Monthly Archives: July 2019

Heading to college with social anxiety

By Bethany Bray July 31, 2019

The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety.

The key is preparation, says Holly Scott, a licensed professional counselor whose Dallas private practice is a regional clinic of the National Social Anxiety Center. Counselors who are working with college-aged clients with social anxiety should talk through and create a plan for the client to navigate the many anxiety-provoking situations that may arise as they begin (or return to) school.

Try and anticipate daily challenges with the client, such as eating in the cafeteria with peers instead of taking food to go and eating it alone in their dorm room. Talk through healthy ways to negotiate shared space with a roommate who has a different lifestyle or sleeping schedule, Scott suggests. Help the client identify places on campus where they can study quietly as well as plan for ways to meet new friends, such as joining clubs on campus or finding volunteer or extracurricular activities.

“If I’m working with a client who is getting ready for college, we focus a lot on getting rid of avoidance behavior. People with social anxiety might rush back to their dorm room [after class] because it’s scary for them, which can lead to isolation … Their strongest coping skill is often avoidance,” Scott says.

Help the client identify what might be the most fearful experiences for them, and build a plan with healthy coping mechanisms and small goals they can work toward. Perhaps they’re anxious about the thought of having to share a bathroom and walk down the hall to take a shower. Talk that through with the client and get creative, Scott suggests. For someone with social anxiety, the best plan might be to schedule a daily shower in between classes during the day, when the dorms will be quieter.

“The first step is educating the client on what to expect at college. Some have a good idea but others don’t,” Scott says. “The more they can see what it will be like – what will their dorm room look like, where they will eat, what the classrooms look like – the better. Lower their level of uncertainty as best you can. Establish a daily plan. [Unmanaged] social anxiety can lead to depression so it’s good to equip clients with a routine.”

Scott recalls a college-aged client whose social anxiety would spike on weekends, when he didn’t have scheduled classes. She worked with him to set small goals and establish a plan for weekends, such as inviting someone to lunch or going to a sporting event on campus.

More than being shy, introverted or socially awkward, social anxiety is a diagnosable form of anxiety that is accompanied by a constant feeling of apprehension regarding social or performance situations and a fear of judgement from others.

Roughly 12% of U.S. adults will experience social anxiety disorder in their lifetime, according to the National Institute of Mental Health. In adolescents (ages 13-18), the lifetime prevalence is 9.1%.

In cases of severe social anxiety, a counselor can work with a college for special accommodations for the client, such as finding a single (unshared) dorm room, Scott notes.

While planning ahead for the college transition is important, it’s equally vital to ensure that clients with social anxiety continue to check in with a counselor throughout the semester, Scott says. It’s helpful for clients to debrief – and readjust, if needed – on the ways they’re managing their anxiety, as well as the goals they’ve set with a counselor.

If a client goes to college far from home, teletherapy or phone conversations with their existing counselor may be an option. But ideally, a client who needs regular sessions should find a local counselor to see while on campus, either at a college counseling center or in the community, Scott says. If granted permission by the client, a counselor can work in tandem with the client’s college counselor, sharing treatment plans and keeping in contact.

 

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Read more on living with social anxiety in Counseling Today’s August cover story, “More than simply shy.”

 

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Transitioning to college life: Tips for success

“Should I change my major?” “What should I do this weekend?” “Should I drop this class?” It’s easy to feel paralyzed by all the potential and possibilities that come with starting college. Decisions — even minor ones — often feel as if they will have an unchangeable and lasting impact on the direction your life will take.

If you’re feeling overwhelmed, know that you’re not alone. University counseling centers across the country are seeing an increase of students looking for support as they face the academic and social challenges college can bring, says Richard Tyler-Walker, president of the American College Counseling Association. Social anxiety, social isolation, interpersonal and self-esteem issues are some of the most common issues that bring students to college counseling centers, according to the Center for Collegiate Mental Health.

Setting small goals – and reaching out to your college counseling center for extra support – can help you find balance and manage anxiety as you start college, says Tyler-Walker, a licensed professional counselor supervisor and associate director of the College Counseling Center at North Carolina State University in Raleigh. He suggests the following:

  • Set realistic goals. A student who may not have had the social life they wished for in high school may view college as a fresh start or a “do-over.” College is a time to build new friendships and deepen existing ones. A person can set themselves up for success by setting goals that reflect who they are, not who they wish they were. It is unlikely that someone who is most comfortable with quiet conversation will feel content becoming the life of the party.
  • Build a network. Many students report feeling socially isolated at college. As you walk across crowded lawns and through noisy hallways on campus, it can feel like everyone else has all the friends they need. Reach out to acquaintances who are going to the same college. Start a conversation with your roommate before you arrive on campus. Get to know your resident advisor (RA), teaching assistants, academic advisor and other helpful personnel. Join a group for people with similar interests. Identify a cultural center on campus that interests you. Most colleges have centers for groups that include women, African American, LGBTQ and multicultural students.
  • Practice being friendly. Introduce yourself to a new person each day. Join clubs that focus on things of interest. Student involvement can help with getting a sense of the college or university and starting to build connections with others. Challenge yourself to go to meetings at least three times before deciding if it’s right for you. This will allow you to see the core group of people that attend and allows the members to become more familiar with you at the same time.
  • Embrace orientation. Orientation is staffed by student affairs professionals and trained students who focus on creating a welcoming environment for all new students. It’s a time to learn about the ins and outs of the system and make connections with others. Everyone is new to the college, so orientation is a great level playing field.
  • Pick a residence hall that suits you. “Where will I live?” It’s one of the first decisions a college student makes. Residence halls may be massive dormitories where there are shared rooms and bathrooms. In other cases, they’re set up with suite-style rooms or learning villages. Some students may enjoy the anonymity of a larger space while others may benefit from a smaller environment – especially where there might be common thread that connects. Learning villages at universities put students with common interests such as the arts, international studies, women in science, technology or other subjects together.
  • Find a space to breathe. Colleges and universities range from massive to virtually pocket-sized. Whatever the size of your school, look for a quiet corner where you can get away when you need to have some quality alone time. You might have done this by your choice of residence, such as a single room. For those whose living quarters are not a solitary refuge, every library, student union, green space and building on a college campus can have a nice spot for sanctuary if you keep your eyes open.
  • Reduce avoidance. No one likes the feeling of anxiety and we tend to avoid those situations that make us anxious. The more we do that, the more we create an endless loop of anxiety and avoidance. Your anxiety is trying to tell you that it is keeping you safe by not putting you into situations that will be scary. Once you put a name on fear it has much less power over you.
  • Practice, practice, practice. No one is a virtuoso the first time they pick up an instrument. It takes practice and skill. Don’t get caught up in whether [social skills] seem easier for others than for yourself. This is a challenge that you can welcome with the right attitude. Practicing these skills isn’t a matter of standing in front of a mirror, it’s about incorporating small moments of opportunity throughout the day. Practice smiling at others, saying hello, accepting a compliment, telling a joke or even flirting.
  • Ask for help if you need it. College counseling centers have trained staff that can help through counseling, either in group or individual formats. Counselors can build on the skills you’ve identified and help create harmony between your public and private selves.

Source: Richard Tyler-Walker, LPC-S, president of the American College Counseling Association, a division of the American Counseling Association.

 

 

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

 

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

 

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

More than simply shy

By Bethany Bray July 29, 2019

Social anxiety is different from — and much more than — simply being shy or introverted or having poor social skills. Even so, people who live with social anxiety often find the disorder trivialized or minimized by others, including some mental health professionals, according to Robin Miller, a licensed professional counselor (LPC) and a member of the American Counseling Association.

“Shyness doesn’t necessarily have a negative impact on someone’s life. That’s an important thing to remember from a clinical point of view,” explains Miller, who specializes in working with adults with anxiety disorders at an outpatient practice just outside of Milwaukee. “Many of my clients get a pat on the head from people and [comments such as], ‘You’re just shy. You have nothing to worry about.’ But you wouldn’t get that for [symptoms of] posttraumatic stress disorder or other mental health issues. You wouldn’t say there’s nothing to worry about.”

Most of all, clients with social anxiety need support and reassurance as they try to discontinue old patterns and behaviors that they have adopted to cope with the paralyzing fear that often accompanies the disorder, says Brad Imhoff, an LPC who was diagnosed with social anxiety disorder in 2012 as he was working on his doctorate.

One characteristic of social anxiety is a constant feeling of apprehension regarding social situations. It is difficult to express just how oppressive and pervasive that feeling can be, says Imhoff, an assistant professor of counseling at Liberty University who lives in central Ohio and teaches in the university’s online program. “You carry this feeling of ‘I just can’t do this’ all the time,” he says. “As human beings, we’re social. And apprehension in every one of [those social situations] can be overwhelming.”

Imhoff, a member of ACA, says he recognizes the irony of his career choice: a person with social anxiety who speaks regularly to rooms full of people, both as a counselor educator and as a frequent presenter at conferences, including giving a session on social anxiety at the ACA 2019 Conference & Expo in New Orleans.

Imhoff has learned to navigate the challenges of social anxiety since his diagnosis, but he acknowledges still feeling anxious before speaking engagements. “The question is, how do I manage it and not let it get in the way of life?” he says. “I will have to manage this, to some extent, for my entire life and not let it get to the extremes it has in the past.”

Navigating life through avoidance

Social anxiety is one of a number of related issues — including specific phobia, panic disorder, separation anxiety disorder, generalized anxiety disorder and others — that fall under the anxiety heading in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Called social phobia in decades past, social anxiety disorder is characterized by persistent fear over social or performance-related situations, according to the National Institute of Mental Health, which cites diagnostic interview data to estimate that 12.1% of U.S. adults will experience social anxiety disorder during their lifetime. Among adolescents ages 13-18, the lifetime prevalence is 9.1%. For all ages, social anxiety disorder is more prevalent in females than in males.

Researchers have not singled out a specific cause for social anxiety disorder, pointing instead to a combination of biological and environmental factors as contributors. Genetics appears to play a large role in many cases, as can negative childhood experiences such as family conflict or being bullied, teased or rejected by peers. It is also believed that individuals who have an overactive amygdala may experience more anxiety in social situations.

According to the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, “Social anxiety disorder can affect people of any age. However, the disorder typically emerges during adolescence in teens with a history of social inhibition or shyness. The onset is usually accompanied by a stressful or humiliating experience, and the severity varies by individual. … There is a higher incidence of social anxiety disorder in individuals with first-degree relatives affected by other panic and anxiety disorders. However, there is no one gene that explains this biological trend. General findings indicate that personal experiences, social environment and biology all play a role in the development of the disorder.”

People often experience symptoms of social anxiety disorder to varying degrees across the life span, according to the center. Symptoms may lessen for stretches of time and then worsen during periods of change or stress, such as a job transition or when dealing with feelings of grief and loss.

What sets social anxiety apart from general anxiety is not only the social component but also an intense fear of judgment by others, explains Holly Scott, an LPC whose Dallas private practice is a regional clinic of the National Social Anxiety Center. People with social anxiety often harbor strong and pervasive feelings that others will notice their anxiety and judge them, which triggers avoidance behaviors, she says.

At the same time, there are nuances to the diagnosis, and social anxiety can look different in each client, Scott adds. For example, someone may be fine with public speaking and yet not be able to walk into a room in which they don’t know anyone.

“People think it’s not treatable,” Scott says. “Clients label it as ‘this is just the way I am, and I can’t change the way I am.’ It can be difficult to treat or to find a qualified practitioner, but it is treatable.”

Imhoff says he has read that on average, people go 15 years before seeking treatment for social anxiety. Counseling itself is a social interaction, he notes, and people with social anxiety may avoid treatment out of a fear of the close interaction or of being scrutinized by a practitioner.

Because people with social anxiety typically adopt avoidance as one of their coping mechanisms, and perhaps because of the way that social anxiety tends to get minimized or passed off as simply being introverted or shy, these clients often live life without seeking treatment until they reach a breaking point. As Imhoff points out, people can self-manage their social anxiety for an extended period of time by maintaining the same small circle of friends and following certain behavioral patterns such as always using the self-service checkout line at the grocery store.

Living with social anxiety is their reality, Imhoff explains, and they “forge ahead until something causes [them] to realize it’s more significant.” For Imhoff, that “something” was the impending scrutiny involved in defending his doctoral thesis.

“For social anxiety, it’s possible to navigate life with avoidance and survive for a long time. Then something comes up — a life change, such as entering the workforce — that causes them to need help,” he says. “A lot of these safety behaviors aren’t being done consciously. They are things we’ve done throughout our lives to find safety.”

Assessment and core beliefs

Avoidance behaviors are one of the biggest red flags that a client might be dealing with social anxiety, Miller says. These behaviors can extend to staying in situations in which the person is unhappy yet comfortable, such as a bad romantic relationship, a toxic friendship or a job that the person doesn’t enjoy or isn’t advancing in.

Other indicators include rumination and overthinking social experiences. This can include asking oneself over and over again, “What did that person think of me?” Miller explains, whether it’s an interaction with a neighbor while walking the dog or a yearly performance evaluation with one’s supervisor.

Counselors should be aware that social anxiety often co-occurs with other mental health issues such as depression and substance abuse (which often becomes a coping mechanism) that may need to be treated first or in tandem with the disorder, Miller adds. In addition, other issues such as grief may be complicating a client’s social anxiety. “They’re not always struggling with one thing. Make sure you’re working on what they’re struggling with the most,” Miller says.

Scott suggests asking clients at intake about how they deal with social situations and how often they go to gatherings or parties. Are they uncomfortable introducing themselves to new people, making a phone call or using the restroom in public places? If Scott hears symptoms that might indicate the presence of social anxiety, she uses a questionnaire (she recommends the Liebowitz Social Anxiety Scale, available at nationalsocialanxietycenter.com) to pinpoint the client’s fear level and to identify goals to focus on in therapy.

It can also be helpful to identify a client’s core beliefs and values and how those are affecting the person’s choices and behaviors, Imhoff says. People with social anxiety often carry a core belief that they’re inadequate or inferior, which spurs a fear of being judged, he explains. These clients frequently place weight and focus on situations that seemingly confirm their core belief and discount those that might disprove it. They might ruminate over a conversation with a colleague that didn’t go well, for example, without giving any consideration to all of the past conversations that did go well, Imhoff notes.

“They move through life paying very close attention to and taking to heart scenarios that confirm their core belief,” he says. “It’s important to help the client take off the blinders. Talk through ways they are competent, and get to the root of their concerns. Be aware of the multitude of their experiences and not just those they struggle with.”

To identify core beliefs, counselors can listen for themes in the way that clients talk about themselves, other people and the world. These themes can suggest deeply held beliefs to challenge or to explore further in therapy. Having clients work on thought journals can also be helpful in finding patterns, Imhoff says. He also suggests using a prediction log, in which clients name upcoming social scenarios that make them anxious and describe what they assume will happen. After the scenario occurs, clients can look back at their predictions with the counselor to talk through how accurate these foresights were.

After core beliefs and values have been identified, the counselor can work with clients to reframe their perspective around new core beliefs. For example, clients who place value on providing for their family could focus on that value to help them overcome their anxiety and discomfort over applying for a new job.

“Look for evidence that supports their new core belief,” Imhoff says. “If their belief is ‘I am capable,’ have them write down even the most minor piece of evidence [in a journal]. It makes it concrete and documented so they can refer back to it and talk it through with a counselor.”

From there, the counselor can work with clients on challenging cognitive distortions and black-and-white thinking, Imhoff suggests. Acceptance and commitment therapy (ACT) can be helpful, as can guiding clients to adopt a growth-focused orientation. With that mindset, every social interaction becomes an opportunity to learn rather than a pass-fail situation, Imhoff explains.

Clients with social anxiety may also feel that they’re failing because they can’t assume an extroverted, life-of-the-party façade. Counselors can help these clients learn that there is a continuum of social skills, Imhoff says. For example, perhaps they got through a work meeting and contributed their thoughts despite having a shaky voice and sweaty palms. “Work on [helping them realize] that it’s not black and white, it’s not all success or failure. There’s an in between for almost all scenarios,” he says. “Help them to recognize that in all social interaction, there is ebb and flow. It’s not a pass-fail exercise but an opportunity to connect with someone and learn moving forward.”

Additionally, ACT techniques can help clients learn to accept their anxiety rather than trying to get rid of it or avoiding triggering situations. Imhoff uses the imagery of “keeping anxiety in the passenger seat because I know it’s coming along but not letting it take control of the wheel.” Clients can learn to say, “There you are anxiety; I knew you were coming,” even as they move on with life and navigate situations they previously would have avoided.

Scott regularly uses cognitive restructuring and cognitive behavior therapy (CBT) with her clients who have social anxiety. She also uses a mindfulness technique called curiosity training that helps clients label their anxious thoughts as “background noise.” With this technique, users try to adopt an approach of curiosity about and interest in what is being said by others rather than assuming that others are judging them.

“In any situation,” Scott says, “whether they’re having a conversation, public speaking or sitting somewhere having lunch, they’ve usually got a constant dialogue going in their head. [It’s] self-criticism about how people must be thinking of them: ‘They don’t like my clothes’ or ‘I just stuttered while speaking.’ Curiosity training helps keep your mind on the present and learn how to pull your mind back when it starts wandering.”

Elizabeth Shuler, an LPC who has been working as an international school counselor in Amman, Jordan, for four years, recommends mindfulness techniques. She has often used Kristin Neff’s self-compassion practices in addition to dialectical behavior therapy, meditation and yoga for clients with social anxiety, both when she was in private practice in Colorado and Wyoming and currently in her work with adolescents and adults at her school.

“When we dig into their fears, most clients with social anxiety are really afraid that other people will agree with their own negative judgments of themselves. They’re worried that they will be proved right,” says Shuler, an ACA member. “I had a client who walked through the office the same way every day to avoid the people he was afraid of interacting with and had panic attacks when his route had to change or people he was avoiding crossed his path. These types of behaviors are meant to stave off panic but end up reinforcing it. My role as a counselor is to help clients see how these behaviors are actually making their panic worse and help them to slowly replace them with more helpful behaviors.”

Exposure

Exposure techniques are often central to treating social anxiety because they gradually reintroduce clients to anxiety-provoking situations in a healthy way.

Miller is trained in exposure and response prevention and finds it a powerful tool for working with clients with social anxiety. The behavioral technique requires clients to put in a lot of work themselves outside of sessions. The counselor collaborates with the client to develop a hierarchy of exposure based on the client’s needs and treatment goals and supports the client throughout the process.

As Miller explains, exposure assignments start small and build over time as clients become comfortable with each homework task. She describes this as a “Goldilocks situation” — not too much challenge and not too little, but just the right amount, tailored to each individual client. Miller says she emphasizes to clients that the treatment is in their hands — they have to do their part to experience a successful outcome.

“A lot of people have anticipatory anxiety, but once they do it [complete the exposure assignment], they’re OK,” Miller says. “A lot of people get over that hill of worry. They do it for a week or two and realize they can do it. Trust between a client and clinician is huge because we’re asking them to do really scary things.”

Miller often gives clients who are early in treatment the assignment of calling multiple businesses to ask what their hours are. Clients might have to overcome feeling a little foolish because that information is readily available on the internet, she notes. However, the goal is for clients to complete the task without falling back on habits they formed to avoid social situations, such as relying on technology in lieu of having personal interactions. Clients repeat the task over and over until they no longer feel anxious about picking up the phone and making a call, she explains.

Once they’ve mastered that task, clients might move on to going inside a store and asking a question in person. Or they might switch to walking their dog in their neighborhood during a busy time of day and saying hello to at least one other person during each walk.

As clients complete each task and return to their next counseling session, they process these interactions with Miller, discussing how the interactions felt to them and what went right or wrong. “Sometimes the client will come in and say, ‘I’m so bored with this.’ I say, ‘Great! That means it’s time to move on to something bigger,’” Miller says. “You need repetition with assignments. You need to do [tasks] over and over for your brain to get used to it. … The more you do it, [the more] it overwrites [old] patterns and anxious feelings.”

As a practitioner who specializes in treating social anxiety, Scott has a laundry list of exposure assignments that she uses with clients, ranging from making eye contact during a shopping trip to asking for directions from a stranger to calling into a radio talk show to singing karaoke. As clients progress, it can be helpful to assign them tasks that are certain to create some level of discomfort or awkwardness, such as going into Starbucks and ordering a hamburger, she says. This can be especially hard for clients who have a strong fear of being judged by others, but dealing with the responses they receive desensitizes these clients over time as they repeat the tasks.

Miller acknowledges that counselors may need to provide their clients with some ongoing motivation during exposure work. If clients come to session without completing their assigned tasks, she suggests asking leading questions to find out if they are avoiding the work or genuinely struggling to make it a priority among their other challenges.

“Who wants to go home and do anxiety-provoking things?” Miller says. “[We] have to find a way to motivate them. We want them to feel empowered to go out and do [an assignment]. Remind them that they’re in pain because something is not changing. … You can’t snap your fingers and make this go away. It’s going to be hard work and take time.”

It can be useful to circle back and remind clients of their core beliefs and the goals they want to achieve. For example, consider clients who say they ultimately want to start a family but whose social anxiety prevents them from entering the dating scene and potentially meeting a partner.

“They may not see how calling a drugstore [as an exposure assignment] is getting them to be able to date. But remind them that they’re building a foundation to be able to do that,” Miller says. “It may not have an immediate payoff, but the easier these things become for you, everything builds.”

Miller often uses the metaphor of training for a marathon to keep clients motivated. You don’t run 26.2 miles right away, she tells them. You start with one or two miles and then keep adding more distance, mile by mile.

Social skills

In addition to exposure work and cognitive restructuring, the counselors interviewed for this article recommend social skills training for clients with social anxiety. Avoidance behaviors may have kept these clients from learning and practicing social skills that are commonplace among their peers who do not deal with social anxiety.

“If you’ve been avoidant for years, you miss out on learning from all of the social interaction that others have had,” Miller says. “Sometimes they’ve built a life to minimize their pain, their anxiety.”

Goal setting and planning ahead, with support from a counselor, can help these clients navigate situations that are foreign to them and that naturally provoke anxiety. Miller suggests troubleshooting with clients. For instance, if their office holiday party is coming up, a counselor can talk through expected behaviors with clients and work on small talk and other exercises to help them get through the evening.

Setting realistic goals can also be comforting, Miller adds. “[They] don’t have to go in and work the room, [but] if they haven’t had a lot of social experience, they may not realize what’s expected,” Miller says. Instead, clients might set a goal of talking to three people whom they already know. Maybe at next year’s party, they can increase that goal from three people to five people.

Miller also reminds clients that a certain measure of social anxiety is simply part of being human. Even she, a therapist who makes a living talking to people, acknowledges sometimes being uncomfortable in social situations.

Kevin Hull is a licensed mental health counselor with a private practice in Lakeland, Florida, who specializes in counseling children, adolescents and young adults on the autism spectrum. Social skills training, along with group therapy, plays a large role in the work Hull does with clients around social anxiety, which he says often goes hand in hand with autism.

In individual counseling sessions, Hull uses puppets with clients to role-play social situations and work through what is expected. For example, Hull might instruct clients to verbalize a food order to his puppet without the usual help from mom or dad or ask his puppet for help finding a certain building on a school campus. Afterward, they process the experience together and talk about the emotions clients felt as their puppet had to interact and ask questions.

Humor can also be a great tool for overcoming the fear associated with social anxiety, says Hull, a member of ACA. He often shows clips of TV shows or movies (via YouTube) in client sessions as a lighthearted way of starting conversations about what is and isn’t appropriate when it comes to social skills. Particularly popular with clients are scenes with The Big Bang Theory’s Sheldon Cooper wrapping himself in bubble wrap to stay safe or wearing a second set of “bus pants” over his work outfit when taking public transportation. Another favorite is the title character in How the Grinch Stole Christmas, who initially can’t stand being around the Whos but ends up transforming over the course of the story.

“Using humor is a great thing to counter the fear,” Hull says. “When you can laugh at something, that gets people opening up and listening.”

Group work

Group therapy — a format in which clients are expected to interact with others and contribute to a discussion — would seem to be a nightmare for individuals who are socially anxious. But that’s not necessarily the case, according to Hull.

Although it can take clients some time to warm up to the idea, group therapy can play a powerful role in imparting the skills needed to navigate social anxiety, says Hull, an assistant professor and faculty adviser in Liberty University’s online master’s counseling program. In addition to helping participants sharpen their social skills, group counseling can instill perspective — something with which Hull’s clients who are autistic sometimes need extra help.

“With autism, clients have a hard time putting themselves in others’ shoes, so group is a great way for them to hear from the mouths of peers [and] hear them talk about what they’re going through,” Hull says. “Maybe someone [in group] had to ride a different bus than usual. It was terrifying at first, but they were OK and actually ended up talking to the person they sat next to.”

The group format, in which participants take turns offering comments, can model and teach the back-and-forth “tennis match” that is the basis of healthy conversation, Hull adds. It can also help clients learn to tolerate and listen when someone is talking about a subject that doesn’t interest them — a circumstance that previously would have triggered their fight-or-flight response and caused them to exit the situation.

Hull often has group participants speak for five minutes each on something they are passionate about. Afterward, he urges all of the group members to ask questions or make a comment about what was said.

“This is really hard with autism. If they don’t like something, it’s utterly meaningless to them,” Hull says. “This has them put themselves in others’ shoes and imagine how it’s like [something that they] like. This can transfer to social situations outside of group, such as a dinner party where other people are talking about whatever. Can you listen and learn something? It’s teaching their brain to overcome fear and learn a new normal. Everyone is scary when you first meet them, but you can do it. If you can do it in group, it’s the same as at school or a new job.”

Hull also uses video games in sessions as a way for participants to learn about group dynamics, leader/contributor roles and overcoming frustration (see sidebar, below).

It is important to prepare individuals with social anxiety for the group setting as much as possible ahead of time. Hull often shows clients the group room at his office (or emails them photos of it) and explains the format and what sessions will entail before they join group counseling.

“I walk back to the [group] room with the client and their caregiver before a group session so they can see it,” Hull says. “I explain, ‘Everyone who is coming here feels what you feel, and they’re all struggling with this.’”

When new clients join a group, he never makes them introduce themselves or speak right off the bat. He also allows them to bring anything that might boost their courage, such as a favorite stuffed animal or even a parent in the cases of younger clients. With social anxiety, it is important to allow clients to warm up and contribute at their own pace, he says.

“I can see group members five or six sessions in and they haven’t talked yet. I never stop trying to get them to engage or open up, even if all they can do is a head nod or fist bump,” Hull says. “[I emphasize that] I’m just happy they can be in the room.”

Hull acknowledges that group counseling isn’t a fit for every client who struggles with social anxiety. Social anxiety falls on a spectrum, and for some clients, the disorder is so severe that a group setting would be too much, he says. It is important to continue individual sessions with these clients, with group counseling becoming a possible long-term goal for some of them, he says.

When it comes to group counseling and social anxiety, it is crucial to take things step by step and to celebrate little victories, Hull emphasizes. With clients on the autism spectrum “the victories are fewer and far between,” he acknowledges, “but when they happen … you feel like you’ve won the Super Bowl.”

The long haul

Hull says that counselors should view social anxiety as a process rather than something to “fix.” Neuroscience tells us that the brain responds better to slow and steady change rather than forced or rushed adaptation. This is especially true for clients who struggle with social anxiety in addition to neurodevelopmental issues, past trauma or other mental health diagnoses, Hull notes.

Something else that counselors should avoid is projecting their assumptions onto clients with social anxiety. Just because the counselor went to prom as a teenager doesn’t mean that should automatically become a goal for every teenage client or, for that matter, even be considered the rite of passage that it once was, Hull says.

Counselors should really get to know their client’s world first before doing anything else, Hull says. “Avoid putting your agenda or perceptions on a client. We often see the potential in our clients, and it’s hard not to say, ‘Just do it!’ It can be discouraging and slow going at times, [but] be patient.”

 

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Technology and social anxiety: A double-edged sword

We live in a world where a person can text a happy birthday message to a friend, order a week’s worth of groceries for delivery and apply for a loan with the click of a button — all without having to speak to another human.

So, when it comes to social anxiety, technology can be a double-edged sword. Clients can certainly use it as an easy escape route to avoid social situations. At the same time, mental health practitioners can use it as a teaching tool with clients and as a bridge to overcoming long-held behavioral patterns.

“As great as it can be, technology can be part of avoidance,” says Robin Miller, a licensed professional counselor (LPC) who specializes in treating adults with anxiety. “Learn how to have conversations [about technology]. Make sure a client isn’t too reliant on it and unable to do things in a more social, direct way.”

Miller suggests that professional clinical counselors ask clients about their technology use at intake along with other questions about avoidance behaviors. Counselors can prompt clients to provide examples of situations where they feel most anxious and then listen for overreliance on technology, such as texting to ask someone out on a date or habitually using the self-service checkout line when shopping.

Social media can also exacerbate the assumption of judgment that often accompanies social anxiety, Miller adds. Clients who see photos and posts about friends’ and peers’ vacations, children or happy life events may come to believe that their lives pale in comparison.

Elizabeth Shuler, an LPC and an international school counselor, agrees. She says social media has created a new layer of social anxiety “centered around likes, comments and followers” in many of the adolescents with whom she works.

“I see students every day who are upset — to the point of panic attacks — that they’ve lost followers or that no one is liking their Instagram pictures. Instead of being afraid of being seen as stupid, these kids are afraid of not getting likes. It is a whole new world of judgment that has been unleashed on our teens, and it is taking a toll,” Shuler says. “However, many people who find face-to-face interaction intimidating can benefit from starting with digital interactions. Using texting, video and other digital means of conversation can help people with social anxiety learn social skills and give them a chance to practice new skills in a safer, lower stakes environment.”

Kevin Hull, a licensed mental health counselor in private practice, finds technology — specifically, video games — a natural tool for working with his young clients, many of whom are on the autism spectrum. In group counseling, Hull uses multiplayer games such as Minecraft to introduce clients to interacting and working together in a way that provokes less anxiety than face-to-face conversation might. Group members take turns being a “foreman” and leader in Minecraft sessions. The group learns to communicate and work together while dealing with frustrations and the nuances of the leader/contributor roles. “If technology wasn’t there, these kids would be even more regressed,” Hull says.

Conversations about technology use can also be an important part of social skills training in counseling, Hull adds. For example, young clients might claim that they are “dating” someone when they are actually just texting or playing video games together over the internet.

Hull often talks with clients about how texting is a good place to start communication but that it should not become their be-all, end-all. He’ll say to the client, “It’s great you’ve made a connection through texting, but what about the next level? Your brain’s process to communicate in text is the same as in speech. It’s just a different route.”

— Bethany Bray

 

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Social anxiety and college

The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety. Read more in our online exclusive, “Heading to college with social anxiety.”

 

 

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Contact the counselors interviewed for this article:

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

 

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

I don’t care what my body looks like on the beach, bro!

By Andrew M. Watley July 25, 2019

Many guys and girls alike trained hard during the frigid winter months under a common belief: Summer bodies are made in the winter. Traditionally, getting “beach body ready” was associated with women. But that idea is so 20th century. Now, through the influence of social media and many other factors, guys are just as likely as women to stress about their appearance during these warm summer months.

Let’s take Instagram, for example. I don’t know about everybody else, but my page is filled with diet tips, workout routines, and guys who have the body type that I desire. The posts from these extremely “ripped” gentlemen are a double-edged sword.

One side is inspirational. These people put in a lot of time, dedication and patience to mold their bodies, like art, into the creation they see fit when they look in the mirror. Guys like me who strive to be in better shape look up to these men, hoping that the same level of fitness is obtainable for us.

The other side of the sword can bring about despair because of society’s decision that these model bodies — a body type that is not like mine — is what is considered favorable. Take a walk in history through People magazine’s “Sexiest Man Alive” covers. Most, if not all, of the men who have won these “competitions” have had favorable bodies. What an honor it must be to be considered the sexiest man to walk the Earth at a given time.

The idea that men don’t worry about their bodies is simply not true. Like the male peacock, we like to “strut our stuff” to gain the attention of those we might find attractive or for the man we see staring back at us in the mirror. He seems to be the hardest critic to impress.

Of course, negative consequences can be associated with the sometimes obsessive desire to be “Instagram worthy.” The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) specifies muscle dysmorphic disorder (MDD) as a subdisorder of body dysmorphic disorder (BDD). Muscle dysmorphia is defined as a preoccupation with the idea that one’s body build is too small or not muscular enough.

MDD occurs almost exclusively in men. This diagnosis can lead individuals down a path of obsessive behavior such as extreme exercise programs and long hours of weightlifting to gain muscle mass. These men may work out to the point of injury and often ignore said injury to continue their muscle growth. These individuals typically engage in unhealthy diet habits such as mass consumption of protein-rich foods to increase weight. In extreme cases, men may resort to the use of steroids or other addictive performance-enhancing drugs.

I conducted a doctoral research project in 2017 that studied men who considered themselves members of the fitness culture. The study conducted interviews of seven men and observed their gym habits. I paid close attention to how these habits and thoughts about their routines and physiques affected their mental health. According to these men, a muscular or fit physique brings not only desired attention but also validation of a man’s masculinity.

Society has equated a muscular or physically fit man with being more masculine than those men who are smaller in stature and weight. Obtaining this physique has become a social norm for the masculine guy. Maintaining a muscular physique is yet another gender norm that men are expected to adhere to in North American culture.

One gender norm that is changing is the notion that men do not talk about their feelings. It is not as far-fetched today to have men lying on the counseling couch as it was previously. It is possible that some of the men who end up in your office may experience symptoms related to a negative body image.

Unfortunately, counselors do not have a magic wand to use to “bibbidi-bobbidi-boo” our clients into the most muscular men at the ball. Nor do we have a single can of spinach that we can give our clients to instantly make them ripped like Popeye. But what we do have is research stating that when treating clients with dysmorphic disorders, cognitive behavioral techniques work best.

One of the first steps in cognitive behavior therapy is gaining an understanding of the problem. BDD/MDD may be the result of an underlying issue or concern. As with most eating disorders, muscle dysmorphia is likely caused by biological, psychological and social factors.

For some, it could be a traumatic event that was caused by unhealthy choices. One of the gentlemen I interviewed during my doctoral research recalled a moment when he had to run after a bus and, because he was overweight at the time, he couldn’t catch up to it in time. He equated his health and the laughter of the bystanders with his image. This moment pushed him into a lifestyle that would eventually lead to body dysmorphic disorder.

Another interviewee who identified as a member of the LGBTQ+ community discussed his desire to be viewed as attractive. He explained that some members of the community could be superficial, and in order to fit in with certain crowds, he needed to look a certain way. These represent just brief examples of how discovering the root of a client’s BDD or MDD may open the door to a helpful discussion about the person’s obsession with obtaining the “perfect” body.

As counselors, we need to help these clients first identify their automatic thoughts. As a theories class refresher, an automatic thought is one that is triggered by a particular stimulus that leads to an emotional response. Individuals maintain certain beliefs about themselves, others and the world. It is safe to assume that our male clients with BDD/MDD have similar negative views of themselves as it pertains to what is beautiful and accepted and what is not. These automatic thoughts can lead to cognitive distortions or faulty ways of thinking. As long as a client’s negative view of himself does not match his positive automatic thoughts about the world, he will feel as if he can’t comfortably be happy with himself as he currently is.

As trained professional counselors, we are no strangers to working with clients with anxiety. Anxiety is a big part of dysmorphia. Clients may experience anxiety when thinking about how others may perceive them. That faulty perception can then be reflected on themselves.

Helping clients to overcome anxiety is key. Anxiety is a fear of the “what ifs” in our lives, and 99% of the time, these events never take place. A person who struggles with BDD/MDD may be preoccupied with the thoughts of “What if I gain/lose weight?” “What if I don’t look like him/her?” Or, more common these days, “What if I don’t get enough likes?”

By helping clients confront the negative thoughts that plague their minds, we can potentially eliminate the harmful and, most times, irrational thoughts that haunt them.

Perhaps the most beneficial thing we can do as counselors is help our clients learn the importance of both acceptance and change. The DSM says that most men who struggle with MDD usually appear to be in pretty good shape already. Although it may be challenging, we must try to help these clients see their muscles as “half full” rather than “half empty.” Introducing them to the habit of positive self-talk may help them remember that it is OK to have a cheat meal or to miss a day at the gym.

If our clients are unhappy with the way they look, it can be beneficial to help them find healthy ways to change. Pointing them in the direction of a nutritionist or a personal trainer may be a healthy alternative for those who take extreme measures to alter their bodies.

Be proud to strut whatever you have at the beach this season, fellas. Remember that maintaining a muscular body takes time, effort and patience. If you aren’t where you want to be this year, set the goal to be there by next beach season. Be proud of the way that you look, and be sure to wear your shades and sunblock so that the rays of the haters can’t touch you.

 

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Andrew M. Watley is a licensed professional counselor and an adjunct professor in New Orleans. His practice specializes in children, adolescents, men’s issues, and struggles that may arise for members of the LGBTQ+ community. Learn more about him and his practice at drandrewwatley.com.

 

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

From pain to empowerment: Lessons learned through physical therapy

By Jane E. Buckingham July 20, 2019

A number of years ago, I gradually and almost imperceptibly began to have lower back problems. Eventually, simple daily activities caused me great pain: lifting a grocery bag, taking a casserole out of the oven, rolling over in bed, getting out of a chair, vacuuming the house (that last one I didn’t really care about). I had to give up things I loved, such as swimming laps and working in my garden. The more my back hurt, the less I did.

As it turns out, that’s one of the worse things you can do in situations like mine, but I didn’t know that at the time. I had been through an extreme amount of stress not long before my back started acting up. As anyone who has a health condition (ranging from a cold to cancer) can attest, friends, family and even perfect strangers feel free to provide you with unsolicited diagnoses and treatment suggestions. So, people kept telling me that my condition was stress related, emotional. I think there may have been some truth to that, but I also knew deep down that there was a structural element that needed to be addressed.

Eventually I got X-rays, which showed that I had not only long-term scoliosis but also erosion at the sites of a couple discs and some arthritic changes in my spine. I didn’t want to relegate my existence to painkillers or a reduced quality of life, so I accepted a referral for physical therapy. I was fortunate to find a wonderful practitioner to whom I returned again and again in the years that followed for a variety of issues — not only my lower back but also an injured shoulder, a knee problem and an unstable cervical area in my neck.

Upon conducting the initial assessment of my back situation, my physical therapist announced, “Jane, you have no core!” She meant physically, not psychologically, but nonetheless the pronouncement sounded dire, so I really took her words to heart. And, indeed, I had been using my back muscles inappropriately because no one had ever explained to me how to strengthen core muscles and why it was important to do so. To this day, I still do most of the exercises my physical therapist taught me as a way to manage my back condition, and I have resumed all the activities I was unable to do previously, including (unfortunately) vacuuming.

So, why this essay about what I learned from physical therapy? Because I believe the lessons and approaches presented in the PT model of conducting therapy, albeit in the physical realm, apply in very concrete ways to our work as professional counselors. Here are my takeaways.

 

Assessment

  • A thorough initial assessment sets the frame for successful treatment. In physical therapy, there was paperwork but not too much. A good portion of the evaluation was my own self-report, along with some objective measurements and observations on the part of the therapist. The preassessment consisted not only of rating my level of pain but also a functional analysis of my ability to perform tasks of daily living. This set the stage for an accurate post-treatment assessment.
  • In terms of diagnosis, instability can be just as concerning as outright pain, but it doesn’t get as much attention. We often hope that those initial warning signs, whether physical or emotional, will go away. However, stabilizing a condition before it becomes painful can help avoid serious problems down the line.

 

Goals

  • In my various experiences with physical therapy, the goals of our work together were very clear and established by me during that first intake session, thus creating a contract for therapy. Usually, one or two goals were sufficient and were completely measurable. Sometimes a goal was merely to reduce (not eliminate) pain and to regain my ability to engage in a particular activity again. My physical therapist estimated the number of sessions I would need, so the work had a beginning and an end, but it always included an invitation to return for a consult if needed.

 

Relationship

  • Trust is essential and was developed through the therapist’s active listening and sincere invitation to provide her with feedback. She had the expertise but understood that I was the expert on myself. Encouragement and honesty went hand in hand. If something wasn’t helping, we decided together to regroup and start fresh. I never really liked anything that involved props such as big rubber balls or elastic bands. She didn’t judge me for this but instead worked with my preferences.
  • My physical therapist was not just a good listener but also genuinely wanted to know how I was doing. In my most recent round of physical therapy for a neck condition, I wasn’t experiencing the results that either of us would have liked. I was feeling discouraged and frustrated that I wasn’t making progress. No problem. She instructed me to forget all the exercises I’d been given so far so that we could start all over at the beginning. We began anew with a different approach and set of practices, and they worked. It’s important to note that, to switch gears like this, total honesty on my part was essential, but it was her nondefensive response that allowed us to find a more effective approach.

Action

  • A little goes a long way. We started very slowly. Each week my physical therapist introduced one or two exercises that I was to practice in between sessions. In fact, my participation and practice outside the sessions were where the real work happened (just like in psychotherapy). The requirements and expectations were so minimal — most exercises involved only 10-15 repetitions one or two times a day — that it was easy to do them, and this led to a sense of accomplishment. My therapist gave me handouts with written instructions and diagrams so that I could refer back to them if needed. I came to understand that when humans are confronted with change on a big scale (even if the change is something we invite into our lives), the organism can set up resistances in both subtle and significant ways. When change is small and gradual, the protective functions of the amygdala don’t get activated, and barriers to change don’t have a chance to develop.
  • Visualization was a primary tool for the physical therapist. When she asked me to locate and tighten muscles I didn’t even know I had, she used imagery and mental practice to get me started. “Just see yourself in your mind’s eye doing the exercise.” “Imagine guy wires attached to your abdomen pulling the muscles tight.” “Bend from the waist, keeping your back straight, like a waiter taking a bow.” “Press your feet to the floor as if trying to keep an egg from rolling away without breaking it.” “Try this with a light touch, like kitten whiskers.”

 

Outcome

  • The results of physical therapy were not instantaneous, but changes became evident in a few short weeks. Stabilization came first, and then strengthening. Small gains were encouraging and kept me motivated. Armed with a menu of exercises to practice on my own, I felt resourced with an increased sense of agency. Slowing down and paying attention with mindfulness became solidified as tools that were readily available (these tools were also transferable to other life situations).
  • If something can’t be cured, at least it can be managed, functioning can be restored, and quality of life can be enjoyed. I felt empowered to continue the maintenance work on my own but also encouraged to come back if past problems resurfaced or new ones arose later on.

 

Final thoughts

Each of the concepts and suggestions I incorporated from physical therapy can be applied to our work in mental health counseling. Some of them are common sense, whereas others reflect what is established as best practice. But organizing them into a frame that is parallel to physical therapy provides a different portal into our therapeutic work.

I have used all of these ideas with clients and found them to be useful. My back continues to be stable, and I have discovered that I do have a core after all.

 

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This essay is dedicated to BB with gratitude.

 

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Jane E. Buckingham is a licensed clinical mental health counselor, national certified counselor, certified clinical mental health counselor and mental health consultant in Brattleboro, Vermont. Contact her at janebuckingham@yahoo.com.

 

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

 

From Combat to Counseling: Service members, veterans and military family mental health

By Duane France July 14, 2019

 

This is the debut article of what is intended to be a monthly online column about counseling military-affiliated clients.

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Service members, veterans and their families face some unique challenges both during and after military service. There’s the stuff that is widely known — deployments, constant moving, a regimented lifestyle — and then there’s the stuff that isn’t so well-known. This includes the experience of living in a mutually supportive community; a lack of individualism and getting used to relying on others while others rely on you; for veterans, a lack of purpose and meaning in post-military life; for family members, experiencing the aftermath of the military, because it’s a stressful job. No one is getting out of the military without a couple of dents in the fender.

Sometimes, the challenges faced by the military population turn into crisis. The high rate of suicide in the service members, veterans and their families (SMVF) community is well-known. Given a higher level of exposure to trauma, service members and veterans may be more likely to develop posttraumatic stress disorder and other psychological conditions. And with greater physical danger comes a higher risk of catastrophic injury, which comes with its own problems, including the need to adjust to a new reality.

This is where the counseling profession comes in. As clinical mental health professionals, we are uniquely qualified to help the SMVF population live the life that they desire and deserve. We look at mental health from a wellness perspective, not an illness perspective. People with a military background will reject the concept of “sickness” and “brokenness” because, to them, that’s equal to weakness. If someone approaches a service member, veteran or military family member with pity, as if they’re a broken-winged bird, there will probably be a bit of a confrontation.

I know, because I’m a member of this community.

Who am I?

I retired from the U.S. Army in 2014 after a 22-year career. After retiring, I took on a new mission to help my brothers and sisters in arms, and their families, adjust to the circumstances that put some of those dents in their fenders. After several years of clinical work, I realized that my lived experience combined with my clinical background could help others. Which is where this column comes in.

Over the coming months, I’ll be sharing some of my insights about the culture and character of the military. Even though the need is great, the counseling profession doesn’t include a lot of people like me — former service members who have become professional counselors. As a matter of fact, that is what brought me to the profession — a chance encounter at just the right time and someone saying exactly the right thing to someone who was open to hearing it.

I was not a mental health professional when I was in the Army. I was in logistics, which is the Army’s euphemistic way of describing supply and transportation. In 2007, knowing that I would eventually have to leave the military, I started going back to school while I was deployed to Iraq. I was looking for a degree with the least amount of math possible and came across an associate degree in counseling and applied psychology. I thought that might make me a better leader, and I was interested in psychology, so I figured why not?

Fast-forward nearly a year. My unit was redeploying from Iraq after 15 months, and we were participating in post-deployment reintegration sessions. We all went to a conference center at a local hotel, where we were presented with breakout sessions on not going too wild with our drinking, not being mean to the neighbors … that kind of thing.

One of the breakout sessions was led by a counselor from the local Vet Center. For those of you not familiar with Vet Centers, they are outpatient mental health clinics that are part of the Department of Veterans Affairs (VA) but separate from the main VA health care system. The counselors at the Vet Centers are typically veterans themselves, as was the case with this clinician. She introduced herself and said that she was a retired Air Force officer. I don’t remember much of what she talked about that day, but something she said struck me then and stays with me now: “By the way, if any of you are interested in psychology, consider a career in the mental health industry. There are not enough combat veterans in our field.”

That’s all it took. Up until that point, I had not considered becoming a mental health counselor. After that, I started on the path that I’m on now and, with the help of many mentors along the way, currently work as a counselor at a private outpatient clinic in Colorado Springs, Colorado, that primarily serves the military population.

What the counselor said that day was correct then, and it still holds true now: There are not enough veterans in the counseling career field serving others in the military population. At the same time, that truth does not minimize the need for mental health counseling for the military population. There are two solutions to this: Bring more veterans into the counseling profession, and help those clinicians in the counseling profession who are not veterans to understand more about the unique needs of the military population.

As professional counselors, we recognize the need to be culturally competent with whatever client populations we work. We can’t work with someone from another culture without knowing about that culture; the ACA Code of Ethics clearly identifies this.

In that sense, the military population is an entirely different culture. Anything that defines the characteristics of a culture — ways of dressing, language, conceptualization of the world — applies to the military. I often describe it this way: It’s as if I went to England to live for 22 years and then moved back to the United States. Sure we spoke the same general language in those two countries, but there were also significant cultural differences between them and, therefore, adjustments that I needed to make. That’s how service members and their families feel after military service.

So, the goals of this column will be:

  • To provide insights into the culture of military-affiliated clients
  • To support counselors who find themselves working with service members, veterans and their families
  • To answer questions (if you have any, feel free to drop me a line at duane@veteranmentalhealth.com)

Thank you for your willingness to serve the military-affiliated population and for your willingness to learn more. Your efforts are greatly appreciated

 

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Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at veteranmentalhealth.com. Contact him at duane@veteranmentalhealth.com.

 

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