Monthly Archives: July 2018

When panic attacks

By Bethany Bray July 30, 2018

3 Comments

Kellie Collins, a licensed professional counselor (LPC) who runs a group private practice in Lake Oswego, Oregon, experienced her first panic attack when she was 14. She remembers suddenly feeling cold, losing sensation in her hands and her heart beating so rapidly that it felt like it was going to leap out of her chest — all for no readily apparent reason.

“I thought I was dying. That’s what it felt like,” Collins says. “It was the worst experience of my life up to that point. It felt like it lasted forever, even though it was just a few minutes. Afterward, I was left with a feeling that I had no control.”

When Collins subsequently experienced more panic attacks, the situation was exacerbated by a close family member who didn’t understand what was happening. The family member suggested that Collins might be having the panic attacks on purpose, to get attention.

Collins’ life changed for the better in high school, when she began seeing a counselor. She learned not only that her panic attacks were manageable but also that she wasn’t to blame for their occurrence.

“Hearing that I didn’t cause this and that it wasn’t my fault set me on the path to get better. It made all the difference,” says Collins, a member of the American Counseling Association. “The biggest thing [counselors can do] is to validate the client’s experience. What they experience is real and not under their control in that moment — and it’s terrifying.”

‘Fear of the fear’

In addition to overwhelming feelings of fear, panic attacks are usually marked by shortness of breath or trouble breathing and a rapid heartbeat. Other physical symptoms can include sweating (without physical exertion), a tingling sensation throughout the body, feeling like your throat is closing up or feeling that you’re about to pass out, explains Zachary Taylor, an LPC and behavioral health director at a health center in Lexington, Virginia. Symptoms vary, however. “I’ve never had two patients describe it the same way,” he says. (Taylor refers to patients instead of clients because he works at a medical health center.)

According to the National Institute of Mental Health (NIMH), an estimated 4.7 percent of adults in the United States experience panic disorder at some point in their lives. The past-year prevalence was higher among females (3.8 percent) than among males (1.6 percent).

Panic disorder is marked by recurring, unexpected panic attacks (or, as NIMH describes, “episodes of intense fear” that are “not in conjunction with a known fear or stressor”). People who experience panic disorder typically worry about having subsequent attacks, even to the point of changing behavior to avoid situations that might cause an episode.

“It’s such a jarring and uncomfortable experience, and it feels so much like a real medical emergency, that they begin to fear the sensations themselves. This fear of the fear is what drives panic disorder,” explains Taylor, a member of ACA. “If it gets too bad, they begin to arrange their life around trying not to experience anything that might resemble or trigger any of those feelings that are associated with a panic attack, and it becomes a vicious cycle.”

At the same time, panic attacks can occur in people who do not have a panic disorder diagnosis. Although panic attacks are often coupled with stress, trauma or anxiety-related issues, they can also occur in clients without complicating factors, says Collins, who notes that she has seen clients who experienced their first panic attack in their 50s or 60s.

“They can happen even when life is going well and have no apparent reason. … Some people have them for a period of time in life and then never have them again, while others will have them throughout life,” she says. In addition, significant life changes, such as getting married, starting retirement or having a child, can trigger recurrences in clients who previously were able to manage their panic attacks, Collins adds.

Among clients with mental illness, panic attacks can co-occur with depression, anxiety, bipolar disorder, posttraumatic stress disorder, obsessive-compulsive disorder, specific phobias (particularly emetophobia, or fear of vomiting) and other diagnoses. Taylor says they can also be associated with a medical or physical issue.

“One of the most overlooked problems that can lead to developing panic is chronic sleep deprivation or insomnia,” he says, explaining that a lack of sleep can overexaggerate the fearful thoughts related to panic. When treating panic attacks, counselors should ask clients about their sleep habits within the first few sessions, Taylor advises. Counselors can also remember the acronym CATS and ask clients about their consumption of caffeine, alcohol, tobacco and sugar — all of which can worsen the feelings associated with panic attacks, he adds.

Learning coping skills and identifying triggers

Clients who come to counseling after experiencing a panic attack may start therapy without understanding the complexity of panic attacks or harbor feelings of shame or embarrassment about succumbing to panic seemingly out of the blue, Collins says.

It is sometimes helpful to explain to clients that during a panic attack, their body is launching into the fight-or-flight mode that is part of their biological wiring, Collins says. However, in this case, there is no tiger chasing them.

“I like to say that [a panic attack] is tripping the sensor, like when a leaf falls on your car and the alarm goes off. It trips the sensor, but your car doesn’t know” that there isn’t any actual danger, she explains. Collins says it also can be helpful to assure clients that “it will never be as bad as those first few times when you didn’t know what was happening to you.”

To identify triggers, Collins suggests walking clients through the months, days and hours that led up to their first panic attack — but only when the individual is ready to relive the experience, she adds. Some triggers can be easily identifiable, such as a spike in work-related stress or the loss of a loved one. Other triggers may be less obvious, meaning more work will need to be done to unpack the experience later in therapy.

“I like to make sure clients have really solid coping skills before they work on the underlying stuff that might be contributing” to their panic attacks, such as trauma, Collins says. “Spend the first few sessions identifying what’s been going on. Once they’re confident and capable of managing and getting through an attack, then ask about what might be contributing” to the attacks occurring.

Outside of session, counselors can encourage clients to devote time to journaling, relaxation, deep breathing and counting exercises that can boost self-reflection and change negative thought processes, Collins suggests.

Counselors can also equip clients with coping mechanisms such as mindfulness to help them remain calm and feel more in control in the event of a panic attack. Collins often gives her clients a small stone to carry with them and hold in their hand when a panic attack strikes. She tells them to focus on the stone and describe it to themselves — is it rough, smooth, cold, heavy? This can help divert their attention from the panicky sensations, she explains. The same technique can be followed using car keys, a coffee mug or whatever else clients can hold in their hands that wouldn’t readily draw undue attention from others, she adds.

Clients can also develop mantras to remind themselves in the moment that even though a panic attack feels all-consuming, it is a finite experience. Among the phrases Collins suggests as being helpful:

  • “I’ve gotten through this before.”
  • “This is only temporary.”
  • “Even though this feels like it’s going to last forever, it will end; it always does.”

Collins acknowledges, however, that “once it gets to a certain point, these things don’t work. You have to accept it for what it is when you’re in the middle of an attack. You have to ride the wave, accepting that it will be temporary and it will go away.”

“Sometimes, even getting angry at the panic attack can help,” she adds. “When [people] allow themselves to accept that anger, it takes away some of the power of the attack itself. Admit that it stinks but it’s something you can get through.”

Uncomfortable but not dangerous

Thinking that a panic attack can be halted or avoided by using breathing or relaxation techniques is a misconception, according to Taylor. Those methods are often the first choice of well-meaning practitioners, but Taylor argues that “it sends a subtle message to the patient that what you’re experiencing is dangerous and we need to do something to prevent it.”

“The first thing you need to do is teach [clients] that what [they are] experiencing is uncomfortable but not dangerous,” he says. “It’s your avoidance of the uncomfortable feelings, and trying to stop it, that has unintentionally made it worse. When it comes to symptoms of panic, trying to suppress or avoid those symptoms is the exact opposite of what you want to do.”

Diaphragmatic breathing and other relaxation techniques can be helpful to manage anxiety, Taylor clarifies, but they won’t stop the symptoms of a panic attack altogether. “The only way to truly stop it is to become accustomed to the feelings” and to understand that a panic attack is not dangerous, he adds.

Taylor finds the DARE method developed by author Barry McDonagh particularly helpful. The technique focuses on overcoming panic with confidence rather than employing futile attempts to calm down, Taylor says. The four tenets of DARE are:

  • Diffuse: Using cognitive diffusion, counselors can teach clients to deflect and disarm the fearful thoughts that accompany panic attacks. The thoughts that flood people’s minds during these episodes are just that — thoughts — and are not dangerous, Taylor explains. “Teach them to say ‘so what?’ to their thoughts: ‘What if I embarrass myself or pass out or throw up? So what?’ Take the edge off that thought by not only demoting it but separating ourselves from the thought: ‘It’s not me. I didn’t put it there.’ Teach patients to say to themselves, over and over, ‘This sensation is uncomfortable but not dangerous.’ Think of it like a hiccup. It’s uncomfortable but not dangerous. There’s nothing medically wrong. The more you focus on it, the more uncomfortable it gets.”
  • Allow for psychological flexibility: It is more important that individuals allow and become comfortable with their negative associations than it is to try to get rid of them, Taylor says.
  • Run toward the symptoms: Moving toward feelings of discomfort is antithetical to human instinct, but in the case of panic attacks, it can actually be an effective tactic. Taylor teaches people who deal with panic attacks to tell their bodies to “bring it on. Ask your heart: ‘Give me more. Let’s see how fast you can beat.’ One of the fastest ways to stop a panic attack, ironically, is to ask for more and try and make it worse. It’s the resistance to the sensations that makes it stick around.”
  • Engage: Teach clients to engage in the moment once the panic attack has peaked and is starting to wind down. This is when grounding and mindful exercises can be helpful, Taylor says. “What’s important is to focus on right here and right now. That will help you continue to move forward and get unstuck,” he adds.

An attachment approach

All of the counselors interviewed for this article noted that cognitive behavior therapy (CBT) is an effective, tried-and-true method to support clients who experience panic attacks by helping them refocus the fearful and overexaggerated thoughts that accompany the experience.

Linda Thompson, an LPC and licensed marriage and family therapist in Florida, finds that using CBT through the lens of attachment theory can be particularly helpful in addressing panic attacks. That holds especially true for clients who struggle with feelings of abandonment or rejection or have experienced attachment trauma, including the loss of a loved one or caretaker. Counselors can identify clients who might benefit from attachment work by asking questions at intake regarding past relationships and loss, Thompson says.

“If they are the kind of person who is very relationship-oriented and attachment is very important to them or there is trauma there, that has to be brought into the conversation,” says Thompson, an associate professor at Argosy University with a private practice in the Tampa area.

Thompson suggests that counselors invite someone to whom the client is attached, such as a partner or a spouse, into the therapy sessions (with the client’s consent). The practitioner can prompt discussion that helps the client share some of the inherent fears that he or she is harboring. Often, Thompson says, the partner’s response to this sharing is “I had no idea you felt that way. How can I help?”

From there, counselors can introduce techniques that the client and the client’s attachment figure can use together when the client is feeling anxious, Thompson says. Eye contact, hand holding and other physical connections can be particularly helpful. “It’s making it about connecting,” she explains.

Once they understand that their loved one’s worry and panic are spurred by issues related to relationships or a fear of isolation, friends and family members can be better prepared to respond differently when the person begins to struggle. If the client is willing, counselors can play a role in training the individual’s support system to help with attachment-oriented responses. For example, if a client wakes up in the middle of the night feeling panicked, a spouse or partner could respond by rubbing the person’s back or whispering affirmations such as “You’re not alone,” “I’m here” or “We’re going to get through this together,” Thompson says.

Attachment-oriented clients may also benefit from learning to do breathing techniques with someone to whom they are attached, Thompson adds. For example, a client may start to feel the symptoms of a panic attack while driving. Relying on techniques learned in session, the client would pull the car over and focus on their child in the backseat — holding the child’s hand, making eye contact and breathing together. The physical touch will boost oxytocin, a hormone connected to social bonding and maternal behavior, Thompson explains.

Thompson also suggests that these clients try yoga to help with relaxation and self-control. She says the practice is more beneficial if it involves a social aspect, so she recommends that clients practice yoga in a class with other people instead of alone at home.

Similarly, Thompson suggests helping attachment-oriented clients build a “tribe” or circle of support beyond the counselor. This is especially important for those who have lost a spouse or partner and those who are more susceptible to isolating themselves. Counselors can guide clients in finding connections that are personally meaningful to them, whether that is through participation in spiritual or religious activities, volunteer work or other community groups such as a book club. Focusing on relationships rather than the physical symptoms of a potential panic attack can help these clients feel less vulnerable, says Thompson, a past president of both the Pennsylvania Counseling Association and the International Association of Addictions and Offender Counselors, a division of ACA.

Thompson recalls one client who struggled so acutely with panic attacks and a fear of losing her loved ones that it kept her from leaving the house for two years. CBT alone wasn’t helping, so Thompson added attachment techniques to their therapy work together.

After a substantial amount of in-session exploration, Thompson discovered that the client’s panic attacks were tied to family-of-origin issues. The physical feelings the client experienced during her panic attacks were in the same part of the body where one of her parents had experienced a significant health problem.

In addition to conducting one-on-one therapy, Thompson included the client’s husband in sessions. They worked together on attachment-focused techniques, and, eventually, the couple was able to go outside of the home for the first time in a long while to celebrate their anniversary.

To prepare, they created notecards with attachment-focused feelings and reminders, such as what their first date felt like. They referred to the notecards throughout the evening and connected consistently via holding hands and making eye contact.

After the date, the client reported to Thompson that instead of thinking of where the exits were in the restaurant, as she would have done previously, she remained focused on the man — her husband — in front of her.

Thompson urges counselors to remain open to adding attachment theory or other complementary methods on top of go-to techniques such as CBT to reach clients who are experiencing panic attacks. “Expand your toolbox,” she says. “A person’s fear, the fear that is triggering panic, can have multiple origins. Help the client to find the source of their fear, and work on that. … Broaden your perspective to recognize that human beings have to be attached with people, no matter what the disorder. Ask, ‘How do I make sure the social needs of my client are being met?’”

Controlled exposure

Taylor knows firsthand how terrifying a panic attack can feel. He began experiencing anxiety in his teens and early 20s that intensified to the point of daily panic attacks.

When things were at their worst, he would often go to the emergency room of his local hospital. He wouldn’t register as a patient but would simply sit in the waiting room, knowing that those uncomfortable, uncontrollable feelings would eventually overtake him again. “Sometimes [I would go] because I was having a panic attack, or other times it was just because I felt I might have a panic attack,” Taylor recalls.

Eventually, Taylor did check himself into the hospital, and a doctor explained that he was going to be OK. That was the life-changing encounter that put him on the path to getting help; he credits medication and therapy for helping him overcome his panic attacks. The experience also inspired him to become a counselor.

This personal history plays into his work with clients. As a specialist in treating chronic anxiety and panic, he often emphasizes to clients that feelings of fear and excitement share the same neurological pathways. “It’s just our perception that makes them different. … You have to be able to ride the waves of panic without resisting it,” he says.

In addition to teaching clients to tolerate and deflect the invasive thoughts and physical symptoms that accompany panic attacks, Taylor finds exposure therapy to be a powerful treatment for panic. In fact, Taylor believes that exposure, or intentionally bringing on a panic attack in a controlled setting (such as the counselor’s office), must necessarily play a large role in overcoming the episodes.

“Patients are not moved by information; they’re moved by what they believe is possible, and they’re moved by new experiences. Just giving them the information [that panic attacks are survivable] is about as good as baptizing a cat,” he says. “If you give them the experience of exposure work in your office, they walk out a changed person. The focus should not be on staying calm but [on knowing] that no matter how hard their heart beats or [how much] they feel a sense of doom, they’re actually safe. It’s just a brain hiccup.”

Inducing a panic attack in the safety of a counselor’s office can prove to clients that what they might experience is uncomfortable but far from fatal, Taylor says. “When a counselor is doing exposure therapy with a patient and inducing panic-like symptoms in the office with them, we as counselors need first to be confident that a panic attack truly is not dangerous to the patient,” he explains. “If they start to panic and then we get scared and try to calm them down, the exposure will fail. We have to be able to stay with it, let the panic attack fully develop and subside on its own, so the patient learns that their fear of having a heart attack, passing out or losing control won’t happen. And unless we can really allow them to go all the way through a panic attack and come out the other side, the exposure just won’t work. They will continue to believe that a panic attack is dangerous and continue to try to suppress and avoid them.”

A good amount of therapeutic work may be required before clients are ready for exposure techniques, Taylor says. Once they are, counselors should begin the experience by asking clients to verbalize the worst thing they can imagine happening to them as the result of a panic attack, he says. Fears that clients typically voice include passing out, vomiting or even having a heart attack.

Taylor says the counselor’s response could be, “OK, are you ready to test that out” in the safety of the counselor’s office?

To induce the elevated heart rate and rapid breathing that accompany panic attacks, the counselor might suggest that the client do jumping jacks, run up and down the stairs or breathe through a straw for an extended period of time. As the panic symptoms swell and peak, the counselor will remain close by to remind the client of the cognitive diffusion and other techniques previously mentioned by Taylor.

Afterward, the counselor can talk about how the things the client feared happening as the result of a panic attack did not actually come to pass. The moment clients realize that they can endure panic attacks without their worst fears materializing is the moment they can begin to overcome the attacks, Taylor says.

Conquering avoidance

Individuals who have experienced panic attacks will sometimes start avoiding situations or places where a prior attack occurred. Often, this includes public places such as shopping malls. If this inclination is left unchecked, it can spiral into the person missing work and social engagements or engaging in other isolating behaviors, Collins says. On top of that, avoidance will serve only to make things worse, she notes.

“That fear of having another panic attack can be crippling,” she says. “One of the fears a lot of people have is having an attack in front of people or being in a place where they can’t escape, such as an airplane or a meeting at work.”

When Collins broaches this subject with clients, she frames it as taking their power back and not letting panic attacks control their lives. “We talk about starting small and [taking] baby steps, especially if they’ve been terrified of a place for a while,” she says.

Counselors can begin by having clients visualize in session the place they have been avoiding. Ask them to describe it and talk about how their body feels as they think about that location, Collins suggests. This process may need to be repeated several times before clients feel comfortable and confident enough to make a plan to actually go to the places they have been avoiding, she adds.

When they do go, make sure the client takes a friend or other trusted person with them for support. Clients should also be directed to stick to the plan they have created and talked through in their counseling sessions, Collins says.

For example, if a client has been avoiding going to a shopping mall out of fear of having a panic attack, a first step in the client’s plan might be simply driving to the mall, parking the car and sitting inside it for five minutes before leaving. The client might even need to repeat that step of the process multiple times, Collins says.

After that, the client can move on to walking through the doors of the mall and then leaving immediately. On the next visit, the client might enter the mall and go into a store, and so on. The idea is to continue going until the client no longer associates that place with feelings of fear.

Often, after repeated visits, “people will say, ‘OK, I don’t need baby steps. I want to go now,’” Collins says.

Above all, compassion

Counselors can provide a holistic approach to addressing panic attacks that clients might not have experienced previously with medical professionals or other mental health practitioners. Most of all, Collins says, counselors should offer empathy to clients who are confronting such a distressing, overwhelming and, often, seemingly unexplainable experience.

“That validation is the most powerful thing I’ve seen that helps people,” she says. “Clients get better with the relationship, the validation, the compassion. Compassion: That’s the No. 1 thing to remember.”

 

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Contact the counselors interviewed for this article:

 

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Learn more:

ACA Practice Brief on panic disorder: counseling.org/knowledge-center/practice-briefs

 

Zachary Taylor recommends these resources for counselors who want to learn more about the treatment of panic attacks:

  • DARE: The New Way to End Anxiety and Stop Panic Attacks by Barry McDonagh
  • Anxious Kids, Anxious Parents: Seven Ways to Stop the Worry Cycle and Raise Courageous and Independent Children by Reid Wilson and Lynn Lyons
  • Interview, “Maximizing Exposure Therapy for Anxiety Disorders” with Michelle Craske, professor of Psychology, Psychiatry and Biobehavioral Sciences and director of the Anxiety and Depression Research Center at the University of California, Los Angeles: sscpweb.org/craske
  • Article, “Get Excited: Reappraising Pre-Performance Anxiety as Excitement” by Allison Brooks, assistant professor, Harvard Business School: apa.org/pubs/journals/releases/xge-a0035325.pdf
  • Dr. Andrew Weil’s 4-7-8 Breathing Method: drweil.com/videos-features/videos/the-4-7-8-breath-health-benefits-demonstration/

Linda Thompson recommends these resources for counselors wanting to learn more about attachment-focused responses:

 

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her
at bbray@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 age of isolation: How Instagram memes describe a lonely generation

By Adriana V. Cornell July 26, 2018

2 Comments

Instagram tells millions of stories. Many exhibit our personal daily moments, and, from a wider lens, others describe entire populations and social movements. With 800 million users, Instagram is one of the biggest and richest collections of societal data on the planet. We can learn a lot by noticing what these users choose to showcase personally and which accounts and posts they choose to follow. Lately, I’ve been paying attention to the latter.

Of course, Instagram has grown since its conception, from personal accounts to brand accounts. It seems every business, school, group, dog and fetish now has an Instagram account. “Celebrities” — foodies, beauty experts, daredevils, singers, comedians and more — are born on Instagram.

In the past year, I’ve been following a few comedic accounts that display almost exclusively memes. A “meme” comes from the concept of memetic theory, championed by Richard Dawkins in his 1976 book The Selfish Gene. Just as genetics connote characteristics passed from generation to generation, memetics refer to cultural ideas transferred from person to person. A meme spreads quickly because it can reproduce itself, jumping from mind to mind and therefore driving cultural influences across the globe. According to the theory, genetics and memetics are similarly affected by Darwinian rules of evolution: Their success is subject to their contribution to the effectiveness of the person carrying them.

Memes can concern any content, but the “units of culture” I have been focusing on seem to be targeting people in their mid- to late 20s who are still navigating the transition from youth to adulthood. I’ve noticed a trend in these memes that seems both disturbing and completely normal.

Here are a few that have been featured and reproduced on multiple accounts:

 

 

 

Posts of this kind receive an immense “ovation” of likes, comments and shares. More than 250,000 people liked the first meme, and more than 14,000 commented. Most comments “at” (or link) a friend’s account, inviting him or her to view the same post, and they remark together on the accuracy and truth of the message. These comments include:

“haha, us literally.”

“Lol my life story.”

“So accurate.”

“Us every day, all day.”
“Literally EVERY f*cking time, without fail…! Millennials & bad drivers make being an agoraphobe so much easier nowadays!”

 

Most memes display simply black Arial font on a white background; they seem to rely entirely on the words that compose them. Others feature text accompanied by graphics, pictures or GIFs, such as this one:

 

But even as memes become flashier and more complex with recycled photos or videos, the rule of Darwinian evolution remains critical: The success of memes depends on the effectiveness of the person carrying them — in this case, the account holder. The popularity of a meme, evidenced in the comments section, seems to multiply if the account holder’s caption provides funny, insightful, witty commentary on the meme: in essence, a meme upon a meme.

For example, in the third meme, an account holder captioned the image with: “I’m At Lunch Not Talking To The Person I’m With, But Instead Looking At A Facebook Photo Of The Lunch Belonging To A Girl I Haven’t Seen Since […] 2007.”

This caption — using a relatable, all-too-real anecdote — brings new life and humor to a recycled post. It successfully reproduces the memetic, refueling the cultural influence and giving it new shape before it is passed on.

Users react accordingly, many of them employing the “Face with Tears of Joy” emoji as they comment specifically on the caption:

“Hahaha omg ur caption”

“the caption!!!”

“what if ur sitting with a really boring person at lunch”

“hahaha the caption tho”

 

I simultaneously find myself laughing about and relating deeply to these memes and their captions. Even if my feelings don’t agree in the moment, many of the messages tap into emotions, reactions or thoughts that I’ve certainly had. I have wished that plans would fall through. I have spent too much time scrolling through Facebook. And I have used emojis and exclamations in text that I would never say or emote in real life.

Meanwhile, I can’t help but feel disturbed by these messages and the amount of praise and endorsement they receive. They are all deeply sad and negative in tone and content because they seem to connote a total lack of feeling, social inclination and zest for life, yet at the same time, the need to be liked, included and embraced.

For this reason, I started saving memes of this kind to a “collection” — an optional, user-controlled repository for images on Instagram — that I titled “Oxymoron.” The contradiction of craving and simultaneously rejecting social interaction became an apparent theme that puzzled me. I started asking myself and lots of other (mostly 20-something) people: What’s going on here?

Some friends, while acknowledging that we’re naturally social animals, offered a simple answer. “After working a 12-hour day, that desire to socialize becomes secondary to my need for sleep,” Kelly, 28, explained. “I’m so happy if plans fall through because I feel exhausted by the idea of devoting any more energy to anything in my day.” Others echoed similar ideas and sentiments.

But this explanation didn’t seem to capture the full picture, and it seemed even my busy friends agreed. As our email exchanges developed, so did our ideas about other possible contributors to what seems like an age of isolation, neediness and sadness. After all, depression rates for teens and young adults are higher than ever (12.7 percent as of 2015, according to Psychological Medicine). The chief perpetrators, we concluded: social media and smartphones.

 

Socializing without the authentic self

Comedy is successful when it shamelessly and nakedly brings to light the truest feelings we all possess but don’t readily admit to or talk about. It can be an immensely satisfying relief to hear our private thoughts, habits and emotions exposed and articulated in an anonymous way that lets us know we’re not the only ones experiencing them — that we’re not alone.

And we will do anything to avoid feeling lonely. We will maintain friendships that we don’t enjoy. We will agree to plans that we don’t look forward to. We will stay in relationships that make us unhappy. We will join gangs, extremist groups and cults. In studying our basic human needs, Abraham Maslow determined that we will even sacrifice our safety for the sake of belonging, as evidenced, for example, by children who cling to abusive parents.

Loneliness is deadly. According to research conducted by Julianne Holt-Lunstad, professor of psychology at Brigham Young University, loneliness has the same effects on our health as smoking 15 cigarettes a day. It is more fatal than obesity.

Conveniently, smartphones have given us a tool to dismiss and evade feelings of loneliness quickly and with little effort. Texting, of course, provides the sense of company and togetherness in any and every moment. But even scrolling feeds on Facebook or Instagram can make us feel invited into the lives of friends whom we might not readily meet up with or call.

“We know that engagement with social media and our cell phones releases a chemical called dopamine,” noted Simon Sinek in a 2016 interview on Inside Quest. “That’s why when you get a text, it feels good. It’s why we text 10 friends when we’re feeling a bit lonely, a bit sad. … It’s why we count the ‘likes’ on our Instagram.” And we can do all of this without getting off the couch, without putting on fresh clothes and — best of all — without actually speaking to anyone.

Because socializing in person, face-to-face, is hard. We’re required — in real time — not only to process and listen to what others are saying, but then also to compose (witty, sensible, empathetic, affirming, interesting) comments in reply, sensitive to the situation, conversation and environment. All the while, we must align our facial expressions to the context and content, some of which changes by the second. If live conversation can be described, as it often is, as “dancing,” then texting or using social media might be described as a card game. Both require thought and strategy, but in-person communication demands spontaneity. It commands us to be our authentic selves.

But that can be complicated and challenging. What if we don’t like who we are? What if we don’t know who we are?

The pressure to be perfect has never been more intense. In his 2015 bestseller Sapiens: A Brief History of Humankind, Yuval Noah Harari wrote, “If you are a teenager today, you are a lot more likely to feel inadequate. … Even if the other guys at school are an ugly lot, you don’t measure yourself against them, but against the movie stars, athletes, and supermodels you see all day on television, Facebook and giant billboards.”

Social media allows us to craft, edit, filter and recraft ourselves so that we can come closer to this ideal. We can even consult friends before we reply to a text or post a photo, giving us the ability to depict the (airbrushed) story we wish to tell. But allowing real-time spontaneity to eventually and inevitably reveal who we really are can feel risky and terrifying.

Brené Brown boils this down to a deep aversion to vulnerability. Because we are social animals, we need to feel connected and a sense of belonging in order to survive. “Connection is why we’re here,” Brown said in her 2010 TED Talk. “It’s what gives purpose and meaning to our lives.”

And it is the fear of disconnection, Brown asserts, that often makes us feel the most challenging feelings, like vulnerability and shame.

 

A downward spiral of loneliness

The memes I have observed and collected are popular because they send the message that putting ourselves out there is not worth the risk. No one else is going out; why should you? Why let yourself feel judged, offended or not good enough?

But “for connection to happen,” Brown continues, “we have to allow ourselves to be seen. Really seen. …When we numb vulnerability, we numb joy, gratitude, happiness.” We must accept who we are and embrace vulnerability. People who are most connected, Brown found, “were willing to let go of who they thought they should be in order to be who they were. You have to do that for connection.”

The concern that has nagged me over the past year is that these memes openly reject this kind of self-exposure and authenticity, essentially instructing us to give in to our fear of vulnerability. This not only prevents others from knowing us, it prevents us from knowing ourselves. We get stuck, therefore, in a developmental stage that looks and feels a lot like adolescence — afraid of judgment, lacking self-confidence and without a sense of true belonging.

Another distinct and crucial feature of face-to-face conversation is the opportunity for touch. A pat on the back, caress on the arm, stroke of the hair or hold of the hand is essential to our mental and physical well-being. “Being touched increases the number of natural killer cells, the frontline of the immune system,” says Tiffany Field, founder of the Touch Research Institute at Miami Medical School. “Serotonin increases. That’s the body’s natural antidepressant.”

Deprivation of the sensation of touch from another human often results in feelings of isolation, social exclusion and depression. What’s more, these feelings make people fearful and put them “into a kind of defensive state where the levels of cortisol [the hormone released by the brain in times of stress] are raised,” says Kellie Payne, researcher at the Campaign to End Loneliness. “Having had negative experiences, they anticipate that their connection with people will also be negative, which makes it hard to reinstate contact.”

In short, lonely people can get trapped in a downward spiral of loneliness. These memes tap into and perpetuate this vulnerability, actively discouraging ambition, social connection and productivity.

Fortunately, our brains are resourceful; they find alternative ways to satisfy our needs. For many, this compensation is happily found in communicating via text message and social media. That dose of dopamine can be the fix we need in sad or lonely moments so that, with the approval and company of tens of thousands, we can quickly wipe them away.

Returning to Maslow, these memes, therefore, allow us to reach the two highest orders of human need: esteem (being accepted and valued by others) and self-actualization (reaching our full potential; being all we can be).

The problem is that this solution is shallow, artificial and temporary. Because although it feels like we’re raising unspoken issues of loneliness and depression, and relating to others when we like or comment on these memes, we’re not actually facing our feelings or each other, or talking about them in a way that allows us to be honest, authentic or vulnerable. At the end of the day, the humor used in these memes is merely numbing and normalizing some of our deepest and truest emotions by providing a false sense of togetherness and belonging that inevitably lets us down.

But because “connecting” to others via social media has become so easy and satisfying, like any dopamine producer, it is highly addictive. We’re no longer willing to devote energy, time and effort to our relationships (or any project) because it is —comparatively — too hard.

In other words, social media has yet to find a way to produce serotonin: a far more gratifying, long-lasting and pleasure-inducing hormone. Serotonin provides a sense of relationship, allegiance and pride after dedicating time and effort to a project or task that transcends selfish motivations. But when a meme caption says: “If you do anything interesting or important today, you can go f**k yourself,” we’re excused from trying. Instant gratification has overtaken meaningful, lasting reward, and dopamine has overtaken serotonin.

And just as any addiction — drugs, food, sex — is, by definition, extremely satisfying in the first stages, it often loses appeal, allure and thrill as it becomes more intense and demanding. The craving or desire becomes a need or chore, and we in turn become a slave to our addiction. These memes and apps such as Instagram are designed not only to “rescue” us in times of loneliness or sadness, but to draw us in constantly, at all times of day and night.

“That itch to glance at our phone is a natural reaction to apps and websites engineered to get us scrolling as frequently as possible,” wrote Bianca Bosker in a 2016 edition of The Atlantic. “In short, we’ve lost control of our relationship with technology because technology has become better at controlling us.”

When we are or feel controlled, we lose our sense of self and self-worth — our ability to produce, invent and create. The majority of Instagram users are merely consumers of information; only a small percentage of users are actually creating the message, the humor and the trend. It requires far less thought and effort to simply “at” a friend or double tap to “like” a photo than it does to lean in and think about and interact with society so that we can create our own ideas — or even just talk to one another about them.

 

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Adriana V. Cornell has spent the past two years living in Nairobi, Kenya, working as a school counselor and college counselor at an international school. She has worked primarily with high school students and has focused her writing and research on students in transition and social media. She moved back to the United States with her husband in July. Contact her at adriana.v.cornell@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.

In search of an affirming faith

By Laurie Meyers July 25, 2018

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One of Cyndi Matthews’ most vivid memories of growing up in a fundamentalist Christian church was watching the minister point at her brother’s best friend during a service and say, “You don’t belong here. Get out.” The reason? The boy was gay.

Matthews, a licensed professional counselor supervisor (LPC-S), says that incident was her first glimpse of a pattern of spiritual abuse directed at congregation members who identified as lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ). The animosity that leaders of the church held for LGBTQ members did not fit Matthews’ conception of Christianity. This religious cognitive dissonance would lead her to leave the church and subsequently focus her research and counseling practice on spiritual abuse.

Matthews, a member of the American Counseling Association, sees many LGBTQ clients in her Garland, Texas, private practice who struggle to reconcile their religious beliefs and experiences with their affectional orientation or gender identity. Many of these clients grew up internalizing a message that it wasn’t just their identity or orientation and behaviors that were wrong, but that there was something “wrong” with them as people, she says.

The LGBTQ community has frequently encountered intolerance from religious institutions. Although there are religious traditions that are affirming and open to LGBTQ people, many are not, says Misty Ginicola, lead editor of the book Affirmative Counseling With LGBTQI+ People, published by ACA. Nonaffirming religious groups usually have markedly rigid beliefs — there is wrong and there is right, and nowhere in between, she says. These are the voices that call for anti-LGBTQ legislation under the guise of exercising their religious freedom. As a result, even LGBTQ individuals who do not identify as religious are affected by nonaffirming religious beliefs, points out Ginicola, a member of ACA.

This conflict has produced not just a broader culture clash, but in some religious traditions, a pernicious history of rejection and outright abuse of LGBTQ individuals. Many of Matthews’ LGBTQ clients have been subjected to a wide range of religiously sponsored or endorsed abusive techniques intended to “cure” them. One client — a gay male — was not allowed to cross his legs or wear pink. He was directed to pray anytime he had “gay” thoughts and to replace “gay behavior” with Scripture reading or increased proselytizing. Other of Matthews’ clients were sent to church-sponsored “reparative” retreats where they were prayed over or even subjected to “exorcisms.” Matthews, an assistant professor of counseling at the University of Louisiana Monroe, has also been told about particularly horrific techniques such as forced ice baths and electroconvulsive therapy.

The emotional and even physical abuse that some LGBTQ individuals from strict religious traditions experience is so traumatic that Matthews says all of the survivors she has encountered in her practice were actively suicidal or had been suicidal in the past. At the same time, because clients from strict religious traditions have internalized the idea that what they are told in their churches is God’s word, it is often difficult for them to label their experience as abuse, she says.

Even LGBTQ individuals who break away from their religious traditions so they can fully embrace their affectional or gender orientation have a hard time discounting what they were taught. If someone who identifies as LGBTQ has been told from a young age that they are inherently wrong and immoral, it creates an inner message that lingers, says Ginicola, an LPC in West Haven, Connecticut, whose practice specialties include LGBTQ issues.

Brady Sullivan, a provisionally licensed professional counselor specializing in LGBTQ issues, has worked with clients who believed God hated them. “Every time they engage in sexual or romantic behavior or participate in pride activities, they feel an overwhelming sense of guilt,” he says.

Examining beliefs

Matthews says that, despite their experiences with spiritual abuse, some of her LGBTQ clients still want to find a way to reconnect with religion or at least retain a sense of personal spirituality. Others no longer want anything to do with religion; they come to counseling to untwine the message of being sinful or wrong from their sense of self and sexuality or gender identity.

The therapeutic relationship that is the core of counseling is especially crucial with clients attempting to navigate a conflict between their religious upbringing or current beliefs and their identity as LGBTQ, Matthews says. When people have been taught to seek comfort and strength from a religious tradition that then ends up rejecting them, it feels like a violation of trust, she says. Unfortunately, that sense of rejection can be further compounded when people in the LGBTQ community seek therapy from a practitioner who turns out to be nonaffirming. Matthews always asks clients if they have previously been in counseling and, if so, what that experience was like. This information helps her to address the therapeutic trauma that some LGBTQ clients have experienced.

Matthews screens for spiritual abuse as part of her intake process. She asks clients about their religious background and beliefs and if their experiences are something they would like to address as part of the counseling process. She says that LGBTQ clients from strict or fundamentalist religious backgrounds are highly likely to have experienced spiritual abuse, so the question usually isn’t “if” they will need to work through their experiences, but “when.”

These clients don’t always disclose or even perceive a history of spiritual abuse. However, counselors can look for a number of red flags, Matthews says. These include clients who:

  • Talk about how they are the cause of their own suffering and need to attend church more and to be more faithful and forgiving to alleviate their suffering.
  • Display magical thinking attached to “good” and “bad” behavior; they commonly believe that accidents, illnesses and other tragedies are the result of their “sinful” behavior.
  • Have a difficult time setting boundaries and saying no because of underlying guilt and shame.
  • Feel powerless to take action or make decisions because they fear repercussions from family members, church members, church leaders or their personal deity.

It is critical that counselors understand their role as helping professionals dedicated to providing a safe and affirming space for all clients, including those who are LGBTQ, says Ginicola, a professor of counseling and school psychology and coordinator of the clinical mental health counseling program at Southern Connecticut State University. Simply sitting with clients, supporting them in their pain and validating their experiences helps the healing process begin, she says.

Once clients are ready to talk about their conflicted views and feelings related to their sexual or gender identity and their experiences with religion, Matthews helps them explore the harmful beliefs they have been holding on to and works to dispel them. She is careful not to disparage clients’ faith traditions but does encourage them to question whether the condemnation they have been confronted with is actually the voice of God.

Lorrie Byrd Slater, a licensed professional counselor-mental health services provider in Chattanooga, Tennessee, who counsels many survivors of spiritual abuse, uses her knowledge of Christianity to help clients examine their beliefs. She urges clients whose religious communities have condemned or disparaged them to consider what the Scriptures say about the nature of Jesus Christ. She then asks them if their experiences are in line with Christ’s teachings. Slater, an ACA member, also reminds clients that their particular church is just one church out of many; other places of worship hold very different — and affirming — views of LGBTQ individuals.

Ginicola says cognitive behavior therapy is particularly helpful when confronting clients’ internalized beliefs that being LGBTQ is wrong or sinful. She asks clients to consider how those beliefs began and who taught them that they are inherently wrong. Ginicola exposes clients to religious viewpoints that are affirming to LGBTQ individuals through documentaries and bibliotherapy or putting them in touch with affirming pastoral help. She also encourages clients to explore a question for themselves: If God is love, as they have been taught by their faith communities, how could he hate them?

Practicing GRACE

Both Ginicola and Sullivan have found the GRACE model — originally developed by counselor R. Lewis Bozard and pastor Cody J. Sanders — particularly helpful for guiding LGBTQ clients through the resolution of their conflicted religious views. Sullivan, who is practicing part time in addition to earning his doctorate in counselor education at the University of Missouri–Saint Louis, emphasizes that the model is just a guide, not a step-by-step process. For most clients, he uses only a few of the “stages.” The process involves:

  • Goals: Sullivan, an ACA member, talks to clients about their religious background, asking questions such as what faith tradition they grew up in (Christian, Muslim, Jewish, other) and whether they identify with a particular denomination or sect. He also asks how they feel about what they have experienced, both good and bad.

Ultimately, he wants to find out what clients are hoping to achieve by addressing the conflicts they feel between religious belief and who they are as a person. Sullivan asks: “If you woke up tomorrow and all these issues went away, what would that look like?”

As Sullivan guides clients through their background and goals, he stays alert for reactions, particularly any signs of trauma. If a client seems too upset in a particular session, he will back off and switch to another topic.

  • Renewal of hope: This stage involves uncovering shame and abuse and working through it, Sullivan says. For instance, some nonaffirming religious leaders individually confront LGBTQ congregants with questions about their affectional orientation or gender identity. These confrontations often take on the tone of an interrogation, culminating with  a reminder that “God hates those people.”

Sullivan tells clients that although a particular pastor might think that God hates LGBTQ people, many other religious leaders and faith communities do not hold that belief. If clients are amenable, Sullivan offers to help them make contact with an affirmative pastor to talk about religious views that do not condemn those who are LGBTQ.

  • Action: This stage represents decision time. Sullivan and the client have talked about the religious conflict for a while, and together they’ve processed the client’s trauma and grief. What does the client want to do now?

Sullivan says his role is to explain clients’ options to them and help them identify what they need to do to move forward. Some clients choose to remain planted in their current religious tradition, unready to move on from a community in which their spiritual roots were cultivated, even if that means continuing to wrestle with painful beliefs and practices. Other clients want to stay under the larger umbrella of their current religious faith but choose to find another church home or denomination that is more affirming of LGBTQ people. Still others decide to make a more drastic change, such as converting to a different faith system entirely. And, finally, Sullivan says, many clients decide that they no longer want anything to do with religion at all.

  • Connection: For some clients, processing their past experiences and finding a new place to worship isn’t enough, Sullivan says. Instead, they need to examine their personal relationship with God or whatever higher power they relate to. Ultimately, this involves clients identifying what God or that higher power believes about them and how that affects their view of their religion as a whole.

For instance, Sullivan might probe by asking clients what they believe God’s reaction is when they engage in sexual activity with someone of the same sex. He says that most clients are only able to develop the view that although they are sinning, God loves them anyway.

Sullivan does not like to end the GRACE process with this belief still intact. However, he says the pervasive sense of shame that many LGBTQ clients feel often makes it difficult for them to let go of the notion that living a life that embraces their true affectional or gender identity is sinful behavior. “It’s a struggle to get people to realize that God has made them this way and to accept that they are not sinners,” he says.

  • Empowerment: Sullivan acknowledges that he doesn’t see this stage achieved very often. It takes place only after clients have taken some kind of step such as attending a different church, joining a church-affiliated small group gathering or Bible study, or connecting with a church-sponsored social event, he says. Counselors have an obligation to help clients process these experiences, particularly if they are negative.

“The goal of the empowerment phase is to keep the client traveling down the path toward connection of spiritual and sexual identities, even if they have a negative experience,” Sullivan explains. “This is important because self-confidence and comfort with sexual identity are increased as a result of exploring the intersection between spiritual and sexual identities.”

In reality, Sullivan says, most clients who go through the GRACE model still struggle to reconcile their religion beliefs with being LGBTQ, but they are more at peace with the conflict.

Looking for aff irmative alternatives

One way that counselors can support LGBTQ clients who want to maintain their religious affiliation but feel conflicted is to help them find an affirming congregation, Sullivan says. However, he stresses that counselors must do their due diligence. It isn’t enough to read that the church is part of an affirming denomination or to see that it includes a rainbow flag on its website.

To ensure that he isn’t sending clients into a religious environment that appears affirming but actually isn’t, Sullivan makes a point of calling churches directly. He tells whoever answers the phone that he is a gay man and wants to know the church’s stance on the LGBTQ community. If the person tells him that he is welcome to attend the church and that the church will pray for him and support him in efforts to leave the gay lifestyle, Sullivan thanks them for their honesty but says the church is not for him. Although “welcoming” to LGBTQ people on the surface, churches that hold those types of beliefs do not make it on to Sullivan’s “recommended” list for clients.

Matthews notes that some faith traditions pose a specific and significant challenge to LGBTQ individuals who want to maintain a religious connection. Churches such as the Jehovah’s Witnesses and the Church of Jesus Christ of Latter-day Saints (the Mormon church) embrace particularism — the belief that their particular religious tradition is the only authentic path to God. These paths rest on tenets that are significantly different from what mainstream Christians believe.

For those raised in a church that embraces particularism (and is not affirming of LGBTQ individuals), pursuing their faith by switching denominations is akin to losing their religion entirely, Matthews says. When someone has been told all their life that there is only one path to becoming a Christian and gaining salvation, envisioning another form of faith and worship is almost inconceivable, she explains.

LGBTQ individuals struggling to align their personal and religious identities may look to their families for support. Unfortunately, families are sometimes part of the problem, Matthews says. Many families find it difficult to reconcile their religious beliefs with the reality of their child identifying as LGBTQ.

Matthews has worked with couples from strict religious backgrounds grappling with how to support a child who, according to what the parents hear in church, is living a sinful lifestyle. She provides these parents with psychoeducation by recommending books, giving them information about PFLAG (an advocacy and support organization for the friends, families and allies of those who identify as LGBTQ) and answering their questions, such as whether being LGBTQ is a choice. Matthews might also ask the couple to look for what the Bible actually says about being gay rather than relying solely on what their religious leaders say.

Counselors must also consider that particularly for LGBTQ people of color (POC) or those of low socioeconomic status (SES), leaving their religion behind may also mean losing their community, Ginicola says. “If you are a POC or have low SES, religion is not just a place you go sometimes; it could be a lifeline,” she says.

Losing a whole community can be devastating for anyone, but particularly for someone who has multiple marginalized identities, Ginicola continues. She gives the hypothetical example of a gay black man who, by coming out, loses his church. But when he turns to the LGBTQ community, he may encounter sporadic instances of racism. As a result, he ends up feeling like he is not fully accepted — and, thus, can never feel totally comfortable — anywhere.

Counselors need to let those with marginalized multiple identities know that counseling is one place where they can be fully themselves, Ginicola says. Counseling can encompass all of who these clients are — black, Christian, gay — without judging. Many people seem to think that they can identify either as LGBTQ or religious, but not both, Ginicola notes. She believes the idea that these two identities can’t coexist is harmful because faith — believing in something greater than ourselves, even if it isn’t a deity — is an integral part of life.

Given their negative experiences, some LGBTQ people lose all desire to return to organized religion. Regardless, spirituality can remain a significant part of who they are as people, says Slater, an assistant professor of counseling and associate dean of students at Richmont Graduate University. Spirituality is not the same as religion. In fact, an individual’s spirituality may not even encompass God. Spirituality is simply something that is bigger than us and that provides people with a sense of purpose, Slater says. For some people, that sense of spirituality and meaning can derive from nature, philosophy, personal ideology, science or even the belief in human rights for all, she explains.

Even when LGBTQ clients ultimately decide that they no longer identify with their past religious faith, Matthews tells them that it is possible to hold on to certain positive aspects and values of their religious upbringing that still resonate with them, such as practicing generosity and gratitude and loving others. Or, if these individuals previously enjoyed reading the Bible as literature, she might suggest that they explore other religious or spiritual texts outside of their faith tradition. If the ritual of prayer once provided clients with a sense of peace, she might encourage them to replace that experience with something nonreligious, such as a meditation practice.

Wearing blinders

Counselors who identify as religious know that imposing their values on clients is unethical, and most counseling professionals work hard to bracket their beliefs. Laura Boyd Farmer, an assistant professor of counselor education at Virginia Tech, has published numerous research studies on LGBTQ issues. She recently completed a research study that has not yet been published but that was presented at the 2017 ACA Conference & Expo in San Francisco. The study consisted of a survey that asked 455 mental health and school counselors how they thought their religious beliefs affected their work with LGBTQ clients.

Some respondents said that because their religious traditions were based on acceptance and the idea that Jesus loves everyone, their beliefs had a positive effect, helping them to provide LGBTQ-affirmative counseling. Other participants said their work was in line with their religious tradition, which calls on believers not to judge. Some counselors said that they disagreed with the LGBTQ “lifestyle” but chose not to judge. Others disclosed that their religious beliefs pose a conflict with which they struggle — striving to practice ethically despite their nonacceptance of LGBTQ individuals. Some respondents said that they agreed with the statement “love the sinner, hate the sin” and that this belief did not negatively affect their counseling of LGBTQ clients.

When counselors refuse to counsel LGBTQ clients because their religious beliefs tell them that doing so is wrong, that represents an obvious violation of the ACA Code of Ethics. But where things get tricky is with counselors who take a low-profile nonaffirming stance, says Farmer, an LPC who provides pro bono counseling for LGBTQ individuals in the Roanoke, Virginia, area. These are the counselors who say that they don’t agree with the “lifestyle” but wouldn’t refuse to counsel LGBTQ clients. These practitioners may think that no matter what their beliefs are, they can still maintain unconditional positive regard for their clients, but they might be operating with a big blind spot, Farmer contends.

To illustrate her point, she describes a recent casual conversation she had with a practicing counselor. This person talked about working with gay clients despite believing that being LGBTQ is a sin. The counselor said that they just tried not to judge. Farmer, an ACA member, asked how the practitioner was able to do that. Their response: “To be honest, it doesn’t come up.”

In providing counseling yet not fully accepting LGBTQ clients, this counselor was attempting to manage conflicts with their personal religious beliefs by avoiding pertinent topics. For example, Farmer says the practitioner was working with a gay youth struggling with depression, yet the challenges of identifying as LGBTQ “never came up.” Farmer says this makes her wonder how many other professional counselors are walking around wearing blinders.

Counselors like the one in Farmer’s story are not fully owning — or understanding — their bias, Ginicola says. A bias isn’t just, “I hate these people,” she explains. It’s also that working with someone who is LGBTQ doesn’t feel “right” and the counselor isn’t comfortable with it. By not confronting the discomfort, counselors are much more likely to miss signs (even if unintentionally), miscommunicate and project their worldview on the client rather than identifying the real issues, Ginicola asserts.

Disaffirming counselors resent that ACA’s ethics code requires them not just to set aside their personal beliefs to work with LGBTQ clients but to actually be advocates for them, Ginicola says. These counselors don’t view the experiences of LGBTQ clients as valid, she adds, and it is impossible to work effectively with clients unless you intrinsically embrace their value.

 

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Additional resources

To learn more about the importance of exploring aspects of religion and spirituality in clients’ lives, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Critical Incidents in Integrating Spirituality Into Counseling, edited by Tracey E. Robert and Virginia A. Kelly
  • Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice, second edition, edited by Craig S. Cashwell and J. Scott Young
  • Understanding People in Context: The Ecological Perspective in Counseling, edited by Ellen P. Cook

Journal of Counseling & Development (counseling.org/publications/counseling-journals)

  • “Psychological Safety and Appreciation of Differences in Counselor Training Programs: Examining Religion, Spirituality and Political Beliefs” by Amanda L. Giordano, Cynthia M. Bevly, Sarah Tucker and Elizabeth A. Prosek
  • “The Ways Paradigm: A Transtheoretical Model for Integrating Spirituality Into Counseling” by Joseph A. Stewart-Sicking, Paul J. Deal and Jesse Fox

Competencies (counseling.org/knowledge-center/competencies)

  • Competencies for Addressing Spiritual and Religious Issues in Counseling

ACA divisions

 

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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 Counseling Connoisseur: Enough: A call to action

By Cheryl Fisher July 20, 2018

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“Thou shalt not be a  perpetrator, thou shalt not be a victim, and thou shalt never, but never be a bystander.” ― Yehuda Bauer

 

The sun warmed my body. Blissfully fatigued following several laps around the pool, I stretched out on the chaise lounge chair. I sipped my cool lemonade and haphazardly lifted my phone which had been vibrating endlessly. Who on earth was trying to reach me? I had prepared my clients for weeks regarding my vacation. I had set my away message on my phone. Who could possibly need me right now? My eyes squinted at the list of messages. “Are you ok?” “Where are you? I am worried?” “Please tell me you are safe?!”

My lazy summer mental fog abruptly dissipated as I sat up in my chair and began to read through the barrage of inquiries. What on earth is going on? I quickly tapped my responses. “I am fine. At the beach. What is happening?” I read the responses over and over waiting for the punch line, but there was none. My beloved community of Annapolis joined the ever-growing fraternity of gun violence and those men and women who reported the daily news were the target this time. The Capital Gazette was under attack with several fatalities and multiple injuries.

Reaction

I have been a counselor for twenty-plus years. I am a volunteer for the American Red Cross disaster mental health team and Maryland Responds Medical Corps. I have been deployed and provided crisis intervention to victims, and offered crisis debriefing to first responders. Professionally, this work is not new to me. However, to watch the devastation and suffering of my community from one hundred miles away was excruciating. I watched as the first responders whom I had brought homemade cookies to during the holidays risked their lives to enter the building under attack. I witnessed people I know being escorted from the building — the same building I had visited a week earlier for an endodontist appointment. I observed the swift and definitive execution of the emergency plan play out on national television. including scenes of the ambulance taking victims to the emergency room where I had served as an on-call counselor for 10 years. These were my people! The agony was palpable even from the safety of the beach. Rumors flooded social media, and I waited for news of missing persons.

I took inventory of my internal status. I am, after all, a therapist. I felt frightened for the families who had to sit with so many unknowns about the well-being of their loved ones. I felt helpless being so far away. I felt angry that we continue to experience this type of violence. Enough is enough! It is past time for counselors to make decisions and act.

Action

Counselors have a unique role following a disaster in that we are called to help heal a community’s trauma. We counsel survivors and families and debrief first responders. We help bring agency back to a community that may feel disempowered and devastated. The safety once experienced, crumbles and we aid in the creation of a new normal.

My first act was to contact Maryland Responds to see if we were going to deploy. The local Warmline — a non-emergency helpline that offers immediate counseling or referral services — had begun advertising grief counseling services and I knew that the first responder employee assistance programs would soon reach out for aid in debriefing the responders. However, like many communities, the Annapolis area is tight-knit, so the traumatic effects of the tragedy would be widespread. One of the local mental health networking groups spearheaded the creation of a list of providers willing to volunteer both medical and mental health services over the next several weeks. Clinicians from all over the county responded, zealous to do their part to help in the recovery effort. As clinicians, we know that initially there are rituals, memorials, vigils and casseroles that remind us of the solidarity of experience in these losses. However, when people attempt to resume their previous lives, they trip over metaphorical landmines that they don’t expect. Counselors can help clients to anticipate and disarm the mines.

Change

On February 27, ACA adopted a resolution supporting and highlighting the role that school counselors and other professional counselors play in addressing the anxiety, stress and trauma students experience after a school shooting.  The resolution also calls for adequate federal funding for research into the public health impact of gun violence and evidenced-based strategies for preventing and addressing gun violence.

In an Annals of Epidemiology article published in 2015, researchers Jeffrey W. Swanson, E. Elizabeth McGinty, Seena Fazel, and Vickie M. Mays reviewed research on the relationship between violence and mental illness. They found that the presence of mental illness is not an effective predictive factor for violence against others. Instead, they advise policymakers to focus on evidence-based risk factors such as previous violent behavior. They advocate for “time-sensitive risk assessment for violence as the foundation of evidence-based criteria for prohibiting firearms access, rather than focusing broadly on mental illness diagnoses and a record of involuntary psychiatric hospitalization at any time in one’s life.”

The authors’ conclusions highlight the need to train all mental health providers in violence assessment. The use of evidence-based criteria — rather than a diagnosis of mental illness — to prohibit firearm access requires a change in current policies and procedures. Saying “enough!” in the face of gun violence is neither a partisan statement nor an opposition to the Second Amendment. It’s a call for an end to the death and trauma. Gun violence permeates our society in multiple ways — not just in mass shootings but also through gun-related crime and suicide. Complex issues surround this violence, but there are definite steps we as a society can take such as reexamining gun control policy, demanding further research on predicting violent behavior, addressing insufficient access to mental health care and reducing the stigma attached to seeking care.

As counselors, we are trained to be value-neutral. We support the goals of our clients even when they directly oppose our own beliefs. We offer a non-judgmental presence. Regarding mental health care accessibility and gun violence, we need to dare to have an opinion. We need to know the platforms of our representatives and have their office number on speed dial. We need to use the strength of our collective voices and demand change.

Conclusion

Annapolis, Maryland, USA downtown view over Main Street with the State House.In the wake of the attack, I heard my community’s resounding cry of solidarity with all the victims of gun violence. Naptown Strong! We love you, Annapolis! And just like every other school, church, concert, movie theater and community affected by gun violence, we are striving to put the pieces back together from a horror that will forever inform our narrative. Enough is enough! Prayers and thoughts must be followed with action!

Annapolis and the Capital Gazette will not be defeated by violence. In the immediate aftermath of the shooting, the staff at the Gazette refused to be silenced. “I can tell you this: We are putting out at damn paper tomorrow,” tweeted reporter Chase Cook. And they did. Let us all be inspired by the courage and the conviction of these journalists.

 

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Resources from ACA relating to gun violence and trauma for, both counselors and consumers: counseling.org/knowledge-center/gun-violence-trauma-resources

 

 

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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.

 

Is depression lurking in your medicine cabinet?

By Bethany Bray July 16, 2018

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An estimated one in three American adults are taking one or more medications that can – and often do – cause depression.

A recent Journal of the American Medical Association (JAMA) study found that many common medications that Americans take regularly, such as drugs for acid reflux or high blood pressure, have the potential to cause depression as a side effect.

The study, published in JAMA‘s June 12 issue, analyzed federal health survey data collected from U.S. adults between 2005 and 2014. Of the more than 26,000 participants, 7.6 percent who were regularly taking one medication reported having depression — and this doubled in those who were taking three or more medications.

“The estimated prevalence of depression was 15 percent for those reporting use of three or more medications with depression as an adverse effect, vs 4.7 percent for those not using such medications,” wrote the article’s co-authors.

The study also found that the number of Americans who regularly take medications that carry depression as a side effect has increased from 35 percent to 38.4 percent between 2005 and 2014. The percentage of people taking three or more these medications concurrently increased from 6.9 to 9.5 percent over the same timeframe.

American Counseling Association member Dixie Meyer says these findings only affirm the importance for counselors to familiarize themselves with medical diagnoses and commonly prescribed medicines. Also, counselors should routinely screen for depression in clients who take medications with depressive side effects, as well as those in at-risk groups, such as minorities, clients with low socio-economic status or who identify as LGBTQ.

As the evidence for the intertwined nature of the medical and mental health fields continues to accumulate, it becomes increasingly important for counselors to bring themselves up to speed on medical research that may inform clinical practice, says Meyer, an associate professor in the medical family therapy program in the department of family and community medicine at the St. Louis University School of Medicine. This can happen both through individual professional development and a profession-wide focus.

“We know that for professions to succeed, there needs to be a continual adaption. For the counseling field, counselor training programs need to include not only counseling but medical research evaluation,” Meyer says. “Counselors need to be trained in understanding the relationship between physical and mental health disorders. For example, trauma increases the likelihood for chronic health conditions.”

Meyer is also the director of the Relationships and Brain Science Research Laboratory at the St. Louis University School of Medicine. She frequently gives presentations to counselors on the importance of understanding their clients’ medications, including at ACA’s 2016 conference in Montreal. She recommends that all counselors have a copy of the Physicians’ Desk Reference on hand so that they can quickly look up any medication. Counselors can also refer to resources like Medscape.com for updates on the latest medical research that may inform clinical practice.

“Because this [JAMA] research is not a clinical trial or a prospective study that can inform the reader of temporal implications, we should interpret the results with caution as they are correlational in nature,” says Meyer. “It is not uncommon for physicians to prescribe, at the onset of treatment or later concurrently with treatment, a medication intended to manage side effects. While the sample with the 15 percent increased risk were taking three or more medications with the depression side effect, we can still expect the majority of individuals using these medications will not experience an increase in depression. Thus, any preventative care could be needless without symptoms present.”

 

 

When it comes to counselors, clients and medication, Meyer suggests the following:

  1. Intake forms should include use of both prescription and over-the-counter medications. The form should specify that he or she should include medications taken periodically or on an as-needed basis.
  2. Counselors should implement regular, monthly checks to assess if medication usage has changed.
  3. In addition to counselors systematically assessing how clients perceive the effectiveness of their psychotropic medication and side effect evaluation, the medication management component of counseling should include an assessment of those medications associated with depression risk, like anti-hypertensives, hormonal contraceptives and other hormone replacement therapy and proton pump inhibitors (commonly used to treat acid reflux).
  4. Clients being treated for depression, those in at-risk groups (LGBTQ, racial minorities, women, low-income) and those taking medications with depressive side effects need to be routinely screened for depression. A monthly screen for depression using widely available tools like the PhQ-2 or PHQ-9 can easily be incorporated into clinical practice without being too cumbersome for clients.
  5. Counselors need to monitor both the mood and somatic symptoms of depression in high-risk groups. Many of the symptoms of depression are somatic; thus, clients may be experiencing depressive symptoms that go unnoticed because they are unrelated to mood changes.
  6. Counselors need to be well-versed in who is at risk for depression. The [JAMA] research reported that the medications with potential depressive side effects were more likely to be given to those individuals already at an increased risk for depression (e.g., female, widowed, older populations and those with more chronic health conditions). Not only does this make it difficult to determine if the research is uncovering depression prevalence already present or if vulnerable populations are being placed in a position that increases their depression risk. Thus, counselors need to understand what the research tells us about who is at risk for depression — and counselors need to identify if these individuals are also taking medications with this potential side effect.
  7. Counselors need to encourage self-monitoring of mood symptoms and discuss with clients taking medications with depressive side effects how to intentionally monitor their mood at home. For example, smart phone apps designed to track mood are widely available.

 

 

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Find out more

 

Read the full JAMA article: jamanetwork.com/journals/jama/article-abstract/2684607

 

From NPR, “1 In 3 Adults In The U.S. Takes Medications Linked To Depression”

 

From the Counseling Today archives:

“The counselor’s role in assessing and treating medical symptoms and diagnoses”

“Healthy conversations to have” (on discussing psychiatric medication usage with clients)

 

 

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Bethany Bray is a staff writer and social media coordinator 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.