Monthly Archives: February 2019

The gifts of volunteering as a disaster mental health counselor

By Suzanne A. Whitehead February 19, 2019

I was presenting at the Western Association for Counselor Education and Supervision Conference in Santa Rosa, California, on the evening of Nov. 8, 2018, when the urgent call came. The American Red Cross was frantically looking for certified disaster mental health counselors to help with what appeared that it might become a large disaster due to the wildfires that had sprung up near the areas of Chico and Paradise, California. (This would later be named the Camp Fire.) I responded that I could be there on Nov. 11 to help out as much as possible. I had been watching the news reports while at the conference, and I could tell the situation was growing dire.

As I left the conference, being held about an hour west of the fires, that Saturday evening, the acrid smoke filled the air and pellets of ash hit the roof and sides of my car as I made my way south. I live in the Central Valley of California, about 2.5 hours south of the fires and Santa Rosa. All the way home, the smoke lingered in the air like a very dense fog, yet I knew it was far worse.

I raced back to Sacramento (1.5 hours north) the next morning to go to the American Red Cross headquarters to get my assignment. The fires had been raging and spreading for more than 3 days at that point. The skies above were thick with smoke, and I wondered what I might be getting myself into.

A decimated landscape along Highway 33 in Ojai, California after recent wildfires.

As I approached the Red Cross headquarters, I encountered a scene of organized chaos. I had an appointment with our area chief, but finding her took some time. When we finally met, she ushered me into a side office and gave me an assignment to one of the nine shelters opened in the fire areas. She also gave me several breathing masks, some bottled water and a “Go with God” message. There was no time for idle chatter.

I swallowed hard and drove the extra hour north. As I progressed, I couldn’t help noticing that fewer and fewer cars were headed toward the wildfire areas; many, many more were leaving. I had volunteered with the Red Cross along the Gulf Coast for two weeks in 2005 after Hurricane Katrina. After that experience, I also served as a disaster mental health volunteer in the wake of several local disasters on the East Coast, where I lived at the time. So, I already knew what to expect when it came to “shelter life,” but at the same time, I also was aware that each disaster — and each set of life circumstances — is unique. I braced myself for the possibilities, knowing I had to be strong.

 

In the shelter

As I approached the shelter, I again encountered organized chaos. The air was sooty and couldn’t be escaped, either in your car or in the buildings. I was stationed at an old fairground that had been turned into a makeshift shelter. A large building housed a common area, a kitchen and a gymnasium that had been turned into the sleeping quarters. There were two sets of bathrooms, but they featured cold water only – and no shower facilities. For showers, the Red Cross had placed trailers outside that contained three showers on each side for the “residents” to use. There were also dozens of people staying in their cars, in tents, in campers and in recreational vehicles, all surrounding the main shelter. These were the survivors who had escaped with their animals but were not allowed to bring them into the shelter.

As I entered the main hall, crowds were everywhere, lining up to get food, clothing, toiletries, diapers, wipes, supplies and water. I could hear the sense of panic and distress in the voices around me, and the looks on the survivors’ faces told of their immense grief and shock. I made my way over to where the two other disaster mental health counselors were located, inside the gym turned sleeping quarters. They filled me in on some of their areas of concern — and the individuals whom they were concerned about. Every cot was filled, with the distance between each being about 2 feet. My disaster mental health colleagues thought we had in excess of 125 survivors inside. They estimated at least another 75 or so people outside. I knew that we had our hands full because the need was tremendous.

By Nov. 11, the disaster had grown to a Level 5, one of the highest levels the Red Cross declares. It would later grow to a Level 7, the highest level possible, based on loss of life, the number of people affected, duration and overall cost. I started mingling throughout the crowd and saw a tremendous outpouring of distress. Many survivors were simply “walking wounded,” too much in shock to say much and still just trying to absorb all that had happened to them. Many asked me to help them find their loved ones; others cried over the fear that they had lost their precious pets.

I quickly found the list of referrals and resources to hand these survivors, but many didn’t even have a phone or the numbers of loved ones to call. The fires had spread like no one could remember, raging at their backs as they tried to flee. They had time to gather little beyond the clothes they wore. They shared stories of racing through the burning brush with the flames licking their cars as they fled.

Others spoke of quickly abandoning their vehicles when they got stuck in a standstill traffic jam on the few small roads that led to their once beautiful towns. They left their cars with few or no belongings, running along streets, paths and through the forests to escape on foot. When they spoke, their eyes lit up with fear, as if reliving the nightmare.

 

Personal encounters

You do a lot of psychological first aid as a disaster mental health volunteer in the first few days after a disaster. You mentally sort out those who seem to be coping, albeit shakily perhaps; those who don’t talk at all, keeping it bottled inside; and those who are clearly in great distress. You look for support systems of any kind and try to surround them with those who still have some “reserves” to give.

I encountered people from every walk of life during those first few days in the shelter, including those who were desperately poor to begin with. The stories of rescues and heroism made my heart skip, reveling at the strength of the human spirit. There were so many older adults, with walkers and wheelchairs, frightened and seemingly all alone. They struggled to remember phone numbers, addresses and the medications they needed — all common artifacts of trauma and disaster situations. We were eternally blessed at our shelter with several wonderful nurses on staff and a physician. They were a godsend, especially when the norovirus invaded the shelter a few days later. It wasn’t the best time to try to quarantine vast amounts of people, and yet there we were.

For many, the shelter offered a brief respite as they gathered their senses and financial resources, decided which relative or friend to travel to, and filled their gas tanks or purchased their plane tickets. The main hall meeting room was filled to capacity at meal times. The food was prepared at a central location in town and transported to all the shelters via the huge Red Cross emergency response vehicles.

People of all walks of life slowly began to reach out to one another; donations of food, clothing and supplies poured in; and no one was turned away. Friendships began to emerge by the fifth day, and a few smiles began to peer through the depression. The wildfires were still raging, and everyone instantly stopped what they were doing when the fire marshals came in each day to give their updates and reports. You still couldn’t go outside safely without a breathing mask on, and by this point, the acrid smoke and soot were in our hair, clothing and lungs.

And so it went. The days went by with little word about the survivors’ homes. There was one small television in the gym/living quarters, and the “residents” huddled there whenever a news report came on. I began making mental notes of the individuals I was most worried about: the young man who was clearly going through withdrawal of some kind; the older adult women with walkers and canes who were frightened easily and tired quickly; the caring gentleman who reached out to others but quickly escalated to outbursts of anger when he felt distrust; the man recovering from a recent stroke and estranged from his family, wishing now that it wasn’t so.

There were stories of heartache, pain, remorse, forgiveness, bravery, heroism and hope. All the while, I knew that this could happen to any one of us, in a heartbeat. When these people had awoken that fateful morning, they had no warning of the impending doom, no way to prepare and just barely enough time to get out of harm’s way. The fragileness of humanity struck me as I tried my best to help those in dire need. Given the same circumstances, I wondered how I would react.

 

What’s left behind

By the following weekend, Nov. 17, the only residents left in the shelter were the truly needy. These were the poor souls who had lost everything in the fires — they had no resources, no home owners insurance, nowhere to go, no one to go to. A feeling of great malaise and sadness had come over the group, and we did our best to try to restore hope.

It was a normal process and cycle, one I had witnessed after Hurricane Katrina so many years prior, and I was mentally prepared for it. However, these are human lives you are working with, and to say it doesn’t pull at your very soul would be a lie. People wanted and deserved answers, yet few were forthcoming because it was deemed unsafe to return to what remained of their homes.

The fires were mostly contained by this point; the grizzly, heart-wrenching job of finding the missing was well underway. The numbers feared missing had gone from an early count of 20 or so to well over 800, and then back down to less than 100 eventually. The residents cried at every news update and mourned the loss of their dear pets much more than the loss of belongings. Repeating their stories of survival to all who would listen was therapeutic and helped to alleviate some of the general malaise. It was a necessary element for returning to any sense of “normalcy.”

Nov. 18 arrived, and I had to return home, 2.5 hours south. I am a counselor educator, and my university had been closed for several days due to the horrid air conditions; we would remain closed until after Thanksgiving. Yet, there these people remained, trapped in a place they could not leave.

I felt great sadness as I left the shelter that evening to return to my home. I was reminded again and again of how very fortunate I am in life, and I felt blessed that I could be there to give solace to a few dear souls. I was not able to get the smell of smoke out of my hair and clothes for days — and out of my car for weeks — yet I was the supremely fortunate one.

It is so very true that disasters bring out the very best and the very worst in people. I chose to focus on the very best, and I witnessed it over and over. Just as when I deployed with Hurricane Katrina, I learned so very much about myself on this assignment. As a disaster mental health volunteer, you dig deep into your soul and discover what is truly important in this life. Just as with my Katrina experience, I received so many thank-you’s and bless-you’s this time that I was humbled to my core. The survivors told me I had given them so very much, but especially a sense that someone deeply cared about their plight. I am truly the lucky one, however, because giving our time and talents is such a precious gift to share.

The crisis of the wildfires in Northern California has now left the airwaves, but it still looms large. The American Red Cross continues to request assistance there; the need will go on for months, if not years, as the towns of Chico and Paradise try to rebuild.

If I can do anything now, it is to encourage professional counselors to volunteer with the American Red Cross. The trainings are easy, and most can be completed at your own time and pace. The need is tremendous because there is no shortage of disasters in our world. To volunteer, you need to be a clinical mental health counselor or a certified/credentialed/licensed school counselor. It just may be the most precious gift of your lifetime to give, and I can’t encourage you enough.

 

 

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Suzanne A. Whitehead is the program coordinator and an assistant professor of counselor education at California State University, Stanislaus. She is a licensed mental health counselor, national certified counselor and licensed addiction counselor. She has volunteered with the American Red Cross since 2005. Contact her at swhitehead1@csustan.edu.

 

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ACA Disaster Mental Health webpage: counseling.org/knowledge-center/trauma-disaster

 

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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.

Study: Genetic wiring as a ‘morning person’ associated with better mental health

By Bethany Bray February 11, 2019

Are you a morning person or a night owl?
Most people consider themselves to be one or the other, with a natural inclination for productivity either in the morning or after sunset.

Not only are these tendencies wired into our genes, but they have a correlation to mental well-being, according to a study published Jan. 29 in the journal Nature. A cohort of researchers found that the genetic tendency toward being a morning person is “positively correlated with well-being” and less associated with depression and schizophrenia.

“There are clear epidemiological associations reported in the literature between mental health traits and chronotype [a person’s ‘circadian preference,’ or tendency toward rising early or staying up late], with mental health disorders typically being overrepresented in evening types. … We show that being a morning person is causally associated with better mental health but does not affect body mass index (BMI) or risk of Type 2 diabetes,” the researchers wrote.

A person’s tendency toward what the researchers refer to as “morningness” is wired into the genes that regulate our circadian rhythm. In addition to sleep patterns, the body’s circadian rhythm affects hormone levels, body temperature and other processes.

Using data from more than 85,000 people, the researchers found that the sleep timing of those in the top 5 percent of morning persons was an average of 25 minutes earlier than those with the fewest genetic tendencies toward morningness.

The study also highlights the connection, reported by previous research, between schizophrenia and circadian dysregulation and misalignment, as well as the increased frequency of obesity, Type 2 diabetes and depression in people who are night owls.

“One possibility which future studies should investigate is whether circadian misalignment, rather than chronotype itself, is more strongly associated with disease outcomes,” wrote the researchers. “For example, are individuals who are genetically evening people but have to wake early because of work commitments particularly susceptible to obesity and diabetes?”

 

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Read the full study in the journal Nature: nature.com/articles/s41467-018-08259-7

 

From the Australian Broadcasting Corporation: “Early birds have a lower risk of mental illness than night owls, genes show

 

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Related reading from Counseling Today:

 

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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 there an epidemic of emotional support animals?

By Cynthia K. Chandler February 6, 2019

On June 6, 2017, ABC News reported that a man had been severely injured on a Delta Air Lines flight after being attacked by another passenger’s emotional support dog. The dog had been sitting in its owner’s lap in a center seat. The dog reportedly growled before the attack, prompting the man to ask the owner if the dog was going to bite him. The victim received multiple bites to the face, became covered in blood, and was removed from the plane and transported to the hospital. The dog’s owner was in the military and said he had been issued the dog for emotional support.

On Oct. 29, 2017, USA Today described an incident in which a service dog, a yellow Labrador retriever, was sitting calmly in an elevator next to its owner, who was in a wheelchair. Then another woman entered the elevator carrying a toy poodle in her purse. Just as the elevator door closed, the poodle jumped out of the woman’s purse and bit the service dog on the snout, causing blood to drip on the elevator floor. After this occurred, the woman first declared that her poodle was a service dog. She then changed her story and said the poodle was an emotional support dog. Finally, she admitted the poodle was a pet that she had just wanted to bring into the building with her.

On Feb. 22, 2018, The Washington Post reported that an emotional support dog on a Southwest Airlines flight bit a 6-year old girl in the face during boarding. The flight was delayed for takeoff while paramedics examined the child and declared her healthy enough to continue with the flight. The dog and its owner were left behind.

There are important lessons we should take away from these reports, the first being that dogs bite. Or, to be more accurate, dogs without the proper temperament and training to be out in public may bite. Second, people often are not objective about their pets’ behavior and, because of this, may put other people and other dogs at risk for injury. And third, some people, such as the woman with the toy poodle on the elevator, may not be honest about their need for an emotional support animal.

Confusion around emotional support animals

The Fair Housing Act that established the right for an emotional support animal to live with its owner in pet-restricted housing does not provide any right for the pet to accompany the person anywhere else. The Air Carrier Access Act established the right for an emotional support animal to accompany its owner during air travel. As a public safety issue, it is extremely important to understand these two pieces of legislation and what an emotional support animal is exactly.

First of all, an emotional support animal is not a service animal. Therefore, rights related to emotional support animals are not covered by the Americans with Disabilities Act. Currently, there is no official oversight regarding the qualifications of a pet to be an emotional support animal. There is currently no requirement for a pet to be evaluated by a qualified animal evaluator to be called an emotional support animal. The pet’s owner is the one who decides that the pet is an emotional support animal. The Fair Housing Act regulation about emotional support animals stipulates that these animals do not have to be trained, certified or registered. It is my opinion that the absence of a requirement for proper training and evaluation of pets to be emotional support animals is a real public safety concern.

Opportunism and irresponsibility have gravitated to the realm of emotional support animals. Many services now exist, mostly in the form of websites, that charge a fee to pet owners to register their pets as emotional support animals. In reality, this type of registration means nothing because it does not signify that a particular pet possesses a temperament that makes it safe to be around, either in public or on a plane. Nor does this registration mean that the pet has any special aptitude or skill to serve in the role of an emotional support animal.

In my opinion, current commercial services that register pets as emotional support animals are mostly a scam. These services take people’s money for no legitimate purpose and mislead the public by implying that people and other animals are free from danger when around pets that are registered as emotional support animals. Presenting a pet as a registered emotional support animal is equivalent to promoting the falsehood that the pet possesses some special qualification.

Most of these website services will also sell a vest or some other type of uniform for a pet to wear in public that indicates the pet is registered as an emotional support animal. This can insinuate that the pet must be allowed in places other than the owner’s home or on an airplane (the only two places legislation actually designates that emotional support animals must be allowed). In essence, registration of a pet as an emotional support animal is worthless to everyone except the commercial enterprises that take money from the pet’s owners.

A significant lack of understanding also exists concerning the documentation required to establish a person’s need for an emotional support animal. Recently, a counselor forwarded me the official policy of a college in Florida that requires pets to be registered as emotional support animals before they can live with their owners in college housing. That policy is out of compliance with the Fair Housing Act, which does not require pets serving as emotional support animals to be registered as such. And, as a matter of course, the college’s policy is forcing people to participate in — that is, pay money for — a worthless scam known as emotional support animal registration (although the college is likely unaware of this fact). The college’s policy is further out of compliance with the Fair Housing Act because it requires health care and mental health care providers to name and describe a client’s diagnosis or disability when providing emotional support animal documentation. Naming or describing a person’s diagnosis or disability is not required by the Fair Housing Act.

The Fair Housing Act does require emotional support animal documentation to be provided by a licensed health care or mental health care provider, as well as for the recipient of the documentation to be under the care of the provider. The required documentation involves a few statements by a health care or mental health care provider, on an official prescription pad or letterhead, declaring that:

1) The person is under the provider’s care.

2) The person has a diagnosed disorder or disability. (Remember, there is no requirement to name or describe the diagnosis or disability.)

3) The person can benefit from having an emotional support animal to reduce or alleviate symptoms associated with the diagnosis or disability. (These symptoms do not need to be named or described; however, for readers’ information, common symptoms that the presence of an emotional support animal might reduce or alleviate include anxiety, depression, loneliness, and emotional or physical pain.)

Health care and mental health care providers should never specify a particular pet as an emotional support animal in supplied documentation. Why is that? One, health care and mental health care providers are unlikely to be qualified to evaluate animal behavior. And two, they would basically be endorsing that particular pet as an emotional support animal, thereby placing themselves at jeopardy for a lawsuit should the pet injure someone. By the way, the flawed college policy I mentioned earlier also erroneously required health care and mental health care providers to describe in their documentation the specific emotional support animal and its abilities. Once again, this is not in compliance with the Fair Housing Act.

Documenting need

Another major public safety issue is the documentation that health care and mental health care providers are now supplying to support the seemingly epidemic need for emotional support animals. Over the past few years, I have found that a large number of mental health care providers, including many licensed counselors, are playing loose with the ethics of the duty of care in the way they are providing this documentation.

Allow me to outline three questionable activities I have observed or learned about that give me cause for concern.

  • Some mental health care providers supply documentation of a person’s need for an emotional support animal after only a single visit and then exercise little or no follow-up. Thus, the client’s need is not thoroughly assessed or properly monitored.

Technically, a person may be considered to be “under the care” of a mental health care provider after only one visit, but in my opinion, a single visit for the sole purpose of providing emotional support animal documentation is a gross misrepresentation of the duty of care. Also, I recommend that mental health care providers place a termination date of six months on the supplied documentation because a person’s condition can change and, thus, so can the need for an emotional support animal.

  • When supplying documentation, some mental health care providers do not assess or consider the client’s ability to determine whether a pet (emotional support animal) might be a disturbance, a danger or destructive.

Providers of emotional support animal documentation need to consider their obligation to public safety — that is, their role in helping to protect those with whom a client with an emotional support animal may come into contact. Remember, an emotional support animal is any pet that an owner wants to declare as such. It is unlikely that the designated emotional support animal will have training or have been evaluated for proper temperament.

  • Some mental health care providers supply documentation endorsing the need for an emotional support animal to people with whom they have had little to no direct contact.

Consider this scenario: A new for-profit enterprise is growing by leaps and bounds. This enterprise involves website services that document individuals’ needs for emotional support animals. These internet services are recruiting large numbers of mental health care providers, especially licensed counselors, to join a network to review questionnaires completed by applicants requesting documentation of their need for an emotional support animal. On the basis of the questionnaire, and sometimes a brief communication with the applicant via telephone, email or webcam, the mental health care provider assesses the applicant, provides a diagnosis and determines that the applicant could benefit from having an emotional support animal. On the basis of the mental health care provider’s brief assessment and applied diagnosis, the website service then provides a form letter to the applicant after taking a fee.

Several counselors have contacted me asking whether they should accept the invitation they received to become a provider for this type of web-based service that supplies emotional support animal documentation. I always recommend that they decline such offers. I do not consider these types of services ethical or responsible. Furthermore, I believe any mental health care provider who works for this type of service to provide emotional support animal documentation in this accelerated and impersonal manner is:

1) Performing at a highly questionable level of ethical functioning regarding duty of care

2) Contributing to the potential endangerment of those who may come into contact with emotional support animals that do not have the proper temperament and training to be out in public

3) Contributing to an epidemic of emotional support animals

An escalating problem

The large and growing number of emotional support animals is highly problematic. The public often confuses emotional support animals with working service animals. Unfortunately, because of this, people have learned that they can get away with taking their emotional support animals just about anywhere, even though they have no legal right to do so.

This confusion often occurs because:

  • Federal law does not require that a service animal wear a uniform or have documentation.
  • People often do not want to offend a person who may be accompanied by a service animal, so they do not inquire if the animal is truly a service animal.
  • The law places a limit on what a person accompanied by a service animal can be asked. Only two questions regarding a service animal are allowed: Is the animal required because of a disability? What work or task has the animal been trained to perform? Specific questions about the person’s disability are not allowed.

Because of the general public’s confusion concerning service animals versus emotional support animals, people with emotional support animals can easily misrepresent themselves as being accompanied by a service animal and go places where they are not allowed. Falsely claiming that a pet, including an emotional support animal, is a service dog is illegal in some states. According to a 2018 article in Texas Monthly, such a false claim made in Texas is classified as a misdemeanor and is subject to a fine of up to $300 and community service at a place that serves people with disabilities.

There is no way to determine how many emotional support animals there are, but it is clear they are rapidly growing in number. A 2014 article in The New Yorker detailed one commercial website that registers pets as emotional support animals. It reported 2,400 such registrations in 2011; the number at just that one site grew to 11,000 in 2013. So, yes, we have a growing epidemic of emotional support animals.

Lack of official oversight regarding the behavior of emotional support animals, along with the poor judgment of some owners, is resulting in public nuisances and endangering public safety. It has been demonstrated that people want to take their pets places that pets should not go. Furthermore, the public’s confusion about rights of access for service animals versus emotional support animals is adding to the problem. In addition, many health care and mental health care providers are contributing to the epidemic numbers of emotional support animals by their irresponsible, and perhaps unethical, approach to providing documentation.

Significant efforts need to be made to address the problems caused by the epidemic numbers of emotional support animals. USA Today reported that several states are cracking down on individuals who falsely claim to have service dogs just so they can take their pets or emotional support animals anywhere they please. Mental health care providers can certainly assist by being more responsible in their provision of documentation for emotional support animals. This can be accomplished by:

1) Providing proper and thorough assessment of a client’s need for an emotional support animal

2) Placing a time limit on the validity of the documentation they supply

3) Requiring follow-up visits from clients to renew documentation for emotional support animals

Mental health care providers can also decline to associate themselves with commercial web services that provide emotional support animal registries and documentation, because these services are designed to attract as many customers as they can, as fast as they can, for as much profit as they can.

In concluding this article, I want to clarify that I am very much in favor of emotional support animals living with their owners in housing. However, until federal or state governments pass legislation requiring greater oversight for emotional support animals, especially related to animal behavior requirements, and until many suppliers of emotional support animal documentation act more responsibly, we are all going to be at risk for being bitten, especially on an airplane. For now, our welfare is in the hands of the owners of emotional support animals.

 

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For more information, refer to the following resources:

 

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Cynthia K. Chandler is a licensed professional counselor and a licensed marriage and family therapist in Texas. She is a professor in the Department of Counseling and Higher Education at the University of North Texas and director of the university’s Consortium for Animal Assisted Therapy. Contact her at cynthia.chandler@unt.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.

Counseling encounters with the puppet masters

By Gregory K. Moffatt February 5, 2019

Utter the words sociopath or psychopath in any public forum, and everyone knows what you’re talking about. “Like serial killers, right?” Yeah, like serial killers. Even in clinical settings, these dated terms are sometimes still used. They’re simply easier to say than antisocial personality disorder (APD), the label currently given in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Years of working with law enforcement agencies on cases involving shootings, serial crimes and sexual homicides have given me plenty of exposure to APD. But diagnosing was rarely my role with those cases, and the subjects were always men in trouble with the law — a distinctly biased sample. In clinical settings, I rarely found use for the APD diagnosis until about a dozen years ago, when my entire perspective was transformed by reading Martha Stout’s 2006 book The Sociopath Next Door. Stout, a clinical psychologist, does a masterful job of describing the disorder and providing examples of the various ways in which the disorder manifests. As I should have known, not everyone diagnosed with APD is — or will become — a serial killer.

As a young clinician many years ago, I assumed that I wouldn’t see APD in my general practice. After all, serial killers weren’t known for voluntarily pursuing psychotherapy. Knowing what I know now, however, I must have seen clients with APD many times without realizing it. Estimates on the frequency of the disorder vary widely, but according to the DSM-5, the presence of APD in the U.S. population is about 4 percent. Given the broad effects of APD, this is a very large number, and mere probability means that most clinicians will be exposed to APD at some point in their careers. After reading Stout’s book, I began to understand why. My two experiences — homicide work and the clinical office — might also explain the wide-ranging estimates. My law enforcement sample increased my exposure to individuals with APD. In the clinical setting, on the other hand, I was misdiagnosing or underdiagnosing — thus limiting my perception of the existence of APD.

Hiding in plain sight

This is an oversimplification, but I probably missed correctly diagnosing APD because I associated it only with criminals. Although many individuals with APD are criminals, there are many other manifestations of the disorder.

In brief, the DSM-5 criteria for APD require that a person be at least 18 years of age and do the following: lie, deceive, have a reckless regard for the safety of others, be impulsive or irritable, manipulate, lack remorse for actions, fail to conform to social norms and behave irresponsibly. This very broad and generalized set of criteria can be exhibited in a variety of ways. According to the DSM-5, APD is much more common in males than in females, and my experience — both in the world of criminal justice and in the clinical setting — reflects that claim. 

Some years ago, I was consulting with a business, helping with team building among its upper-level administrators. One senior administrator in particular frustrated me. Alex (not his real name) would give the impression that he was working on something for our project, but then it would become evident that he had no intention of doing anything. If I asked Alex directly if he planned to do the project work, he wouldn’t come right out and say “no” in defiance of his superiors. Rather, he was simply evasive.   

I didn’t trust Alex, and he gave me little reason to. He gave slippery answers to simple questions, and more than once, I noted contradictions in things he told me. On some occasions in private conversation with me, he would slip into an arrogant attitude regarding his bosses, as if he perceived that he — rather than the CEO — should be leading the company. A time or two he even tipped his hand to me, describing how he had lied to his co-workers or others. He seemed quite proud of getting away with his deceptions. I reasoned that if Alex lied to others and was proud of it, he would probably lie to me too.

In the few meetings Alex attended and in conversations in the hallways, he could be kind and often flattering. He used all the right lingo, especially if the boss was around, and in my view seemed so overly effusive on occasion that it bordered on disingenuous. At other times, Alex condescended to his fellow employees, the secretarial staff and other “underlings,” both in private and in front of others, as if these co-workers were idiots. He would then cast glances at those around him, suggesting that they were all in on some big joke of which the target was unaware. His attitude came across as if he believed everyone was too stupid to see what he was doing.

Alex consistently failed to show up at meetings where his presence was critical, including during my final week with the project, when he was supposed to lead the meeting with our team. Instead, he left us all waiting in the conference room. I found out he had instead decided to go on a picnic with his family. He had left a message with a secretary saying he would get back to me about rescheduling, knowing full well that I wouldn’t be returning after that week.

It was no wonder this administrative team had troubles. Alex wasn’t lazy and he most definitely wasn’t incompetent. In fact, he was very bright and capable. At times he seemed so on top of his game that I wondered if he might be bored with the relatively minor challenges of his job. But that wasn’t his problem.

Instead, I think it delighted him that nobody could tell him what to do. He believed he was pulling the wool over the eyes of his bosses, his colleagues and his “underlings.” I think he reveled in messing with them, making their jobs harder and knowing that they couldn’t do anything about it. For example, I don’t believe that Alex had any reservations about leading my final meeting or that he hadn’t done the work. On the contrary, he probably had. It was part of his insurance package. If the boss had asked Alex about his work, he would have pulled it from his hip pocket in a heartbeat. Instead, the picnic with his family was a way of flipping me the bird and knowing that I couldn’t do anything to stop him. After reading Stout’s book, the APD diagnosis for Alex seemed obvious. That diagnosis answered all my questions regarding his behavior with me and with his co-workers.

But these individuals with APD aren’t always men. One client from years ago was referred to me from an employee assistance program because she was exhibiting symptoms of paranoia. In my assessment, Linda (not her real name) was indeed clinically paranoid. In a cruel twist of irony, however, her boss was working hard behind the scenes to get Linda fired and, more relevant to this conversation, a fellow employee (whom I’ll call “Millie”) knew that Linda was troubled and used that realization to her advantage. So, although Linda was clinically paranoid, people really were out to get her.

Millie tormented Linda, dropping hints that this person or that person in the company was asking about Linda or questioning the quality of her work. Millie carefully crafted comments that went to the very heart of a paranoid individual’s anxieties. As Millie inflamed Linda’s paranoid thoughts, those thoughts exacerbated Linda’s annoying behaviors in the workplace — the very things that led Linda’s boss to seek options for her dismissal.

At other times, Millie would overtly lie, saying a manager or vice president had come by looking for Linda when she was out of the office. These statements would aggravate Linda’s fears that she was in trouble or that her bosses thought she wasn’t working — neither of which were true. Out of fear of confrontation, Linda wouldn’t ask any of the administrators if they had come by to see her. If she had, Millie would have been exposed, but Millie knew Linda wouldn’t risk that confrontation.

Millie did similar things to other co-workers. For example, one woman was struggling with the fear that her husband was having an affair, and she confided this to Millie. Thereafter, Millie would find opportunities when she was alone with the woman to talk about a movie she had seen in which a man was unfaithful or to gossip about a co-worker who was suspected of philandering. On another occasion, she shared details about a friend whose husband had been exposed for having a long-term affair and how “foolish” her friend had been not to have seen it.

Millie’s purpose was not to gossip but rather to cause turmoil within these two employees — throwing gasoline on the fire of paranoia with one and on the fire of emotional anguish with the other. All the while, she could innocently defend herself, saying she was merely discussing company business or the sad facts behind a broken marriage.

Antisocial personality simplified

The abridged way that I describe APD beyond the DSM-5 criteria for my students and interns is twofold, with one additional caveat. First, we have to think of those with APD as puppeteers — a metaphor that I borrow from Stout. Each time the puppet master moves the wooden cross pieces of the marionettes, the strings move the puppets below them. These puppeteers are essentially saying, “Dance for me.” Millie made my client and other employees dance any time she wanted. To Millie, these women were toys she could manipulate at will. Both Millie and Alex were very good at covering their tracks so that they could keep their jobs. They had perfected plausible deniability.

The second thing to know about individuals with APD is that they are takers. In some cases, they can be violent, such as the taking of another person’s life in the case of serial killers or the taking of someone’s sexuality in the case of rapists. But there are many other things that people with APD can take. For example, they take advantage of the goodness of others, becoming leeches who move into someone’s home under the guise of getting back on their feet. Instead, they won’t leave until they are kicked to the curb. Some people with APD become police officers and federal agents, reveling in the taking of another person’s freedom. And some of these individuals become hucksters, taking money whenever they can for the sheer pleasure of getting away with it.

Individuals with APD create chaos in their homes, workplaces, sports teams and social environments, taking peace from those around them. I served as the vice president for student life at a Southern university for several years in the late 1980s and early 1990s. During one particularly challenging year, the first several weeks of school brought one crisis after another. Issues in dormitories, in classrooms, on athletic fields and even in the cafeteria had me investing hours, on a daily basis, to manage these crises. By October, it dawned on me that one particular student had been involved to some degree in each and every major problem that had come across my desk. He was either the complainant or the target of a complaint in each instance.

In the end, this student had stolen credit cards, jewelry and cash from various students. He repeatedly lodged baseless accusations of racism against professors, staff and fellow students. He was suspended for the stolen property issue and left our campus — but stayed in his dormitory room until the very last minute he was required to vacate. And he wasn’t done yet.

In true APD style, he later filed a baseless lawsuit against our university with the American Civil Liberties Union (ACLU) and used his college mailing address on the paperwork — an address that obviously was no longer valid. He also listed me as a reference for a job he applied for just hours after leaving our campus, undoubtedly hoping that the company wouldn’t follow up on his references. In his job interview, he completely misrepresented the reasons for his withdrawal from school, telling this employer that he had decided to take some time off to figure out what he wanted to do in life. The ACLU lawsuit was dropped for lack of evidence, and the employer did, in fact, follow up on references. Fortunately for us, after this student was dismissed, peace returned to the community.

The caveat that accompanies these two descriptors regards the conscience. It is an oversimplification to claim that individuals with APD have no conscience. In fact, some argue that they must have a conscience. It is proposed that to enjoy the suffering of others, one must have at least a minimal sense of right and wrong and one must have the ability to imagine what others are thinking and feeling. We know this as empathy. Simply put, our conscience is a powerful voice that keeps our behaviors in check, even when primal urges push and pull us in other directions. This voice allows us to empathize and causes us shame when we violate its dictates. But in clients with APD, these violations cause pleasure. At a minimum, there is either a deficit in that governing voice with these clients or they lack it altogether.

Prognosis and the APD continuum

The most common question I get regarding clients with APD is whether they can be treated. That is not an easy question to answer. There is very little research on the efficacy of therapy for these clients. There is also the problem of biased samples. Most research is done on hospitalized patients or on those who have been mandated to counseling, which may not be reflective of the population of individuals with APD at large. Given APD’s symptoms, we can expect that many, if not most, of these clients won’t engage in counseling voluntarily. Therefore, in therapy we may see only those who want help (motivated clients) or those who have been mandated (resistant clients).

But there is hope. A 2010 comprehensive report by the National Institute for Health and Care Excellence (NICE) in the U.K. provided some important information for clinicians, including that treatments for APD do exist. The study notes that treatment is most helpful when there is early intervention. The second important bit of information is that even though there is no “cure” for personality disorders, symptoms can be treated. Medication and treatment for comorbid issues (anger management, social skills training and relaxation training) are the most likely areas of focus. 

It is important for clinicians to recognize that most mental health issues exist on a continuum. We formally recognize this continuum in several areas, including autism, suicide risk and developmental delay. Although the DSM-5 does not provide a continuum for many disorders — APD included — anyone who has been in the field for very long can recognize that the continuum exists. Most of us have seen clients with major depressive disorder who cannot get out of bed, and we have also seen clients with the same diagnosis who function far better. Personally, I miss the Global Assessment of Functioning scale in previous DSM editions because it provided exactly the continuum I’m describing.

Follow-up on Alex

The case involving Alex had an interesting conclusion. A few months after my summary meeting with Alex’s company, I got a call from the CEO asking me to see Alex on a one-to-one basis. The CEO wanted to retain Alex but was considering firing him because of a series of problematic behaviors like the ones he exhibited when I was working with the management team. 

For weeks, Alex and I worked together as I tried to help him salvage his job. He resented his employer, and he resented having to come see me. Every session was a battle for control — Alex trying to manipulate me and me trying to stay on task.

I wish I could say that I discovered some therapeutic magic trick and that Alex changed. Unfortunately, he did not. I tried anger management, relaxation, social skills training, perspective-taking exercises, problem-solving exercises and long-range planning. I repeatedly appealed to Alex’s self-interest in keeping his job. Nothing worked. Alex’s marriage was cold and emotionless, he had only cursory involvement with his two daughters, and he had no hobbies or activities that brought him pleasure outside of work — the one place where his puppet stage was always open. My therapeutic attempts were interrupting his theater.

Even though I tried to give Alex control as much as possible, just as I do with most of my clients, we butted heads repeatedly. He fought me every minute of our monthslong therapeutic relationship. Just like when we worked together on the team-building project, I suspect Alex had no intention of working on anything in counseling from the start. In the end, we terminated therapy after his required period of intervention. The CEO fired him, and I’ve never heard from Alex again. 

But this doesn’t discourage me. The NICE study confirmed what I experienced: The older the client with APD is, the harder it is to intervene. Despite my frustrations with Alex, I don’t regret trying to help him. As I tell my clinicians-in-training, anyone can work with the easy clients. Professionals work with the hard ones. Sadly, Alex wasn’t one of my success stories. Linda, on the other hand, was.

Follow-up on Linda

Helping clients whose lives are being disrupted by individuals with APD is no easy task either. Just like people who batter their spouses, people with APD are very good at manipulating others while making it appear that they didn’t. This causes the individual being manipulated to introspect rather than to see the inexcusable behaviors in front of their eyes.

Linda was mandated to counseling because of her paranoia and the challenges in her job. Yet because of her paranoia, she was convinced that people were trying to get her fired, and that was a claim that I couldn’t deny. However, by acknowledging that people really were out to get her, I risked feeding her paranoia. What a challenge.

This is what I did. We spent much of our early clinical work polishing relaxation techniques. Then we moved to reality testing. This helped Linda in two ways. First, when she feared someone was plotting something, she now had tools to evaluate the legitimacy of that claim. For example, when Millie said a boss had come by “wondering” where Linda was, we looked for ways to confirm or deny such claims.

We then worked on Linda’s assertiveness skills. This, combined with reality testing, almost completely put a stop to Millie’s manipulations. The next time that Millie said Linda’s boss had come by or implied that a supervisor might think that Linda wasn’t doing a good job, Linda confronted Millie and asked her whom she was referring to specifically. Then Linda went to that boss to see what she might do to improve. Millie never counted on Linda taking that assertive action. When she could no longer easily manipulate Linda and predict what she would do, Millie moved on to other targets.

These three skills also helped Linda salvage her job. Because she was more relaxed at work and felt more confident when she faced her fears head-on, her paranoia no longer created workplace issues. As a result, her boss who had been seeking a way to fire her backed off and let her do her job.

Summary

There is no question that many people involved in crime could be diagnosed with APD. Actions that seems so reasonable to them are sometimes comical. One individual I worked with explained his stealing behavior to me: “I saw the woman’s purse in her car and the car was unlocked. So, I’m like, ‘God brought that purse with the money in it to me, and I helped that lady because I taught her not to leave her car unlocked.’”

But as Stout so clearly outlines in her book, there are many other ways that APD is manifested. Individuals with this disorder can be cutthroat businesspeople or politicians. They can be covetous psychopaths — individuals with an inordinate desire for the possessions of others. They can be individuals who steal, lie and commit fraud. They can appear lazy — living in a rent-free house, sleeping on someone’s couch, or taking advantage of their spouse and children. They can be people like Millie who “gaslight” others, a descriptor taken from a movie of the same title in which a man tries to drive his wife mad. If those with APD are intelligent, like Millie and Alex, they can manipulate social impressions. Those with APD who are less intelligent end up in trouble, in prison, homeless or dead.

These individuals aren’t bothered by cheating on their spouses, causing chaos at work, or defrauding and stealing from their friends. They use their charisma to deflect attention from their devious behaviors, essentially hiding in plain sight. Their accomplishments, such as financial success, can conceal their dysfunctional motives. And when challenged, they use intimidation and their domineering personalities to cause anyone who might question them to back off.

And perhaps most important for us to know as counselors, individuals with APD will manipulate us if we aren’t careful. We will see these clients in our offices, but what is even more likely is that they will be the husbands and wives, sons and daughters, bosses and co-workers of our clients. The seemingly inexplicable behaviors that our clients relate to us will make much greater sense in the context of the potential APD diagnosis for these people in their lives. That powerful knowledge can help us set goals and establish solutions for managing these situations.

 

 

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Gregory K. Moffatt is a licensed professional counselor, a certified professional counselor supervisor and a professor and department chair of counseling and human services at Point University in Georgia. He has been in private clinical practice for more than 30 years, specializing in work with traumatized children for much of that time. An author and international speaker, he has also worked as a consultant to the FBI and as a homicide profiler. Contact him at greg.moffatt@point.edu.

 

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.

Counseling Connoisseur: Cannabidiol and mental health therapy

By Cheryl Fisher February 4, 2019

Carol presented with concerns related to continuous panic attacks that were jeopardizing her work as a medical professional. “I can’t think straight when they happen and I cannot be this debilitated when I see patients,” she explained. Carol had also been self-medicating with alcohol on the weekends to “ease the stress.” Throughout a year and half of intensive therapy, Carol’s panic disorder began to subside, but her general anxiety continued. One day during therapy Carol announced, “I have not been anxious for two weeks!” Thrilled for her, I asked what had caused such a significant change. She looked sheepishly at me and whispered, “cannabis.” I inquired whether she had shifted to smoking marijuana versus drinking alcohol (which she had recently begun cutting back on). She quickly responded, “Oh no! That would get me fired from my job. I am taking a cannabidiol tincture.”

 

Geraldine came to therapy having returned from a year deployment to a country that is without sunlight for months at a time and has very limited pharmaceutical access. She had been without her medication for anxiety and depression and was feeling overwhelmed. “I can’t function,” she lamented. She had contacted a psychiatrist, but the only available appointment was a month away. We identified some tools she could use to help ease her symptoms while she waited, but they only worked for short periods of time. As a result, she was constantly anxious and depressed. Three weeks into our work together, Geraldine announced that she was feeling much better and attributed it to the cannabidiol-infused honey that she was using in her morning oatmeal.

 

Tim presented with depression and insomnia related to chronic pain caused by lupus. He had been taking psychotropic medication for years, but it no longer brought him any relief. Despite taking sleep aids, he was unable to get a good night’s sleep. Tim worked hard in therapy and was able to ease some, but not all, of his symptoms through regular mindfulness meditation. To my surprise, Tim appeared one afternoon smiling in delight. “I slept all night this week!” he exclaimed. Again, the answer to his dilemma was cannabidiol, which he consumed in capsules.

 

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As a counselor, I strive to create the best evidence-based, holistic and individualized treatment plans through collaboration with my clients. In addition to traditional talk therapy, I use a variety of therapeutic approaches, including a wide range of expressive arts and animal and nature-assisted therapies. Recently multiple clients have reported symptom improvement through the use of an over-the-counter supplement that works with the body’s endocannabinoid system (ECS). Approved in the form of an oral solution (Epidiolex) in June 2018 by the U.S Food and Drug Administration (FDA) for the treatment of Lennox-Gastaut syndrome and Dravet syndrome — rare and severe forms of epilepsy — cannabidiol (CBD) has also drawn interest as a therapeutic agent for use on a variety of neuropsychiatric disorders.

 

What is cannabidiol?

CBD is a naturally derived, non-psychoactive hemp derivative. Proponents describe CBD as a food supplement that provides the therapeutic element of cannabis without tetrahydrocannabinol (THC), which is the component that produces a high. It can be found as a tincture, vapor, infused in honey or creams and is used in food products such as smoothies. Reported side effects include possible positive drug screening results, appetite changes and sleepiness.

How does it work?

CBD affects the ECS, which consists of endogenous cannabinoids, cannabinoid receptors and the enzymes that synthesize and degrade endocannabinoids. As noted in a 2018 article in the journal Frontiers in Molecular Neuroscience, research has found that the ECS plays a significant role modulating physiological functions such as mood, cognition, pain perception and “feeding behavior.” The ECS also interacts with the immune system and moderates inflammatory processes. Animal studies and anecdotal observations have shown that modulating the ECS can have beneficial effects on mood, but the authors note that numerous additional factors, such as the placebo effect, could be influencing these findings.

Research that focuses specifically on targeting the ECS with CBD has also been intriguing. In a 2015 article appearing in the journal Neurotherapeutics, a review of studies on animal and limited human populations concluded that acute doses of CBD can reduce anxiety. The authors call for research on chronic doses and note that because past human studies of CBD were conducted with healthy volunteers, future work should focus on clinical populations.

Overall, current research indicates that CBD has significant potential as a treatment for a number of mood disorders.

What does this mean for counselors?

As counselors, it is important to be informed about supplements clients are using to manage mental and physical disease. While we cannot prescribe medications and should refer clients to their doctors for medical advice around pharmacology and supplements, we do have a duty to provide our clients with psychoeducation and research.

 

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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.

 

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EDITOR’S NOTE: Counselors should be aware that according to a U.S. Food and Drug Administration (FDA) statement issued in December 2018, although hemp has been removed from the Controlled Substances Act, it is still illegal to add CBD to consumer food products or to market it as a dietary supplement.

Some jurisdictions, such as the cities of New York and Los Angeles, have begun ordering restaurants to stop selling food containing CBD. The FDA is not currently preventing the manufacture of CBD as a dietary supplement. However, counselors and clients should be aware that like all dietary supplements, those containing CBD are not subject to set standards regarding dose or strength.

 

Learn more about risk management issues related to client marijuana use (ACA members only): counseling.org/docs/default-source/risk-management/ct-risk-management-july-2018.pdf

 

FDA statement on CBD cannabis regulation: fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm628988.htm

 

FDA and marijuana Q+A: fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm#enforcement_action

 

 

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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.