opportunities for social interaction; a sense of independence and privacy; the ability to express and form their own identity; a sense of community that includes those that are marginalized; and instant alerts and communication. All of these elements allow youth to seek and find like-minded communities that can provide immediate support and strategies for coping with myriad life issues — including death and dying, and grief and loss.

 

Social Interaction

Online bereavement forums and chat rooms provide a sense of social connection with users. Sites such as Caring Bridge allow multiple users to maintain a virtual journal offering information and capturing narratives that are accessible to members. Tumblr, Facebook and Instagram create spaces where youth can just “hang out.” Video calling technology such as FaceTime and Skype bridge the distance between users and promote interaction and communication. Additionally, grief counseling may be offered via video, phone, chat or email formats.

Independence and Sense of Privacy

Teens turn to technology to carve out a private space for self-expression. However, research indicates that internet use often provides the illusion of anonymity, which may encourage a false sense of privacy. The struggle for privacy is nothing new: The tension between privacy and personal expression has existed between teens and parents for decades. In It’s Complicated: The Social Lives of Networked Teens, danah boyd*, principal researcher at Microsoft Research notes that social media introduced a new dimension to this age-old power struggle. Instead of worrying about what teens wear outside, parents are concerned about what pictures teens are posting about what they wear outside.

[*boyd prefers to spell her name with lowercase letters.]

“Although teens grapple with managing their identity and navigating youth-centric communities while simultaneously maintaining spaces for intimacy, they do so under the spotlight of a media ecosystem designed to publicize every teen fad, moral panic, and new hyped technology,” writes boyd.

Yet, online spaces allow for exploration of feelings and thoughts, examination of death anxiety, and expression of grief and loss. For example, a 14 year- old client crafted an entire mix of music and prose around the complicated emotions she experienced related to the death of her estranged father who had abused her as a little girl. Using an alias, she posted the eulogy online and watched as strangers connected with her, validating her feelings and experience.

Expression and Influence of Identity Formation

The internet provides creative space for expressing grief and honoring loved ones. Sites such as KIDSAID.com, offer children the opportunity to connect, interact and creatively express their grief. In addition to expressive sites and online memorial services such as Legacy, Remembered.com and Your Tribute provide an unfettered opportunity to honor loss, especially for those who are marginalized or disenfranchised. The use of letters, photos and sound provide rich and detailed memorials that allow users to express their grief, absorb their loss and ultimately move forward.

Sense of Community

Blogs provide a venue to capture experiences and to cultivate topic-based virtual communities. Boyd suggests that these constructed networks serve as a public place to interact with real and imagined communities, thus satisfying a desire to be part of a broader world.

Instant Alerts

Online communication is often in real time. Twitter, Snapchat and a variety of other digital sites offer instant notifications and ongoing engagement. Technology allows users to gather multiple streams of almost instantaneous information from afar. For example, recently I was at a social gathering where a young woman, glued to her phone, was continuously texting. At one point I interjected, “Is everything alright?” She looked up and shook her head. “No, I have a friend who was just in a car accident and the medics are transporting her to shock trauma. Her parents are on their way to the hospital — but no one thinks she’s going to make it.”

The accident occurred in another state, yet this young woman was experiencing the event minute by minute via her phone messaging.

There are numerous attractive features to thanatechnology. Information is persistent and endures. There is a sense of immortality and legacy when a person’s comments, photos and work is posted in cyberspace. It is visible to infinite numbers of individuals. It is spreadable, and with one repost or share, hundreds more are invited into our experience. It is searchable. Just yesterday someone emailed me after reading my article on pet loss and grief. She had been Googling information about pet loss and my article popped up. I was able to provide her with additional support resources.

While there are many helpful aspects of using technology for grief support, there are some serious causes for pause. Are the online interactions healthy? Who is actually participating in the network communities? Are youth oversharing personal information while in a vulnerable state? How pervasive are social divisions and are they perpetuated in the participating forums?

Clinicians, parents and educators must be digitally literate and provide opportunities for genuine face to face connection while acknowledging the cyberworld of teens. Using technology during this very vulnerable time can provide tremendous support and healing, but it may pose risks. Counselors have the responsibility to help youth develop the skills to navigate technology in a way that creates a safe environment for their grief experience and promotes bereavement support.

 

 

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling.  Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy: and geek therapy. She may be contacted at cyfisherphd@gmail.com.

 

 

 

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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: Why counselors need to understand health information exchange

By Rob Reinhardt June 6, 2018

Because most counselors have flown under the “meaningful use” radar so far, they may not be familiar with the term health information exchange (HIE). Moving forward, however, it will be important for counselors to educate themselves because the model for provision of care in the United States continues to move toward that of interoperability and integrated care. In this article, I discuss the basics of HIE and the reasons that counselors need to understand it.

Interoperability

The picture of how HIE came about is complex. It developed over many years and includes previously existing Medicare and Medicaid programs, programs created by the Affordable Care Act, as well as the Health Information Technology for Economic and Clinical Health (HITECH) Act. The overarching goal that resulted in the genesis of HIE was that of interoperability as a critical component of improving the quality, efficiency and safety of health care delivery while reducing its overall costs.

As described on the HealthIT.gov website, interoperability is generally accepted to mean the ability of two or more systems or components to 1) exchange information and 2) use the information that has been exchanged.

The promise of interoperability is that health care providers can readily share and use each other’s information in the provision of services. This means that if you visit your primary care physician (PCP), who then sends you to a specialist, that specialist should be able to receive your records from your PCP before you arrive. In other words, there is no need for you to cart your records around and report the entire story over again. There is no need to repeat tests that have already been completed. This also means that in emergency situations, a hospital should be able to quickly access your medical history and know exactly what medications you are currently taking.

From a big-picture standpoint, interoperability also means that data can be aggregated more quickly and effectively to track things such as outbreaks of the flu or other illnesses. These are just a few examples of the benefits of interoperability, but they illustrate why it is considered critical to the mission of the Affordable Care and HITECH acts.

The Meaningful Use program and HIEs

How critical is interoperability? In 2010, the State Health Information Exchange Cooperative Agreement Program was created, which led to $548 million being awarded to states for the purposes of establishing and improving state-managed HIEs. In April 2015, Congress declared it “a national objective to achieve widespread exchange of health information through interoperable certified EHR [electronic health record] technology nationwide by December 31, 2018.”

The Meaningful Use program was created to provide incentives for EHR adoption by eligible professionals. The program also includes reimbursement penalties for those who do not participate. (For more, see tameyourpractice.com/blog/meaningful-use-and-mental-health-professionals.) Although the Meaningful Use program tasked providers with adopting EHRs that could exchange information, that process has been slow, and it is not always efficient or effective. In addition, counselors have not been included in the incentives or penalties for meaningful use (the same holds true for all mental health providers apart from those who prescribe medications).

HIEs are meant to speed up the achievement of interoperability while also filling in gaps and providing a central repository of records. Providers who haven’t fully achieved the ability to exchange information with other providers can at least provide it to the HIE. For example, rather than a hospital having to query multiple providers for records, it can query just one system, the HIE, to get vital information about a patient. The time savings in emergency situations can also save lives.

Implications for counselors

So, if counselors haven’t been a part of meaningful use, why do we need to pay attention to it? The fact is that despite of our exclusion from the Meaningful Use program, the national engine pushing for all health care providers to achieve interoperability has still been running. States have been incentivized to help move that engine along too, and their ability to continue to fund their programs is attached to milestones.

To that end, states are increasingly enacting measures requiring participation in HIEs or other programs in an effort to achieve widespread interoperability. For example, here in North Carolina where I am located, participation in HIE has been mandated for any health care provider receiving state funds. This includes not only those who accept Medicaid, but also those who work with employees of the state (through a plan currently managed by Blue Cross Blue Shield of North Carolina). As of this writing there are over 700,000 people in North Carolina dependent on the State Employees’ Health plan and almost 2 million Medicaid recipients. Counselors will be able to continue serving those clients only if they meet the HIE mandate deadlines (currently June 1, 2018, for Medicaid and June 1, 2019, for state employees).

Other states have or are pursuing similar measures. The following website links to each state’s respective HIE website so that counselors can stay up to date on developments: healthit.gov/topic/onc-hitech-programs/state-health-information-exchange.

Before proclaiming, “I don’t accept insurance” and turning the page, read on. In some states (such as Minnesota), mandates have been applied to all providers, regardless of how payments are received. (Minnesota’s mandate has since been amended to provide some exceptions and currently carries no penalties.)

Perhaps more important, as other providers experience the benefits of efficient and timely exchange of health information, they are looking to partner with other providers who already possess this capability. In the future, providers who cannot exchange health care information through their EHRs or HIE may find themselves receiving fewer referrals from other health care providers. This same effect may also be experienced with clients as they begin to understand and appreciate the value of having all of their health care data conveniently accessible in one location, most likely through their PCP.

The momentum for EHRs and interoperability is also being bolstered by other initiatives, including reimbursement based on outcomes. As part of the Affordable Care Act — and currently primarily associated with the Medicare Access and CHIP Reauthorization Act of 2015 (see tinyurl.com/MACRA2015) — is a move toward merit-based payments for providers, as opposed to the current service-based payments.

In a merit-based payment program, providers are paid more when achieving efficient, effective outcomes instead of being paid for providing individual services. In other words, providers are incentivized to work harder to help clients achieve positive outcomes rather than “rack up charges” by providing multiple services. Participation in these programs currently requires a data management system that can not only track but also report outcomes electronically. It is likely that similar programs will find their way into the commercial insurance market and beyond in the future.

Exploration of this topic would require an article of its own. I bring it up here to note that the forces behind this movement — and their reasons for pushing for all health care providers to use electronic records and achieve interoperability — are myriad and regularly making progress.

These topics take on additional weight when combined with other initiatives. For example, we can strengthen our argument that counselors should be able to join the ranks of mental health professionals who provide services for Medicare recipients if we demonstrate an understanding of current reporting and reimbursement policies.

As the world becomes further steeped in technology, it is important that counselors keep up. This will allow us not only to keep pace as providers and businesspeople but also to better serve our clients.

Resources

  • I recently did a webinar with the American Counseling Association titled “Private Practice: Choosing a Best-Fit EHR” (see aca.digitellinc.com/aca/sessions/10741/view). It was telecast May 16 and is now available on demand. In the webinar, I explain how counselors can select electronic practice management resources to meet the unique needs of their practice and explore how to avoid costly mistakes.
  • Are you considering an EHR to meet your technology/HIE needs? Be sure to check out the freely available reviews on my website at tameyourpractice.com/EHRReviews.

 

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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.

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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.