Monthly Archives: December 2018

America’s mental health disparities

By Bethany Bray December 10, 2018

Mental health care availability and access vary tremendously depending on where you live in the United States. In Massachusetts, for example, there is one mental health care provider for every 180 residents. That ratio is far different in Texas and Alabama, however, where there are more than 1,000 residents for every one provider.

Mental Health America (MHA) recently released its annual report of mental health indicators across the U.S. For the ratios above, MHA included counselors, psychiatrists, psychologists, licensed clinical social workers, marriage and family therapists, and nurses specializing in mental health care in its categorization of “mental health provider.”

MHA ranked Massachusetts as the best state for mental health care availability, followed by the District of Columbia, Maine, Oregon, Vermont, Oklahoma, New Mexico, Rhode Island, Alaska and Connecticut. All of these states and the District of Columbia have fewer than 300 residents per mental health care provider.

On the other end of the spectrum, Alabama (with 1,180 residents for every one provider) and Texas (1,010:1) were the lowest-ranked states, along with West Virginia (890:1), Georgia (830:1), Arizona (820:1), Mississippi and Iowa (760:1), Tennessee (740:1), and Florida and Indiana (700:1).

Although Oregon was near the top of MHA’s list for mental health care availability, it also ranked highest for prevalence of mental illness among adults. Nationwide, 18.07 percent of adults – or more than 44 million people – have a mental illness, defined as “a diagnosable mental, behavioral or emotional disorder, other than a developmental or substance use disorder.”

See MHA’s full report, “The State of Mental Health in America 2019,” at mentalhealthamerica.net

In Oregon, that prevalence was 22.61 percent, followed by Utah (22.27 percent), Kentucky (22.08 percent), Idaho (21.62 percent) and Arkansas (21.02 percent). West Virginia, Vermont, Washington, Montana, Colorado and Alaska followed with rates that were between 20 and 21 percent.

States with the lowest prevalence of adult mental illness included New Jersey (15.5 percent), Hawaii (15.55 percent), Illinois (15.73 percent), Texas (16.04 percent) and Maryland (16.59 percent). North Dakota, California, Florida, Louisiana, Michigan, Mississippi, Arizona, New York, Maine, Delaware, Iowa, Georgia and South Dakota all had rates between 17 and 18 percent.

MHA, a Virginia-based nonprofit advocacy organization, compiles a report titled The State of Mental Health in America each year from nationwide survey data, including information from the Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention. Released this fall, MHA’s current report includes statistics on access to mental health care, uninsured citizens, rates of substance abuse, suicide indicators, youth depression and other factors.

See MHA’s full report, “The State of Mental Health in America 2019,” at mentalhealthamerica.net

 

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Mental Health America’s The State of Mental Health in America 2019

When it comes to mental health, how does your state stack up?

View the full report and state rankings at mentalhealthamerica.net

 

See MHA’s full report, “The State of Mental Health in America 2019,” at mentalhealthamerica.net

 

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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.

 

Thriving in times of crisis

By Lennis G. Echterling

I am now reaching the age when people assume that I have achieved a certain amount of wisdom. I admit that I usually enjoy playing the role of the sage as a professor, but at times it definitely has its downside. For example, a new faculty member once said to me, “Hey, Lennie, you’re the silverback gorilla in our department. What’s your advice about this proposed new policy?” I was so irritated that I wanted to hit him with a banana.

For me personally, a more serious downside of aging is that I am now facing a threat to my health, well-being and life. Two years ago, I was notified that I have cancer. A biopsy that I had fully expected to be benign instead turned out to be malignant. I received the call in my office, just before leaving to teach my crisis counseling class. Ironically, after decades of responding to the crises of others, I suddenly became my own case study.

When I entered the classroom late and out of breath, still reeling from the shock of the cancer diagnosis, I realized that I had taught my students well — they immediately sensed that I was troubled and kindly invited me to talk about it. Touched by their sensitivity and concern, I decided to take a risk and openly share with them my bad news.

As I told my story, I began to feel a mixture of profound emotional relief as a person and immense pride as a teacher because my students intervened in my personal crisis with empathy, skill and compassion. It turned out to be a powerful lesson, both for my students and for me. I believe that my students learned to trust the process of counseling, no matter when, where and with whom an intervention suddenly is required. The lesson I learned was to accept the gifts that others generously offer me in my own times of turmoil. That is the essence of counselor education — to practice our craft with one another to promote professional growth and personal healing.

Four principles of thriving

As counseling students, supervisors, teachers and practitioners, we all will have our share of personal, professional and family crises. So, I offer here four principles of thriving that emerged from my own life lessons in dealing with times of turmoil, threat and adversity.

The first principle of thriving is to be resilient. Resilience comes from the Latin word resilire. To resile means to bounce back. In physics, resilience refers to the elasticity of material that can endure strain. For each and every one of us, personal resilience involves not only surviving those inevitable crises ahead, but also truly thriving in our lives.

As I reflect on my two years of cancer treatment, I find that my personal experience has mirrored the typical reactions to a life-threatening situation. I appreciate now more than ever how adaptive negative emotions such as fear and anxiety can be because they focus our attention on the threat and press us to take appropriate action rapidly. But during this time, I also have been discovering deep and abiding positive emotions such as hope, compassion and heartfelt gratitude. Those emotions have broadened and enriched my ways of being. The truth is that both negative and positive feelings are essential for surviving and thriving in times of crisis.

My second principle for thriving is a reminder that you are not alone (and neither am I). Every culture has its folk tales and myths that portray a hero on a quest. No matter how talented and strong this protagonist may be, the person neither travels nor triumphs alone. Jason, the ancient Greek mythological hero, counted on his Argonauts in his search for the Golden Fleece. Somewhere over the rainbow, Dorothy was gifted with the Cowardly Lion, the Tin Man and the Scarecrow to help her find the Wizard of Oz. And in his Star Wars adventures, Luke Skywalker relied on Obi-Wan Kenobi, Princess Leia and Han Solo.

Like the protagonists in those archetypal stories, we also will encounter others who will have a profound impact on our life’s journey. To thrive in our future endeavors, we must accept the gifts that others offer us. To flourish in our personal lives and professional careers, we need to join with others to engage in the collaborative work of supporting, inspiring, challenging and encouraging one another. We are not islands unto ourselves in achieving our potential. We cannot succeed as completely, or as joyfully, on our own.

Third, thriving in our future involves remaining committed to learning throughout our lives. Our graduate training is not a mere dress rehearsal. It is an integral part of our lifelong dedication to continued professional development. A mind is like a parachute — it works best when it’s open. And actions do speak louder than words, so we must seek out mentors who exemplify what we aspire to become, because the most important lessons in life are not taught but caught. Passion, commitment and curiosity are highly contagious. For that reason, I regularly take a close look at my colleagues and my students. What do I want to catch from them?

The counseling profession is like a fidgety kid who is never still — it is constantly on the move as students and practitioners contribute to its vitality. The Mbuti of Africa have a ritualized song that offers a wonderful example of what every professional community should aspire to achieve. In the song, individual singers are responsible for specific notes, but no one carries the entire melody. As a result, only the community can sing the song.

My fourth and final principle for thriving is to make the journey your destination. In Travels With Charley, John Steinbeck wrote, “We do not take a trip; a trip takes us.” I am neither the person who originally entered my own training program nor the beginning counselor who launched my counseling career. Along the way, I have gained a sense of confidence and trust in my own abilities. I have questioned my old assumptions and, as a result, made new discoveries that guide my work. I aspire to continue going with the flow of my career and to be open to the enormous possibilities of future transformations.

Decades ago, as I was immersed in my own graduate education, I was fortunate to develop lifelong friendships with members of my cohort. We brought to our training a similar mixture of rough edges and fine potential, nagging doubts and yearning dreams, neurotic hang-ups and transformational hopes. We told our life stories to one another and threw ourselves into heartfelt discussions that lasted late into the night. Along the way, we would party together. My fellow students taught me how essential it is not only to work hard with your colleagues but also to celebrate with them.

More lessons to learn

Six months ago, lab results revealed a recurrence of my cancer. After completing 15 more radiation sessions, my skin was a raw and painful reminder of my vulnerability and mortality. I continue to Google for any innovative breakthroughs for my cancer, to remain committed to practicing a healthier lifestyle and to explore complementary approaches. I now face a regimen of medications, phototherapy sessions, appointments and lab tests.

I have become accustomed to the role of the patient, but I endeavor to thrive throughout the process. I cherish my loved ones. I give extra hugs to my family and dear friends. And I take every opportunity to show my gratitude for the countless acts of kindness that others bestow on me every single day. My hopes and dreams for the future, which serve as the personal beacons that light my way, are to savor and cherish all the meaningful, loving and joyful moments that remain in my life. I have many more lessons to learn from my students.

 

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Lennis G. Echterling is a professor of counseling at James Madison University. Contact him at echterlg@jmu.edu.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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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.

Some thoughts on thoughts: The inner critic and self-talk

By Whitney Norris December 6, 2018

There’s no doubt about it: Words are powerful. As a professional counselor, I return to a few themes often because of their relevance to a wide variety of presenting issues and goals that clients bring to my office. Self-talk is among my five most-visited topics in therapy. Still, I have found that the subject usually isn’t treated with the deference it deserves. Its impact on our mental health and general wellness is significant and, in my opinion, well worth exploring with our clients — but always first within ourselves as counselors.

When I use the term self-talk, I’m referencing that voice in our heads — all the thoughts in our minds that sound like one or both sides of a conversation. The unmistakable reality is that we’re constantly talking to ourselves, regardless of whether we realize it. Much has been written on the topic using various terminology. One of my favorite terms used is inner critic. I appreciate this wording because of its intent to externalize our negative self-talk and help us refrain from mistakenly overidentifying with it. Regardless of the label used to describe our negative self-talk, however, key themes emerge in our understanding of its origins, impact and proposed remedies.

Origins, impact, remedies

Many different views exist about the origins of the nature of our internal dialogue. Peggy O’Mara, an author and editor whose work centers around children and motherhood, states simply, “The way we talk to our children becomes their inner voice.” Other authors and researchers also claim that our self-talk mirrors the way we were spoken to and dealt with as children. Geneen Roth explains that as children, we learned to internalize the messages our parents sent us, for better or for worse, as a survival strategy. For example, as children, it’s best that we internalize messages such as “Don’t run out into the street.” However, those messages that sound more like “You’re worthy of love and acceptance only when you accomplish something” don’t do us any favors, either as children or later as adults.

When I delve into this topic with clients, I usually tell the following story of an experience that forever shifted my view of the importance and impact of negative self-talk. It also served as the beginning of the end of my then-thriving inner critic.

While in graduate school, I was given the amazing opportunity to intern at a treatment center where, one evening, I was invited to observe an eating disorders group. During my first visit to the group, the group therapy agenda was set to include the reading of a letter that had been assigned to one of the group members the previous week. After discovering the extreme nature of a group member’s self-talk and its connection to her disordered eating, her therapist had asked her to write a letter to herself from her inner critic, just as she experienced it inside her head on a daily basis.

During the group therapy session, this woman was asked to pick the person in the group whose voice sounded most like her inner critic. The friend she chose was a champ, following through on what he was asked to do, which was read the letter aloud to her, knee-to-knee, in the tone in which it was clearly written. The scene was heartbreaking — not only watching the emotional reaction of the woman who was being read to and hearing the awful things written in that letter, but also watching the friend who was tearfully reading those words, of which he didn’t believe a single word.

Although years have passed since I witnessed that scene, I still can’t tell the story without tearing up. It was an incredibly powerful object lesson about what our unchecked negative self-talk can turn into and just how toxic it can be for all of us and for our relationships. I think most of us can relate to this on some level with a look in the mirror. I encourage you to take a moment and imagine yourself in this woman’s shoes. If others could see and hear your inner critic, how would that change the way you talk to yourself?

Now let’s take it a step further. Not only does this inner critic mirror something we likely have no desire or intention of reflecting, but it is also self-sustaining. Imagine that you have the most healthy, robust self-esteem of anyone you’ve ever known. Then you hire an assistant who is with you continuously and who never ceases to criticize you. Even with your world-class self-esteem, your assistant’s constant monologue about your work and your worth would eventually wear you down. Without anyone else there to defend you (which is the case when this is all playing out only in our heads), you would slowly move toward believing the negativity and criticism, regardless of whether it was true. Like a slow and steady gas leak, this toxicity would filter into the way you think, slowly poisoning your view of yourself and the world around you — likely without you even realizing it was happening.

In many respects, our self-talk is no different than this hypothetical “assistant.” Regardless of whether the messages are true, if we listen to them for long enough, we will eventually come to believe them. The more deeply we believe something, the more likely we are to see the world through that lens of self-fulfilling prophecy.

Brené Brown illustrates this beautifully in her 2017 book, Braving the Wilderness: “Stop walking through the world looking for confirmation that you don’t belong. You will always find it because you’ve made that your mission. Stop scouring people’s faces for evidence that you’re not enough. You will always find it because you’ve made that your goal. True belonging and self-worth are not goods; we don’t negotiate their value with the world.”

In his book The Four Agreements, Don Miguel Ruiz posits that our acceptance of someone else’s abuse is contingent on the severity of our abuse of ourselves. He claims that we will only leave an abusive situation when the abuser treats us worse than we treat ourselves. Regarding a solution to this pattern, Ruiz goes on to say, “We need a great deal of courage to challenge our own beliefs. Because even if we know we didn’t choose all these beliefs, it is also true that at some point we agreed to all of them. The agreement is so strong that even if we understand that it is not true, we feel the blame, the guilt and the shame that occurs if we go against these rules.”

The process of seeing, challenging and replacing these rules is often a core element of therapy. We can’t go back and unsend the messages we’ve received. However, as Ruiz alluded to, we can make the choice to face the blame, guilt and shame that solidify our loyalty to these imprisoning messages. If we never make ourselves aware of these internal beliefs, we will likely continue to shoulder their burden unknowingly and to our great detriment.

So, then, what is the solution? As with many truths, it’s simple but not necessarily easy. In her excellent book Women, Food and God: An Unexpected Path to Almost Everything, Roth explains it this way: “Freedom is hearing The Voice ramble and posture and lecture and not believing a word of it. … Listening to and engaging in the antics of The Voice keeps you outside yourself. It keeps you bound. Keeps you ashamed, anxious and panicked. No real or long-lasting change will occur as long as you are kneeling at the altar of The Voice.”

Roth cites “living as if” as the solution for silencing our inner critic — living as if we don’t believe a word of it. When helping clients move toward healthier self-talk, I take a similar approach:

1) Name the lies that your inner critic is known to speak to you (they can usually be boiled down to a few major themes).

2) Label them as lies (some form of “Is this standard true for me but no one else?” or “Can I imagine speaking this ‘truth’ to a child?” usually does the trick).

3) Treat them as lies regardless of how you feel in the moment.

Every time we act out of the truth rather than a lie we’ve been led to believe, that voice becomes a bit quieter until, eventually, it fades into the background. Sure, it takes practice, but starting down the path to a healthier internal world really can be that simple.

Positive self-talk

I started with the negative side of the coin because, unfortunately, I think many of us are more familiar with it than with the positive side. I do not, however, want to suggest that it is only the negativity of our self-talk that makes it so compelling. Our positive self-talk can be equally transformative and, quite frankly, much simpler.

Similar to the inner critic, positive self-talk as a concept garners a substantial amount of attention via many different perspectives and traditions: modern psychology, meditation, mantras, affirmations, etc. The most recent mainstream perspective aiming to increase focus on the significance of our internal world is positive psychology.

In his highly entertaining 2011 TED Talk, Shawn Achor, author of The Happiness Advantage, stated, “We’re finding it’s not necessarily the reality that shapes us, but the lens through which your brain views the world that shapes your reality.” He posits that, as the adage says, we should work smarter not harder. We’re better off spending our energy remaining positive in the present moment than striving for the next thing that promises to make us happy or successful (and probably won’t deliver).

In his work with businesses, Achor reports, “What we found is that only 25 percent of job successes are predicted by IQ; 75 percent of job successes are predicted by your optimism levels, your social support and your ability to see stress as a challenge instead of as a threat.”

Near the end of his talk, he gets more practical: “We’ve found there are ways that you can train your brain to be able to become more positive. In just a two-minute span of time done for 21 days in a row, we can actually rewire your brain, allowing your brain to actually work more optimistically and more successfully. We’ve done these things in research now in every company that I’ve worked with, getting them to write down three new things that they’re grateful for for 21 days in a row — three new things each day. And at the end of that, their brain starts to retain a pattern of scanning the world not for the negative, but for the positive first.”

If you’re anything like me, you are thinking, “Nope. Sorry, I just can’t believe it could be that easy. Something that affects so much of us so deeply can’t shift significantly with an intervention so simple.” I hear you, and I by no means want to oversimplify a profound topic such as self-talk. As I mentioned earlier, many different factors play into our self-talk, many of which are the stuff of therapy. However, I do believe that the jumping-off point can be as simple as a small consistent habit such as practicing gratitude.

This concept applies across the board, well beyond the scope of gratitude specifically. As Achor mentioned, a daily practice of noticing and acknowledging something shifts how we operate on a subconscious plane. We can change our thinking on a fundamental level, in whatever category, by sheer force of focus. That focus is changing our internal world over time in a way that can bring more lasting change than any amount of in-the-moment, conscious white-knuckling. As Kristen Neff aptly states in Self-Compassion: The Proven Power of Being Kind to Yourself, “Who is the only person in your life who is available 24/7 to provide you with care and kindness? You.”

One of the biggest real-life examples of this for me came from an experience during my college years. One day, a friend invited me to a weekly small group she had been attending for a while. She explained that the group wasn’t studying anything and didn’t have a specific agenda. Group members simply spent their time together talking about the ways they had seen God show up in their lives over the past week. Looking back, I’m sure I went to this group to prove that nothing good could come from warm-and-fuzzy share time without some intellectual bounty involved. What I found, though, surprised me. At no other time have I been more aware of daily divine intervention in my life as when I was attending this group. Do I believe now that God was moving more at that point in my life than at others? No, not at all. What was different was merely the fact that I was looking for it and paying attention. So, I found it.

For those who perhaps need a more research-based example, keep reading. This topic also rose to the surface while I was working at a residential treatment center soon after finishing graduate school. It was a small facility, and I was the rookie therapist, so, naturally, one afternoon I found myself scrubbing some graffiti off one of the bathroom walls next to my office. Apparently, I was using my outside voice while saying “I love my job” over and over to myself (sarcastically, in case that’s not evident).

At that point, one of my supervisors walked past and said, “Hey, you know that actually works, right?” After pausing a second to take in my more-than-slightly aggravated facial expression, he proceeded to tell me about an article he had read on a common practice of Navy SEALs. In doing some fact-checking, I found that Navy SEALs have used positive self-talk as a part of their training curriculum for years, resulting in significantly higher passing rates in their training program.

Eric Barker, in his book Barking Up the Wrong Tree: The Surprising Science Behind Why Everything You Know About Success Is (Mostly) Wrong, says we should pay close attention to what Navy research has shown us about the impact of self-talk: “A Navy study revealed a number of things that people with grit do — often unknowingly — that keep them going when things get hard. One of them comes up in the psychological research again and again: ‘positive self-talk.’ Yes, Navy SEALs need to be badass, but one of the keys to that is thinking like ‘The Little Engine That Could.’ In your head, you say between three hundred and a thousand words every minute to yourself. Those words can be positive or negative. It turns out that when these words are positive, they have a huge effect on your mental toughness, your ability to keep going. Subsequent studies of military personnel back this up. When the Navy started teaching BUD/S [Basic Underwater Demolition/SEAL] applicants to speak to themselves positively, combined with other mental tools, BUD/S passing rates increased from a quarter to a third.”

Simple steps

Let’s sum up some of the practical pieces of positive self-talk. As I mentioned earlier, elements of our internal world create barriers to the simplicity of what I presented here about changing our self-talk. This is where a wise, trusted friend or personal work with a therapist can help you navigate what gets in the way of harnessing the power of healthy self-talk.

When trying to help clients (or myself) understand how self-talk should best sound, I try a few different avenues, asking questions that challenge the internal beliefs that function as the cogs of the internal self-talk machine. If we force one gear (the negative) to stop turning and instead focus our efforts on movement of the positive gear, our mind will automatically begin moving in the direction of wellness.

Even our simplest intentional daily actions change our brains and the brains of our clients. It really is that simple.

 

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Whitney Norris is a licensed professional counselor and somatic experiencing practitioner in Little Rock, Arkansas. In 2017, she co-founded Little Rock Counseling, where she practices as a trauma specialist. She also provides case consultations and private practice business coaching for professionals. Contact her through her website at whitneynorris.com.

 

Letters to the editor:  ct@counseling.org

 

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Related reading, from the Counseling Today archives:

A protocol for ‘should’ thoughts

Quieting the inner critic

 

 

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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 use of evidence-based practices with oppressed populations

By Geri Miller, Glenda S. Johnson, Mx. Tuesday Feral, William Luckett, Kelsey Fish and Madison Ericksen December 3, 2018

Therapy must always be tailored to the individual; there is no one-size-fits-all model. However, certain approaches have been empirically verified for use with a variety of clientele. It is critical that all counselors, especially those working with client populations that are oppressed, have both an overview of evidence-based practices and specific techniques related to these approaches in their clinical toolboxes to help them provide the best counseling services possible.

Counselors are frequently required to use evidence-based practices and need to know how to use them effectively in counseling clients who are oppressed. Specifically, the unique development of the therapeutic relationship between oppressed clients and privileged clinicians must be understood and addressed. Multicultural counseling experts Derald Wing Sue and David Sue maintain that the dynamics of oppression shift the influence of the therapeutic relationship. Thus, counselors must alter their application of evidence-based practice techniques.

Solution-focused brief therapy and low socioeconomic status

Take a moment to think about what the basic needs of your own life are. What is impossible for you to live without? For many of us, our basic needs are continually met. Therefore, they often go unnoticed — they are woven into our everyday lives and ways of being in the world.

For others, questions such as “Will I eat today?” or “Will I have a safe and warm place to sleep tonight?” are asked daily. Often, the answer is “no.” Concerns such as clean drinking water, access to hygiene products and finding adequate shelter affect an inordinate number of individuals in the United States. School counselors and licensed professional counselors have a moral and ethical obligation to address these matters, with the intention of removing barriers and cultivating a safe space for clients in both the therapeutic relationship and the environment beyond our office walls.

Glenda Johnson (one of the co-authors of this article) worked as a school counselor and an advocate in a school system in which the majority of students came from low socioeconomic status (SES) backgrounds. Many of the students were on free or reduced lunch plans because their families’ financial resources were severely limited. At the core of Johnson’s work was the intent to ensure that every child’s basic needs were met while they were at school. She emphasized the importance of working collaboratively with other school staff members to build a team and a foundation for connecting these students and their families to resources.

It is also vital to assess an individual’s behaviors, emotions and reactions through a holistic, biopsychosocial approach rather than focusing only on the school context. Learned behavior concerns, inattention, difficulty with emotion regulation (anger), sadness and loss of hope are often the result of a lack of resources. Johnson recalls that if a student acted out, one of her first questions would be, “Did you have breakfast this morning?”

Johnson shares an anecdote that highlights the powerful act of providing a safe, therapeutic space for students to identify and voice their emotions openly with peers. As a school counselor, she infused the identification of various emotions into a game of musical chairs, and what transpired was completely unexpected. A student identified a “sad” emotion and explained that their father recently had lost his job. The student was experiencing fear about not having enough food to eat during this time. Then, other students began to share similar stories without prompting. The game of musical chairs transformed into a collaborative and touching experience as the students identified common ground and connected on deeper levels of understanding and empathy.

When providing services to individuals from a low SES, counselors may find it helpful to use a strengths-based therapeutic approach. The evidence-based practice of solution-focused brief therapy (SFBT) zeros in on the therapeutic relationship and the clinician’s way of being. In this relationship, there is an acknowledgment of reality but also an emphasis on solution-focused thought and reframing. Focusing on strengths, the counselor and client work together to identify and move toward making small changes in any area because a small change in one area often leads to change in another area.

SFBT often introduces the “miracle” question: “Suppose that when you go to sleep tonight, a miracle occurs that solves your problem, but because you were sleeping, you did not realize what happened. When you wake up in the morning, how will you realize a miracle happened? What will you notice that you are doing differently?” These questions enhance and expose glimpses of solutions that an individual may struggle to identify in everyday life situations.

Additionally, SFBT places great value on successes. The counselor and client celebrate achievement and may use scaling to note the client’s progress. When working in a school system, the counselor could develop a creative and motivating way for children to rate themselves and their progress toward goals. For example, Johnson created a rating scale, complemented by the colors green, yellow and red, for kindergartners and first-graders. Green identified a completed goal, yellow identified progress toward a goal and red identified room for improvement. Similarly, she used a rating scale of 1-5 for students in second through fourth grades. Under this scenario, a student could check in with a rating, such as, “I am at a 3 and working toward a 5.” The counselor might respond, “What would it take to get to a 3.5?” The scale provided a visual for children to identify, track and celebrate their successes.

In SFBT, the counselor acknowledges client strengths and walks alongside these clients as they create and work toward their goals and future successes. “Flagging the minefield” is another technique counselors can introduce to help clients generalize and apply what they learn in counseling to future situations. Flagging the minefield is a particularly important facet of SFBT because it assists individuals in recognizing potential obstacles or barriers that will appear in their lives. The counselor and client work together to identify tools and resources the client can apply in other settings and relationships.

When working with students living in poverty, counselors should introduce a strengths-based approach and identify and gather resources to assist students and their families in removing barriers and meeting basic needs. Cultivating a safe, therapeutic relationship with students that focuses on solution building can assist them in building a stronger sense of self.

Motivational interviewing, SFBT and rural adolescent substance abusers

Adolescence is a vulnerable time and a critical period for developmental outcomes. During this stage of life, adolescents are exploring and forming their peer relationships and personal identities while beginning to distance themselves from family. Experimentation with substances often begins during this time. In 2012, Tara Carney and Bronwyn Myers found a correlation between the early onset of substance use and an elevated risk for later development of substance use disorders. Additionally, because early substance use may impact the growth of the adolescent brain, it has the potential to heighten one’s risk for delayed social and academic development.

Adolescents living in rural areas are marginalized in multiple ways. Children are an underserved minority population, as are rural populations. Sheryl Kataoka, Lilly Zhang and Kenneth Wells (2002) found that among youth with a recognized mental health need (estimated at 10 million to 15 million people), only 20-30 percent receive specialized mental health care. Rural communities are more likely to have fewer clinicians or require a long drive to see those clinicians, making it more difficult to obtain care. These disadvantages are exacerbated by the tumultuous nature of adolescence.

Motivational interviewing and brief interventions are two evidence-based practices particularly suited to this population because these approaches are generally influential in their therapeutic role while also being cost-effective. Motivational interviewing facilitates behavior change through exploration and resolution of ambivalence, and it focuses on being optimistic, hopeful and strengths-based. It uses principles of empathy, discrepancy, self-efficacy and resistance, and offers specific techniques such as OARS (Open questions, Affirmations, Reflective listening, Summarizing). SFBT emphasizes solutions, changes clients’ perceptions and behaviors, helps clients access their strengths and uses techniques such as exception to the problem, specification of goals and the miracle question.

Individual interventions with the use of the same interventions for multiple sessions are ideal, and research suggests that the earlier the intervention, the better the outcome. Early intervention shows better results than both preventive measures and later interventions because it reduces the need for more specialized interventions and provides applicable and useful tools and tactics for adolescents as they enter into various student, peer, familial and professional roles.

Challenges certainly exist when working with children and adolescents, particularly because many biological, environmental and social shifts occur organically during this time. As children and adolescents rapidly transition on a continuum of development, they become “moving targets.” Interventions that prove effective for those ages 11-12 often cease to be effective by ages 13 or 14. It is vital that counselors remain aware of this across the life span. Although adolescents are beginning to distance themselves from their caregivers, familial relationships and parental involvement remain crucial during this period.

To appropriately and competently involve the families of rural adolescents, some understanding of cultural values is necessary. In 2005, Susan Keefe and Susie Greene identified core Appalachian values, including egalitarianism, personalism, familism, a religious worldview, a strong sense of place and the avoidance of conflict. In the Appalachian region, assuming authority without demonstrating an authoritarian attitude is important. Language tends to be simple, direct, honest and straightforward. Family is extremely important, exemplified by the adage “blood is thicker than water.” Individuals’ relationship to the land is complex, and it can be beneficial to explore how clients view economic deprivation. In 2016, Sue and Sue also pinpointed some tendencies of rural clients, including having a “street-smart” attitude and way of being, depending on systems due to living in poverty and valuing survival at all costs.

As a result, subtle techniques such as stages of change, motivational interviewing and SFBT may be useful for this population. In stages of change, the intervention is matched to the stage of the client’s readiness to change (precontemplation, contemplation, preparation, action, maintenance, termination). Motivational interviewing facilitates an invitation to engage, and its strengths-based, hopeful tone can be helpful for clients living in an environment populated by deficits such as poverty and lack of education. The practical nature of brief therapy fits well with the no-nonsense worldview of clients coming from rural backgrounds.

Unfortunately, published rural studies often focus on specific regions or populations. Few interventions have been tested in rural settings, and the evidence from systematic reviews is often too general and not specific to the rural context. Ideally, rural communities could review interventions tested with various target populations in a range of settings. Such information is not usually available, however, and the strength of evidence is unlikely to be the only factor considered in choosing an intervention. The research on rural adolescent populations is limited, and little consistency exists across studies related to measurement tools. Furthermore, disseminating evidence-based practices to schools, families and community settings in rural areas is difficult due to the lack of resources.

However, it is important to note that there have been great improvements in substance abuse treatment and prevention with children and adolescents who live in rural areas. A 2016 Monitoring the Future survey of eighth-, 10th- and 12th-graders by the National Institute on Drug Abuse found the lowest ever reported rates of use for all illicit drugs, including alcohol, marijuana and nicotine. As further research is conducted, it will be important to delve into this information to identify what is already working with these individuals and what can be improved to better serve them moving forward.

Evidence-based practices with transgender clients

Transgender individuals face discrimination on multiple fronts. Many experience familial rejection, unequal treatment, harassment and physical violence during daily living. The rate of substance abuse within the transgender community is three times higher than that of the general population. There is a profound lack of competent health care for transgender individuals, and the care that is available may be inaccessible to a majority of the transgender population. The rate of unemployment within the transgender community is also three times greater than that of the general population, due in part to factors such as workplace discrimination, poverty and homelessness. Transgender people also face discrimination and mistreatment in shelters.

With high rates of homelessness, substance abuse and mistreatment, transgender people also have frequent interactions with law enforcement, where they can be subject to police brutality and discrimination. Within the criminal justice system, a high rate of physical and sexual assault is perpetrated against transgender individuals, and they are often denied medical treatment while incarcerated or detained.

Poor health outcomes for transgender people correlate with risk factors such as economic and housing instability, lower educational attainment, lack of family support and other intersectional factors such as race, ethnicity, immigration status and ability.

According to the 2015 U.S. Transgender Survey, 18 percent of transgender people who sought mental health services experienced a mental health professional attempt to stop them from being transgender. This correlated with higher rates of serious psychological distress and suicide attempts and an increased likelihood of running away from home, homelessness and engaging in sex work.

Research conducted in 2015 by Samantha Pflum et al. emphasized the lack of access to transgender-affirming resources and communities for individuals living in rural locations. The history of mistreatment and abuse of lesbian, gay, bisexual, transgender and gender-nonconforming clients by medical and mental health professionals must be acknowledged. Gender and sexual minority clients still face discrimination within the helping professions, and for individuals holding multiple marginalized identities, these experiences are compounded.

Even well-meaning providers are likely to make mistakes when working with marginalized clients. According to Lauren Mizock and Christine Lundquist, one of these mistakes is education burdening, or relying on the client to educate the provider about transgender culture or the general transgender experience. Resources exist to facilitate competence in these areas, and clinicians have a responsibility to refrain from placing the burden of their education on the client.

Some counselors participate in gender inflation, or focusing on the client’s gender to the exclusion of other important factors. Other counselors engage in gender narrowing, applying restrictive, preconceived ideas about gender to the client, or gender avoidance, which involves ignoring issues of gender altogether. Gender generalizing occurs when a clinician assumes that all transgender clients are similar. Gender repairing operates from a belief that a transgender identity is a problem to be “fixed.” Gender pathologizing involves viewing transgender identity as a mental illness or as the cause of the client’s issues. Finally, gatekeeping occurs when a provider controls client access to gender-affirming resources.

Acceptance of a client’s gender identity is ultimately not enough to provide competent, affirmative services. Understanding the nuances of these common mistakes will help clinicians provide a safe therapeutic environment that is affirming of these clients’ identity and humanity.

The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association, has developed competencies for counseling transgender clients (see counseling.org/knowledge-center/competencies) that focus on the following eight domains:

  • Human growth and development
  • Social and cultural foundations
  • Helping relationships
  • Group work
  • Professional orientation
  • Career and lifestyle development competencies
  • Appraisal
  • Research

Counselors can work within this framework to:

  • Promote resilience by using theoretical approaches grounded in resilience and wellness
  • Conceptualize the development of a transgender individual across the life span
  • Understand internal and external factors influencing identity development
  • Consider how identity interacts with systems of power and oppression (especially for minority transgender individuals)
  • Examine counselors’ own internalized beliefs and how those beliefs affect attitudes toward transgender clients
  • Reevaluate approaches to working with transgender clients as new research emerges

One intervention that has been identified for use with this population by Ashley Austin and Shelley Craig is transgender-affirmative cognitive behavior therapy (CBT). Transgender-affirmative CBT modifies CBT interventions to address specific minority stressors, such as victimization, harassment, violence, discrimination and microaggressions, that transgender people commonly face. This approach uses psychoeducation to help clients understand the connections between transphobic experiences and mental health issues such as stress, anxiety, depression, hopelessness and suicidality. Experiences are processed through a minority stress lens to help clients move from a pathologizing-of-self mindset to an affirming view of themselves as people coping with complex circumstances.

Clinicians are advised to affirm the existence of discrimination and to help these clients identify influences on their mental health by using the transgender discrimination inverted pyramid (see below). 

Transgender individuals internalize messages at each level, and it can be beneficial to have a visual for how these messages trickle down and influence mental health. Clinicians can empower transgender clients by assisting them in challenging internal and societal transphobic barriers. A few examples are challenging negative self-beliefs, connecting with a supportive community and advocating for self and community.

Another approach recommended for use with transgender clients by Joseph Avera et al. in 2015 is the Indivisible Self model, an Adlerian wellness model refined by Jane Myers and Thomas Sweeney that emphasizes strengths. There are five wellness factors of self in this model:

  • Creative Self: Cognitions, emotions, humor and work
  • Coping Self: Stress management, self-worth, realistic beliefs and leisure
  • Social Self: Friends, family and love)
  • Essential Self: Spirituality, self-care, gender identity and cultural identity
  • Physical Self: Physical and nutritional wellness

This model easily can be adapted to a transgender-specific lens, especially regarding the Essential Self, by exploring gender and cultural identity and how they influence client experiences and beliefs. Used in conjunction with the ALGBTIC transgender competencies, the Indivisible Self model offers helping professionals both a conceptual and practical framework for working effectively with transgender clients.

For all clients, and transgender clients in particular, intersectional factors magnify the experience of oppression. Sand Chang and Anneliese Singh recommend addressing the intersectionality of race/ethnicity and gender identity for both clients and clinicians. This involves:

  • Challenging assumptions about the experiences of transgender and gender-nonconforming people of color
  • Building rapport and acknowledging differences within the therapeutic dyad
  • Assessing client strengths and resilience in navigating multiple oppressions
  • Providing a variety of resources that are affirming to transgender and gender-nonconforming people of color

In addition, assisting clients in locating social support is advised. Social support increases healthy coping mechanisms and helps with self-acceptance, thereby reducing psychological stress related to discrimination. Social support can also help to normalize and validate emotions related to discrimination.

Conclusion

Evidence-based practices have consistently been shown to be helpful to clients, but counselors must remember that they operate within the context of a relationship. To use evidence-based practices effectively, we must hold on to our humanness. The implementation of a single technique will look very different depending on who is in the room and what they are bringing with them.

Often, the expectations for using evidence-based practices might create pressure for counselors to follow a strict formula for treatment. Process variables such as honoring the personal relationship between the counselor and the client, maintaining a “therapist’s heart” and respecting the unique aspects of the client may seem to be at odds with the procedure for using a specific intervention. A working knowledge of multicultural issues can provide some context for how to shift evidence-based practices to fit the client rather than pressuring the client to conform to a prescribed, generalized format.

Using interventions with a solid evidence base is good practice. Adjusting their implementation on the basis of the unique identity of the person sitting across from us is great practice.

 

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

Geri Miller is a professor in the Department of Human Development and Psychological Counseling (clinical mental health counseling track) at Appalachian State University (ASU) in North Carolina. She is a licensed professional counselor, licensed psychologist, licensed clinical addictions specialist and substance abuse professional practice board certified clinical supervisor. She has been a volunteer counselor at a local health department since the early 1990s. Her clientele has primarily consisted of women with little opportunity for jobs or education and who experience barriers of poverty. Contact her at millerga@appstate.edu.

Glenda S. Johnson is an assistant professor in the Department of Human Development and Psychological Counseling (school counseling program) at ASU. She is a licensed professional counselor and a licensed school counselor in North Carolina. Her scholarly focus includes school counselors delivering comprehensive school counseling programs, students who are at risk of dropping out of high school and the mentoring of new counseling professionals.

Mx. Tuesday Feral received their master’s degree in clinical mental health counseling and a certificate in systematic multicultural counseling from ASU. They are the support programs director for Tranzmission, a nonprofit organization serving the Western North Carolina nonbinary and transgender community through education, advocacy and support services. Tuesday offers training and workshops in trans cultural competence and cultural humility on local, state and national levels.

William Luckett received his master’s degree in clinical mental health counseling from ASU with a certificate in addictions counseling. He has interests in somatic therapy approaches, mindfulness, religious and spiritual topics in counseling, and substance abuse counseling. He currently provides in-home counseling to rural families in Virginia.

Kelsey Fish is a student in ASU’s clinical mental health counseling program and a clinical intern with Daymark Recovery Services in rural Appalachia. Her clinical interests include expressive arts therapy, adolescents, and gender and sexual minority issues.

Madison Ericksen is a graduate of the clinical mental health counseling program at ASU. She has specialized training and interest in trauma-informed practices that use mindfulness, eco-based and expressive art therapies as complementary treatments alongside traditional therapy. She provides strengths-based and resiliency-focused outpatient counseling for children and families.

 

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.

 

Team sports vs. solo exercise: Which is better for your mental health?

By Bethany Bray

Professional counselors often recommend exercise to clients as a way to improve mood and overall wellness. In addition to boosting serotonin, a neurotransmitter connected to feelings of well-being, exercise offers the chance to unplug from the busyness of daily life and process one’s thoughts.

A recent journal study in The Lancet Psychiatry takes that recommendation one step further, connecting team sports to improved mental health. A cohort of researchers studied four years of recent survey data from more than 1 million American adults.

They found that individuals who exercised experienced 43 percent fewer days of poor mental health in a one-month period than did people who didn’t exercise at all. Individuals who experienced the greatest mental health benefits, however, were those who participated in team sports, followed by those who rode bicycles or did aerobic and gym activities (in durations of 45 minutes, three to five times weekly).

Jude and Julius Austin, American Counseling Association members who played soccer both in college and at the professional level, stress that the study’s correlational findings do not mean causation.

“We think further research needs to be done regarding the lived experience of athletes in team sports who struggle with mental health issues,” said the brothers in a co-written statement to Counseling Today on the Lancet findings.

Although mental health improvements are not caused by exercise, physical activity does, when done appropriately, have biological, cognitive and social benefits — which Jude, an assistant professor in the counseling program at the University of Mary Hardin-Baylor in Texas, and Julius, an assistant professor in the marriage and family therapy and counseling studies program at the University of Louisiana Monroe, say they experienced as soccer players.

“It is exciting to see [researchers] investigating things we believe most athletes can collectively, albeit anecdotally, agree on,” wrote Jude, a licensed professional counselor in residency and Julius, a provisionally licensed professional counselor. “In our experience playing team sports, it feels great to survive a particularly tough practice. Pushing ourselves through seemingly impossible physical tasks with others reinforced that we have everything we need to handle life’s challenges. There is something healing about being swept away by the team’s mentality during a game; pressing or absorbing pressure, counterattacking or keeping possession, the ebb and flow of defense to offense, being in the zone. Even if it’s only for a moment, those sweeping moments were where we received social support, affirmation, genuineness, empathy and unconditional positive regard. These are all therapists’ offered conditions in an effective therapeutic relationship. We could not say this with empirical certainty, but we would imagine that receiving these conditions from a team can cause lessening of mental health issues.”

ACA member Sarah Fichtner, a former Division I women’s soccer player for the University of Maryland (UMD), has mixed feelings about the Lancet study. While there is little doubt that exercise in general benefits both mental and physical health, it can be taken to the extreme when sports are played at a high level, she says.

“I am a firm believer that exercise improves an individual’s mental health, as it produces feel-good endorphins and releases chemicals such as norepinephrine which alleviate stress and anxiety,” Fichtner says. “As an exercise and health enthusiast myself, there is not a doubt in my mind that exercise has many positive implications. However, I am a bit skeptical of the [Lancet] findings pertaining to team sports. I do see the benefits of exercise groups [in] that they provide accountability, comradery and support, but in terms of competitive team sports — particularly at the collegiate level — the environment is extremely different.”

Fichtner is a counselor intern at Hackensack Meridian Behavioral Health and is working on completing a master’s degree in clinical mental health counseling at Kean University in New Jersey. After her experience as a DI athlete, she calls for balance when it comes to competition and team sports.

“During my time as a student-athlete and captain at the University of Maryland, I saw firsthand the detrimental consequences of the collegiate world. When a player is recruited to play at the DI level, he or she is expected to perform. Coaches have one goal in mind, and that is to win,” she explains. “Practices are intense, to say the least, and the idea of healthy competition goes out the window. A player is competing against his or her teammates every day to secure a starting position. They are competing to be the fastest, fittest, slimmest and most technical or tactical player. And every day, their coaches are telling them, ‘You are not good enough,’ ‘You need to lose five more pounds to be in the running for a starting position,’ ‘Your teammates are working harder than you’ and ‘Ask your teammate so-and-so for help. She is outperforming you. She has great skills.’ This high-intensity environment can lead to many mental health challenges such as eating disorders, anxiety, depression and low self-esteem, which I witnessed during my four years at UMD. Thus, when I think about team sports, specifically at the collegiate level, the word balance comes to mind.”

“Aside from the intense environment, there were many positives takeaways from my time as a student-athlete,” Fichtner adds. “I made lifelong friendships, competed at the highest level of collegiate sports, was privileged to visit many states, had top-notch gear, learned important life lessons and would do it all over again in a heartbeat. Nevertheless, now as a mental health counselor, I see the collegiate world through a different lens. Many of the challenges we athletes faced on a daily basis seemed both normal and absolute. But now as I grow both personally and professionally, I realize that colleges need to establish a balance between a healthy competitive environment, where athletes are pushed and held accountable, and a debilitating, harmful environment, in which athletes are placed in harm’s way [of] mental health challenges. Balance is key to any exercise regimen, especially in the collegiate world.”

 

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Read the Lancet study in full: thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30227-X/fulltext#seccestitle10

 

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ACA members: Interested in exploring connections between sports and mental health? Join ACA’s Sports Counseling Interest Network.

 

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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.