Monthly Archives: September 2020

ACA online event encourages conversation about counselor stressors

By Bethany Bray September 21, 2020

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“How can I to continue to hold hope for my clients while I feel like I’m drowning?”

“How can I confront colleagues who commit microaggressions in client sessions?”

“What advice do you have for students whose professors and textbooks do not address multiculturalism?”

These were among the many challenging — and honest — questions raised during “Our Community Gathers: A Conversation With Counselors About Mental Health in 2020,” an online forum the American Counseling Association held Sept. 17 to facilitate professionals connecting with one another and sharing concerns. Much of the discussion from panelists and attendees alike focused not just on the additional stress that counselors and clients have been experiencing throughout the COVID-19 pandemic but also on the trauma, grief and exhaustion raised by recent social turmoil tied to systemic racism in America.

The online event, which was sponsored by the ACA Foundation, drew more than 400 attendees, including ACA members and nonmembers.

“This event is all about you,” said ACA President Sue Pressman as she opened the Zoom session. “Each day it feels like the very fabric of our society is unraveling. The work we do for clients and students is so important, [and] frankly speaking, counselors are needed more now than ever. I could never be more proud to be a counselor. At the same time, counselors are in crisis and in need of support. … Care and compassion for our colleagues is important and can be quite powerful, and this is one of the reasons for this event.”

S. Kent Butler

S. Kent Butler, ACA president-elect, served as the forum’s moderator, while Pressman gave opening and closing remarks. The event panel included several past ACA presidents and leaders from across the counseling profession, including Beverly O’Bryant, Courtland Lee, Gerald Corey, Ebony White, Mark Scholl, Anneliese Singh and Selma Yznaga.

The panelists were open and honest about how they too have been struggling recently. They urged attendees to focus on practicing self-care, taking breaks and staying aware of the body’s signals that one is becoming overwhelmed. They opened the session by talking about the necessity for counselors to seek their own counseling.

White said that counselors are “secret keepers” and noted the importance of processing the pain they carry for others in their own counseling sessions. At the same time, it can be a challenge for Black practitioners and other counselors of color to find a practitioner who looks like them because a majority of counselors are white. This is a barrier that is also shared, of course, by clients of color when they seek counseling.

“Even still in the year 2020, right now, as a Ph.D., LPC [licensed professional counselor], Black counselor who has a [professional] group of people I’m connected to, I’m having trouble finding a Black woman counselor, right now in this moment,” said White, an assistant clinical professor at Drexel University in Philadelphia. “This continues to be an obstacle, particularly for people of color, and it needs to be addressed.”

It is always a good idea for counselors to seek out therapy, but especially so now, agreed Lee, a professor in the counselor education program at the Washington, D.C., campus of the Chicago School of Professional Psychology. “Dealing with this [clients’] intense pain constantly is really going to get to us,” he said.

Lee, a past president of ACA and the Association for Multicultural Counseling and Development, emphasized the importance of resting and only taking on work and tasks that are personally important to individual counselors. He said that was a lesson he learned acutely and personally after his wife, Vivian, passed away suddenly earlier this year.

“What’s not important is sitting in front of a computer all day and having my phone in my hand all the time. Tonight was important to me; that’s why I’m here,” Lee said. “Find what gives you meaning, what’s sacred to you. You’ve got to find ways to take rest.”

White suggested that counselors consider “the bare minimum” amount of time they want to devote to self-care and make sure to hit that mark. For her, that’s 1% of her day. “Dedicate that portion of your day to something that is self-care. Whether that’s for prayer, dancing, drinking wine, whatever it takes,” she said.

Corey and Scholl urged attendees to consider all facets of wellness — physical, social, spiritual, emotional, cognitive, etc. — and focus on areas they find depleted, seeking activities that rejuvenate. For Corey, that includes doing Pilates; for Scholl, it’s enjoying naps that aren’t restricted to “power naps.” Scholl also is intentional about engaging in activities to connect with his Native American heritage, including attending Native gatherings and reading works by Native authors.

“One of the things that I’ve learned is that wellness doesn’t just happen, it takes discipline,” agreed Yznaga. “I have to plan for it, be deliberate. … For anyone who is thinking, ‘I’m not well and I cannot be well,’ yes you can, but you have to work at it.”

Attendees of Our Community Gathers flooded the platform’s chat queue with questions and comments throughout the session. Many posted websites and resources they thought others might find helpful and exchanged email addresses to continue conversations offline.

Panelists stayed online for more than three hours, until 10:30 p.m. Eastern, to answer questions and share ideas with attendees. Judging by the level of engagement the event garnered, counselors found the dialogue sorely needed.

One attendee asked for guidance on how to respond when a client makes a racist statement or uses offensive language in a counseling session. The panelists stressed the importance of responding to clients with honesty in these situations.

“It’s your responsibility to manage that tension in the room,” said White, who noted that counselors are doing a disservice to the client if they let a client’s statement go by without challenging it in session even as another dialogue that disagrees with the client plays silently in their heads.

Confrontation can be a therapeutic tool, White added.

Lee emphasized the term “broaching” in his response and the importance of broaching the subject to help clients un-learn words and perspectives that may have been ingrained in their culture and upbringing.

“Counseling is supposed to be an educative process,” Lee said. “Counselors often skip by teachable moments, but you can’t let them slide by.” When a client expresses a racist view in session, “Broach it and use it as a teachable moment,” he advised.

“We can be authentic and confrontational and still be respectful, even though it’s tough,” agreed Corey, an ACA fellow and professor emeritus of human services and counseling at California State University, Fullerton.

In such an instance, Corey said he would respond to the client by saying, “What I’m hearing you say is X. Let’s talk about it.” Afterward, it would be helpful for the counselor to seek out a mentor or colleague to debrief with and find support, he said.

Several panelists noted that the United States is in the midst of a cultural shift that brings opportunity for the counseling profession.

“Let’s try and take advantage of this moment and show the country what we have to offer, to destigmatize mental health and teach people how we [counselors] can help,” said Yznaga, an associate professor at the University of Texas Rio Grande Valley.

Lee remarked that he never thought he’d witness Confederate monuments taken down in his lifetime or the professional football team in Washington, D.C., change its name.

“We are at an inflection point that I have never seen,” Lee said. “This is much different than the [civil rights movement of the] 1960s. The ‘60s opened the door and made tremendous progress, but this era … It’s beyond just a teachable moment at this point; it’s an opportunity that we haven’t had before. If counselors are agents of social change and social justice, we need to get out there and fill the learning gap.”

 

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Resources

Continue the conversation

ACA will hold a virtual event on racial injustice and policy reform Oct. 14 at 2 p.m. (Eastern). The moderator for the event will be Aisha Mills, CNN and MSNBC political commentator.

Be on the lookout for registration information in ACA’s Member Minute newsletter, or email advocacy@counseling.org to share your interest in attending.

Counseling Today articles on related topics

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

Voice of Experience: The miracle of 28 days

By Gregory K. Moffatt September 17, 2020

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When I began my life as a mental health worker well over 30 years ago, the words “managed care” weren’t even a blip on the radar. Almost everyone had personal insurance. People who had an HMO were mostly factory workers, and to have an HMO or a PPO was generally not regarded as a good thing. Otherwise, you could go to whatever doctor you wanted, there were no “referrals,” and both physicians and counselors had immense latitude in the first few weeks of treatment.

In those days, there was a joke in our profession that went something like this: “How long does it take to treat [fill in the blank with any issue]?”

The answer: “Twenty-eight days.”

The reason for 28 days is that insurance companies would reimburse for up to 28 days of treatment — even in-patient care — without question. After that, lots of other documentation was required. So, miraculously, in-patient care was often — you guessed it — 28 days.

Of course, no responsible therapist planned their treatments based on that 28-day ceiling, but we had tons of latitude on treatment plans. But the late 1980s brought us major changes in health care. Managed care (HMOs and PPOs) changed the way we did business. I was too new in the field to have an opinion at that time, but I remember the outrage among my supervisors and other veteran counselors.

In retrospect, the change in how insurance worked actually helped us (forced us?) to become better in how we provided services. For example, brief solution-focused therapy, which was something that didn’t exist when I was a graduate student, is a result of this change.

You may be asking yourself whether there is a point to this interesting trip down memory lane. Well, I think we may be seeing something just like I described above happening right now.

Americans are innovative. I am confident that the coronavirus pandemic has created a scenario that will permanently change much of our culture. In the 1980s, therapists didn’t have to think about being “brief” or efficient, but the rise of managed care forced our hands, and we got better because of it.

This virus has forced us into telemental health and other ways of offering services that, prior to March of this year, we didn’t have to think about unless we wanted to. I have encouraged all of my supervisees to pursue the telemental health credential in our state, and I have done so myself, both as a clinician and supervisor, but I suspect that lots of veteran therapists just didn’t want to mess with a new modality.

Imagine that. Once again, here is something that we were forced to do that we should have been doing already because it provides options and helps our clients. In my early years, I learned to be efficient — to do in one session what my teachers might have had the luxury of doing in five or 10 sessions. I did things efficiently because managed care forced me to do so. But shouldn’t we have been doing that anyway?

I’m not belittling my predecessors. My teachers and supervisors didn’t have to do something they weren’t accustomed to doing, so they only did it if they felt like it. Now I’m realizing that this current pandemic is changing the way we do business, and that change isn’t going away when the virus eventually fades away. I predict that some of our clients will never choose to go back to the way it was. And maybe they shouldn’t. Young therapists will probably look back on this time in history and say, “Why did my teachers need a virus to get them to routinely offer services that benefited their clients? Crazy!”

This will also affect me as a college professor. My students undoubtedly will be asking, “Why do I have to come to the classroom?” long after the pandemic is history.

My clients will be asking something similar: “Why do I have to drive all the way across Atlanta and deal with traffic every week when I can see you from the quiet of my home office (in my slippers and jammies) if I wish?”

So, in our very near future, I suspect that graduate programs will not offer telemental health as an optional certification. Instead, programs will be adjusted to provide telemental health as an expected option for clients who fit well with this modality.

If any of you reading this are holding your breath until things “get back to normal,” don’t hold your breath any longer. We have a new normal, and this will almost certainly, in some ways, be very good for us, good for the counseling profession and, most importantly, good for our clients.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

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

Self-injury: An overview for counselors

By Lauren Appel September 16, 2020

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The challenges that students face today can be complicated and overwhelming, causing some youth to resort to self-injury to cope with the stress. According to a study by Martin Monto, Nick McRee and Frank Deryck (published as “Nonsuicidal self-injury among a representative sample of US adolescents, 2015” in the American Journal of Public Health), 1 in 4 girls and 1 in 10 boys will self-harm.

From my experience as a school counselor, I have found that the presence of self-injury often indicates significant underlying emotional issues. Given these realities, I believe it is more important than ever for counselors to familiarize themselves with this dilemma. This overview is intended to walk through what self-injury is and isn’t, who tends to be affected and how to intervene.

What is self-injury?

Self-injury, also known as nonsuicidal self-injury (NSSI), can be defined as deliberate, self-inflicted harm to body tissue without suicidal intent. This does not include behaviors that are socially accepted, such as piercings or tattoos. This definition is based on E. David Klonsky’s research presented in “The functions of deliberate self-injury: A review of the evidence,” published in Clinical Psychology Review in 2007.

NSSI includes, but is not limited to, cutting, burning, biting or scratching the skin, head banging, punching and pinching. Common injury sites include the hands, wrists, stomach and thighs, although injuries can occur anywhere on the body.

Who self-injures?

According to data taken from Jennifer Muehlenkamp and colleagues’ 2012 study, “International prevalence of adolescent non-suicidal self-injury and deliberate self-harm,” published in the journal Child and Adolescent Psychiatry and Mental Health:

  • 1.3% of children ages 5-10 self-injure
  • 17% of adolescents self-injure (this figure is high because it includes those who have self-injured only once)
  • 5% of adults self-injure

Overall, females have been reported to self-injure more than males. They tend to prefer cutting more than any other means of self-injury, according to Janis Whitlock and colleagues’ 2011 study, “Nonsuicidal self-injury in a college population: General trends and sex differences,” published in the Journal of American College Health.

Although males are reported to self-injure less often, it is possible that this is being underreported or that the self-injury is hidden behind behaviors deemed as “more masculine.” For instance, males are more likely to deliberately bruise or cause abrasions to themselves by punching walls or instigating fights to have others hurt them.

This aligns with the incorrect perception that males have to demonstrate a certain caliber of “manliness” and that the only acceptable emotion for them to feel is anger. I have had male students who said they would be ridiculed as sissies if they expressed feeling sadness or pain or demonstrated other aspects of vulnerability. Males tend to get more “cool points” for behaviors such as picking fights or punching walls than for engaging in other types of self-harm such as cutting.

Whitlock et al. also discussed how LGBTQIA individuals are affected by self-injury. Those who identify as LGBTQIA self-injure more frequently than do their heterosexual counterparts. In particular, bisexual females were 6.2 times more likely to have engaged in self-injury at some point during their lifetime. These data showed that this subgroup is at the highest risk for NSSI out of the other populations studied in terms of gender and different types of sexual orientation. This is clearly a population at high risk that needs to be monitored.

I have found that individuals in this subgroup often self-injure because they feel split between what is expected of them and who they really are. They tend to carry a significant amount of self-blame for not meeting those expectations or feel frustrated for having what they believe to be disturbing thoughts. When their secret lives become consuming, they often turn to self-injury for “escape.”

Trauma and bullying victims are also at high risk for self-injury according to Laurence Claes and colleagues’ 2015 study, “Bullying and victimization, depressive mood, and non-suicidal self-injury in adolescents: The moderating role of parental support,” published in the Journal of Child and Family Studies. Those who have experienced trauma can internalize the event, which causes emotions that are difficult to handle and makes them more susceptible to NSSI. Clients who frequently experience bullying or peer rejection also tend to self-injure more than their counterparts do. My past students who were victims of bullying or abuse often felt that they could not fight back; in other words, they did not externalize their behavior as a coping mechanism. This then led them to an internalizing coping mechanism, which resulted in self-injury.

Myths about self-injury

The following myths are inspired by a fact sheet on top misconceptions about self-injury produced by Saskya Caicedo and Janis Whitlock for the Cornell Research Program on Self-Injury and Recovery.

Self-injury is a suicide attempt or a failed suicide attempt. Research has shown that most people who self-injure do not have the intention to die by suicide. The main motivation for self-harm is to deal with emotional stress or pain. The category name of nonsuicidal self-injury in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders provides a sense of separation from suicidal intent. This category is also being used by other organizations and in research, thus creating a distinct line between self-injury and suicidal intent. The majority of my students who self-injure have expressed no interest in ending their lives; they were simply causing superficial injuries.

Self-injury is done to seek attention. Some individuals may use self-injury as a tool to seek attention, but it is important to realize that this action still represents a desperate cry for help. Why are they going to such drastic lengths to get attention? This is a question that we, as counselors, need to ask ourselves so that we can intervene accordingly. However, the majority of those who self-injure go to great effort to hide any evidence of cuts or scars. They tend to be secretive and have a difficult time discussing the underlying issues that plague them. Those who cut in secret demonstrate extreme emotional distress and need substantial help.

Anyone who self-injures is part of the Goth or emo subgroups. Research shows that self-injury is not limited to one specific group. Self-injury does not occur on the basis of gender, socioeconomic status, sexual orientation, social group, race, profession or other categories. It is true that some groups are more affected than others by self-injury (as seen in previous demographics), but no group is completely excluded.

Someone who self-injures can quit if they really want to stop. Many experts in this area indicate that self-injury has the qualities of an addiction. The act of self-injury causes endorphins and other neurochemicals to be released in the brain, which essentially gives the person a type of “high.” The chemicals eventually dissipate, and then a craving develops to experience that feeling again. This creates a cycle of addiction that makes it even harder to stop the behavior. Many individuals may need help and additional support to be able to stop self-injuring.

Although I have students who experiment with cutting and do it out of curiosity, there is a subgroup of students who chronically self-injure. They can’t seem to “kick the habit,” no matter how hard they try. Typically, this means that their underlying issues have yet to be resolved and that an adequate replacement coping mechanism needs to be put in place.

Someone who self-injures is a danger to others. Typically, those who self-injure are people who tend to internalize their emotional issues rather than externalize them. In other words, people who self-injure take their frustrations out on themselves rather than on others. This particular trait makes it highly unlikely that people who self-injure would harm someone other than themselves.

Why do people self-injure?

From my experience, there are a few main reasons that someone may self-injure. These do not, by any means, cover every possibility. In addition, some people may have multiple reasons that motivate their behavior to self-injure.

As a coping mechanism: Based on research findings, self-injury is a way to cope with emotional pain and distress that can stem from mental illness or trauma. These two issues typically involve internalizing behaviors, which is one of the factors in the personalities of those who self-injure. Those who self-injure lack healthy coping skills that allow them to function.

To feel or to numb: Especially in cases of depression, there can be physical symptoms such as numbness and emptiness. This disconnect with the body can cause individuals to self-injure for the sake of being able to feel something again.

On the opposite end of the spectrum, some people feel too much. This tends to occur in people who may have anxiety and are overwhelmed by emotions. Self-injury for these individuals is a form of distraction that places their focus on the injury rather than on the tidal wave of emotions engulfing them.

To self-punish: People who use self-injury for this reason tend to loathe themselves and to have extremely poor self-esteem. They often are perfectionists and will punish themselves for perceived academic, athletic or social failures. This is often where the high achievers are grouped: They expect nothing less than perfection from themselves, and they “pay for it” when they believe that they have fallen short.

Immediate interventions

The following are examples of immediate interventions that counselors can take with clients who engage in self-injury.

Screen for suicide. Although it has been established that the majority of self-injury cases do not involve suicidal intent, it is important in new cases to establish which category the action falls under: NSSI or preemptive attempt of suicide.

It is always a good idea to ask some screener questions such as “Have you thought about suicide?” and “Do you have a plan?” But avoid asking, “Do you think about hurting yourself?” It is obvious that the person is already hurting themselves, and if they answer that question affirmatively, then it is likely because they are engaging in NSSI versus trying to kill themselves. However, a misunderstanding about their answer could lead to a false positive of the person being suicidal. If the person does present as suicidal, then follow additional threat assessment guidelines.

Be aware of the need for medical attention. If the individual presents with fresh injuries, counselors should be alert to possible infections, the need for stitches or other medical issues that may arise. Often, people who self-injure cover up their cuts or injuries, and the trapped moisture can cause a bacterial yeast infection. With those who have created bruising, it is important to check for possible broken bones. This evaluation also creates an opportunity for counselors to explain the risk factors that accompany self-injury and how students or clients can protect themselves from medical crises.

Notify a family member or person of support. In these situations, it is necessary to inform the individual’s parent, spouse or person of support. Self-harm is a sign of serious emotional distress, and the family needs to be made aware of what is happening so that they can be on the alert. It is also wise to talk with the person about removing any objects they could use to harm themselves, such as knives, scissors, push pins, lighters and so on. When first speaking with the student or client, try to collect information about which instruments they favor in inflicting self-harm so that there is a better idea of what objects need to be removed. Working with significant people in the client’s life is key to ensuring the client’s safety.

Supportive interventions

The following are examples of supportive interventions that counselors can use with clients who engage in self-injury.

Identify triggers. One of the best strategies for helping students or clients who engage in NSSI is to identify their triggers. Does it involve perceived failure? Does it involve feeling awkward? Does it involve rejection by peers? Once the triggers are named, the next step is to work with the student or client to outline a plan for when these triggers arise. What alternative strategy can they use? What kind of self-talk will they employ? Do they need a break from the stressful activity? All of this needs to be planned and practiced.

Identify a network of trusted individuals. What I have learned on the basis of my students’ experiences is that part of the method of operation for those who self-injure is to isolate. When students or clients do try to stop engaging in self-injury, they will need some sort of outlet for dealing with all of their complex emotions. Working with these students or clients to come up with a group of people they can trust is crucial to their recovery.

Find appropriate replacement behaviors. Odds are, the person has been using self-injury as a coping mechanism for a long time, and in order to recover, they will need to learn healthy coping strategies. Many people who struggle with self-injury are often high-sensory seeking, particularly with tactile sensory input. Replacing self-injury with fidget items that provide tactile feedback (cotton balls, string, erasers, textured stress balls, etc.) may offer more successful replacement behaviors.

Other methods of expression, such as drawing or writing, can also be beneficial because they provide an outlet for the person’s anxieties. This makes it less likely that the person will bottle up their emotions as much.

Use cognitive behavioral techniques. Cognitive behavioral techniques include identifying cognitive distortions (“thinking errors” or “thinking traps”) and learning how to engage in positive self-talk. They involve the realization that when we are thinking negatively or getting stuck on an inaccurate idea, that may skew our perspective. Some examples include:

  • Mind reading: Thinking that we know what others are thinking about us
  • Ignoring the good: Paying more attention to things that are bad
  • Setting the bar too high: Expecting ourselves to be perfect
  • Blowing things up: Making a small thing into a big deal

Once the student or client gains awareness of their faulty thinking, they can replace it with positive self-talk. For example, for ignoring the good, a student might say, “In my paper, I had trouble with this section, but I did a good job with explaining my argument overall.” For further information, refer to the “Thinking Errors” worksheet at therapistaid.com.

Encourage self-compassion. Strategies that involve identifying clients’ strengths and talents can help them to better understand and embrace their positive aspects. Helping students find activities in which they can really shine and develop their strengths is especially beneficial.

Safe websites that offer support

It is important to be wary of online supports for individuals who engage in NSSI. I have often encountered so-called support groups online whose members showed graphic pictures of self-injury in a sense of one-upmanship. These sites are triggering and tend to encourage further self-injury.

Over the years, I have found the following sites to be both helpful and safe:

By using these strategies and resources, we can support our clients in developing new and positive coping skills. Together with their families and outside providers, we can make a difference in addressing NSSI.

 

 

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Lauren Appel is a behavior specialist in a North Carolina school system with a background as a school counselor. Contact her at lauren.appel@caswell.k12.nc.us.

 

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.

A beginner’s guide to client confabulation

By Jerrod Brown and Megan N. Carter September 15, 2020

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In the context of mental health treatment, client confabulation refers to the unintentional recollection and formation of false memories, ranging from subtle embellishments to grandiose elaborations. Confabulation may take the form of a true memory being inserted into an incorrect temporal, spatial or event context. In other words, confabulated memories can be based on an actual memory taken out of temporal context, or they can result from the creation of a completely fabricated memory (one not based on a previously held belief, experienced event or memory). Confabulation may also involve the incorporation of confabulated details or events as part of a true memory.

It is important for mental health professionals to remember that people who confabulate are unaware that they are engaging in this memory phenomenon and have no intent to deceive. Clients who confabulate have no conscious awareness that their memory is false; in fact, they often strongly believe that their memory is true. Confabulation can also manifest in verbal or behavioral displays of unintentional dishonesty.

Confabulation is distinct from delusions, which are firmly held false beliefs that follow a consistent theme and result from psychosis, often involving an alteration of lifestyle to accommodate the false beliefs. It is also distinct from malingering, the purposeful deviation from the truth to achieve a desired outcome (e.g., reporting mental health symptoms that are not present to receive disability payments). Although confabulations and delusions may share a common pathophysiology (i.e., they can present similarly), they are separate phenomena.

Confabulation is a complex and confusing topic with an uncertain etiology, and it remains under-investigated within the context of mental health treatment. It is loosely associated with a number of neurobehavioral/neurodevelopmental disorders (e.g., fetal alcohol spectrum disorder [FASD], intellectual disability) and neuropsychiatric (e.g., schizophrenia), neurocognitive (e.g., dementia, traumatic brain injury) and medical health conditions (e.g., Korsakoff’s syndrome, various brain diseases). Adding to this confusion is the fact that confabulation can also occur among individuals with no identified impairments, disorders or diseases when certain factors are present (e.g., memory confusion, an attempt to fill in a memory gap, high-pressure and stressful interviews).

Although the underlying brain processes associated with confabulation are currently unknown, possible causes have been suggested in the research literature. These include:

  • Attempt to preserve self-coherence
  • Attempt at self-enhancement
  • Competing memories varying in strength and emotional significance
  • Executive functioning deficits
  • Fast-paced and stressful interviewing approaches
  • Frontal lobe dysfunction
  • Guided imagery
  • Hypnosis
  • Impaired attentional control
  • Impulsivity
  • Memory encoding and retrieval deficits
  • Memory loss
  • The mistaking of imagined events for real ones
  • Overconfidence
  • Attempt to preserve a sense of self-identity and self-esteem
  • Reality-monitoring deficits
  • Repeated lines of questioning
  • Self-monitoring deficits
  • An eagerness to please (i.e., wants to demonstrate an ability to answer all the questions)

Most commonly observed in the retrieval of autobiographical memories, confabulations can include information inspired by peers, television, movies and social media. Inspirations for confabulation may also occur from overhearing conversations from other individuals (e.g., inpatient treatment settings, group treatment programs, sober support meetings).

Mental health professionals are often unaware of this topic and typically receive little to no training in the implications of confabulation on client populations. Because of its potential to compromise screening, assessment, treatment efforts, discharge planning and placement, confabulation is a crucial clinical phenomenon for mental health professionals to understand and address in practice.

Types of confabulation

There are two principal forms of confabulation: provoked and spontaneous. Provoked confabulations are incorrect responses to questions or situations in which a person feels compelled to respond. Examples of such situations include intake assessments, investigative interviews and testifying in court.

Research has established that the more stressful a situation is perceived to be, the more likely confabulation is to occur. This is why mental health professionals working in criminal justice or forensic mental health settings need to pay particular attention to a patient’s possibility of confabulation, which may lead to inaccurate diagnosis or symptom identification. Additionally, unintentionally misremembered information can derail the legal process if the person provides inaccurate eyewitness information, prematurely waives Miranda rights, provides false confessions to police or enters inaccurate testimony in court. In the worst-case scenario, it could even result in wrongful convictions.

Spontaneous confabulations are not linked to a particular cue. They range from misremembering insignificant information to generating fantastic and grandiose details. They are believed to result from a reality-monitoring deficit in the frontal lobe combined with organic amnesia. Spontaneous confabulations also differ from provoked confabulations in that most patients eventually stop engaging in the behavior.

Provoked and spontaneous confabulations can be expressed either verbally or through behavior. Verbal confabulation involves articulating a false memory, whereas behavioral confabulation involves acting on a false memory (e.g., going to the wrong home because the person believes it is where they live). Regardless of the form they take, false memories can evoke real emotions from clients, who may have a high level of confidence in the accuracy of their recall despite evidence to the contrary.

An example that one of us experienced occurred in the course of a forensic mental health interview with a woman who was subsequently diagnosed with Korsakoff’s syndrome. During the course of the evaluation, it was clear that she had significant difficulty developing new memories but was able to recall long-term historical memories (e.g., childhood autobiographical memories). She described recently babysitting a neighbor’s three preschool-age children, including fixing them snacks and letting them watch television. A report was made to child protective services because of the woman’s significant impairments and concerns about the safety of the young children in her care. A subsequent investigation concluded that the woman had not been left to babysit the neighbor’s young children; this was an apparently confabulated memory.

Screening and treatment

There are various theoretical models to explain confabulation. One implies a failure to suppress memory traces that were used in the past but that are no longer relevant to what the person is currently trying to remember. Another theory posits that the person simply failed to retrieve the relevant memory. Finally, another theory is that the person failed to locate the memory for that time and context and essentially inserted another memory in its place.

Numerous conditions can increase the likelihood of confabulation, including:

  • Dementia
  • Encephalitis
  • FASD
  • Frontal lobe tumors
  • Frontotemporal dementia
  • Herpes simplex encephalitis
  • Learning disabilities
  • Nicotinic acid deficiency
  • Korsakoff’s syndrome
  • Multiple sclerosis
  • Schizophrenia
  • Subarachnoid hemorrhage
  • Traumatic brain injury

Given that confabulation has an unclear etiology, multiple definitions, and statistical and clinical associations with a range of neurobehavioral, neurodevelopmental, neurocognitive and neuropsychiatric conditions, the use of a valid and reliable screening procedure is essential. This will help mental health professionals avoid inaccurate diagnoses and the development of ineffective treatment plans that could exacerbate underlying conditions. Screening areas for consideration during confabulation evaluations include:

  • Abstract and sequential thinking
  • Attention-deficit/hyperactivity disorder
  • Executive functioning
  • History of trauma
  • Sleep
  • Learning capabilities
  • Social skills
  • Memory
  • Receptive and expressive language
  • Sensory processing
  • Source monitoring
  • Suggestibility
  • Prenatal alcohol exposure

While confabulation can occur for a variety of reasons, early identification, support and monitoring are key. Possible screening tools that may be useful include the Nijmegen-Venray Confabulation List and the Confabulation Screen. Use of these tools may provide a beginning analysis for further exploration of this issue. If confabulation occurs but is thought to be due to an organic condition such as Alzheimer’s disease, dementia or FASD, referral for neurological testing is appropriate and can provide insight into which areas of the brain are most affected. This can assist in determining the best treatment approach given the individual’s particular areas of need.

Regarding treatment, specific intervention strategies have been found to be useful with clients or patients who confabulate. These strategies involve:

  • Avoiding confrontation
  • Avoiding leading questions
  • Avoiding sensory overload
  • Avoiding closed-ended questions
  • Using a slow-paced interview format
  • Using collateral sources to confirm self-report
  • Using developmentally appropriate language
  • Reassuring that it is acceptable not to know an answer
  • Checking for comprehension
  • Minimizing stress
  • Providing family/support-person education
  • Allowing for extra processing time
  • Allowing for long pauses and silence
  • Treating underlying mental health conditions
  • Treating underlying physiological conditions
  • Teaching memory diary use
  • Teaching reality-monitoring techniques
  • Teaching self-monitoring techniques

Establishing a therapeutic relationship with such clients requires acknowledgment that their misremembering is not intentional and that it lacks malice. This can be challenging for clinicians for several reasons: countertransference, frustration at not knowing whether a client’s documented previous diagnoses or symptoms are accurate, and an unconscious bias that assumes the recollection of inaccurate memories is the result of the client trying to gain something else (i.e., malingering) such as money or attempting to get out of trouble.

Clinicians should avoid minimizing what the client is reporting or prematurely assuming that the client is deliberately being noncompliant. In fact, clinicians should recognize that the content of confabulations may even provide useful information regarding the client’s perceptions and behavioral approaches. Additionally, as previously mentioned, the confabulated information may result in real emotions for the client that will need to be acknowledged and processed.

Clinicians must be sensitive to the fact that individuals who confabulate may inadvertently thwart treatment efforts because they lack recognition that their recalled memories are false. To both address this lack of insight and ensure the collection of valid and reliable assessments, clinicians should obtain collateral information to support or refute a client’s claims (especially when a false recollection could result in significant consequences). When clear evidence of confabulation is found, clinicians should appropriately document this in the client’s case file and consider this during the entire treatment process (e.g., intake, screening, treatment planning, discharge planning).

Adaptive functioning

Confabulation can affect a person’s ability to take care of oneself (e.g., personal hygiene, dressing, cooking), carry out activities of daily living (e.g., home cleaning, clothing care, financial management), and effectively maintain a social life (e.g., empathizing, reading nonverbal behavior, establishing a social group, engaging in effective communication). These adaptive functioning deficits can also lead to issues with filing forms to obtain government services (e.g., disability benefits, subsidized housing) and gaining access to medical records to ensure high-quality continuity of care, as well as an increased vulnerability to victimization. Hence, those who chronically confabulate may be less likely to be able to live independently and more likely to require a high level of support.

Therefore, clinicians working with individuals who confabulate should consider administering a “gold standard” adaptive behavior inventory to help guide and inform treatment planning. Among these inventories are the Scales of Independent Behavior-Revised, the Vineland Adaptive Behavior Scales Third Edition and the Diagnostic Adaptive Behavior Scale. Similarly, clinicians working with clients who exhibit significant deficits in adaptive functioning, particularly in higher-level skills such as money management, should be alert to possible confabulations.

Although using a standardized assessment to evaluate adaptive skills can be useful in treatment assessment and planning, clinicians should also be aware of certain disorders, such as FASD, in which confabulation may be common and in which standardized testing does not necessarily identify deficits. For example, those with FASD may be able to complete tasks of daily living such as grocery shopping or managing personal hygiene, but they may have poor judgment (and social judgment in particular) that is not measured on typical adaptive functioning scales. For instance, they may be tricked out of money by someone who is “friendly” to them and then have difficulty understanding or explaining the missing money, so they engage in confabulation to account for it.

In such instances, in addition to using standardized testing, clinicians should carefully assess using qualitative analysis of abilities and interactions. This may be particularly important for those with FASD with regard to social skills or other areas of functioning that are difficult to measure. Confabulation may be demonstrated as a way to present a more functional ability with regard to a wide range of adaptive abilities and may need to be addressed through careful clinical interventions.

If adaptive behavior deficits are found, it is the responsibility of the administering clinician to educate the client’s support systems (family, friends, education system) about the practical implications of these deficits. These support systems may need to be relied upon in cases of severe confabulation to ensure client safety and follow-through on the client’s daily life affairs such as attending appointments and medication compliance. Unfortunately, strong support systems can be less common among this client population. Family, friends and teachers may feel distrustful of the confabulating individual because of a misperception that he or she is willfully attempting to deceive them. Clinicians play an important role in intervening in such misperceptions by educating clients’ support systems on the unintentionality of the confabulations and explaining that they are the consequence of cognitive and neurological deficits.

Conclusion

Confabulation can be a serious obstacle in mental health professionals providing effective care and services. It can have a negative impact on intake, screening, assessment, treatment planning, medication/treatment compliance and discharge planning. For this reason, we urge clinicians to pursue self-study and continuing education training via in-person and online courses to expand their knowledge on this complex and multifaceted phenomenon. When a case of potential confabulation is identified, professionals should seek the guidance of recognized subject matter experts who routinely review key research findings on confabulation on at least a quarterly basis.

Finally, additional research is needed to continue establishing evidence-based screening and intervention procedures to identify individuals who may be at increased vulnerability for confabulation. Such screening procedures could be applied prior to clinical interviewing and in the treatment planning process to ensure that the information obtained is of higher fidelity. The use of such protocols would also familiarize users with the social and cognitive risk factors for confabulation, of which many mental health providers currently lack awareness. Through the adoption of such policies and procedures, the possible negative impact of confabulation can be minimized, appropriate intervention approaches can be implemented, and the likelihood of positive outcomes can be increased.

 

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Jerrod Brown is an assistant professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center in St. Paul for the past 16 years. He is the founder and CEO of the American Institute for the Advancement of Forensic Studies and is editor-in-chief of Forensic Scholars Today. Contact him at jerrod01234brown@live.com.

Megan N. Carter is a board-certified forensic psychologist who practices in Washington state. Her career focus has been on forensic psychological evaluations in both civil and criminal court proceedings. She has also focused on providing education about fetal alcohol spectrum disorders to mental health professionals.

 

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.

Solution-focused tools to help school counselors in a pandemic

By Mark M. Jones September 14, 2020

4 Comments

Counselors in schools are facing unprecedented challenges during the COVID-19 pandemic. School buildings across the country were closed this past spring, and as we transition to the new school year this fall, some students will attend school only remotely through online learning. Others will be in school part time with reduced capacity, whereas still others may return to a full-capacity school but urged to keep physically distant and with their faces covered throughout the long days.

In addition, because of pandemic management measures, students have been spending an unusual amount of time with their families, some of whom are under new and severe emotional, health and financial stress. The pervasive spread of COVID-19 is associated with higher unemployment and poverty, greater use of illegal drugs, and new and sustained trauma experiences. On top of all this are the ongoing string of horrific news stories reporting White on Black violence and ethnic hatred, which are compounding societal stresses.

School counselors must be prepared to support a wide array of student concerns associated with COVID-19 and the accompanying social isolation. Counselors who can assist many students with significant needs in a brief, flexible way in both remote and in-person venues will be particularly valued.

Fortunately, the solution-focused model of counseling is highly adaptable to a wide range of problems, including grief, trauma and anxiety. It is appropriate for suicide prevention efforts, classroom lessons and even brief check-ins with students who are not demonstrating any outward sign of struggle. Instead of a deep dive into problem origination and causation, this form of counseling targets clients’ hopes, resources, exceptions to problems and descriptions of a preferred future. It also fosters vicarious resilience, which will help counselors who may have their own diminished stamina arising from personal struggles related to the pandemic.

Solution-focused counseling was pioneered by Insoo Kim Berg and Steve de Shazer from their work at the Brief Family Therapy Center in Milwaukee in the 1980s. It has evolved and become widespread over the ensuing decades through the work of many advocates in counseling, therapy and coaching. It is sometimes called “brief counseling” because it can be highly effective in a few 20- to 50-minute sessions, or even during a short hallway or classroom conversation.

Counseling in a modern, virtual world now means counseling through video calls without guarantees of confidentiality because students may be in only semiprivate or even public environments. Solution-focused counseling is not problem-phobic, but because of its embedded focus on goals, preferred futures, assets, resources and exceptions to problems, it poses less risk of revealing private, sensitive information that might be overheard by a family member at home.

Three-minute check-ins

Given the long absence from school and the limited amount of time students can be with school counselors, short three- to five-minute check-ins offer one practical way of providing support to students and gauging their emotional state. School personnel are key reporters of child abuse, and there are serious concerns about whether students could be enduring abuse because of having limited access to these trusted adult advocates.

Consider the following eight check-in questions:

  • What is your best hope for this year?
  • On a point scale of 1 to 10, where are you if 10 means that things are going as well as you could hope and 1 is the opposite?
  • What are you most proud of in how you handled being at home for so long?
  • If this turns out to be a really good year, what is something you will have done to make it that way?
  • Who will notice?
  • Do you feel safe at school and home?
  • Who is a trusted adult you can talk with if you are upset?
  • Is there anything else you would like me to know?

These types of questions allow students to express their preferred future, their resources to help them get there and a description of what that future will be like, including who will notice. Humans are social animals, and having students describe what others will see in them when they are successful helps make the path visible to them.

Even if there is not time to ask all of these questions, getting students to describe their preferred future, their resources and their social supports will help them move in small steps toward something hopeful. It will also allow the counselor to gauge students’ emotional states and resources.

Grieving students

Helping students cope with grief does not have to focus only on challenges and sadness. It can also effectively include conversations about joys and happiness. Students first need a counselor who will actively listen to their story of pain in losing a loved one (or a different loss), but a solution-focused counselor will also ask questions that seek descriptions of what the loved one liked to do and the positive aspects of the relationship.

Questions about what the decedent did for the student, enjoyed about the student and how the student knows these things can draw out memories of the relationship and help the student see their own assets and strengths through that relationship. Asking what students sees in themselves that the decedent saw can create rich descriptions of the strength of that connection.

Grief involves coping, so a solution-focused approach may include questions of how the student has managed to get out of bed and arrive at school, and what the decedent would be most pleased to see regarding how the student is getting along. For those students who are less verbal, allowing them to draw their coping skills or positive aspects of their relationship can supplant, or support, the dialogue.

Suicide prevention

All school counselors must be prepared to assess suicide risk in students. Unfortunately, given the diverse demands of school counseling, sometimes single meetings with students in the near term are all that are possible.

Fortunately, solution-focused counseling offers a framework to go beyond just assessing suicide risk; it paves the way toward fostering hope and engaging in critical prevention work. In addition to the classic questions surrounding scaling (e.g., “What keeps you from being one number lower? What will you be doing when one number higher?”) and questions about best hopes and a preferred future, more nuanced questions may elicit additional solution-oriented thinking. Some examples include:

  • If we asked the version of you that has been happier, what would that version tell you to do?
  • What would that version remind you that works for you?
  • How have you made it this far?
  • When in the last week were things a little better?
  • Who is on your support team?
  • Who could we bring into this conversation?
  • What job should we give that person?
  • What would that person advise right now with how you are feeling?

According to John Henden in Preventing Suicide: The Solution Focused Approach, one of the most powerful interventions is having the student imagine being a witness at their own funeral and describing who would be most upset, what advice that person would wish they had given, and what options other than suicide would the student wish they had tried.

Group counseling

Group counseling in schools is often based on themes such as anxiety regulation, social skill development or anger management. In the midst of a pandemic, school counselors may want to expand groups beyond narrow themes to include more students.

Taking a solution-focused approach allows a single group to include individuals with a variety of social and emotional needs. In the first group session, ask students about their best hope for how the group could help them. They can address their preferred future by describing what life would be like if things were better. Describing instances when this has happened and exceptions to the problem allows them to envision the change that is possible. Group members can then scale their current position, followed by questions of what idea they would be willing to try between now and the next session to move one step closer.

Subsequent sessions would start with each member reporting what is better since the last meeting, scaling their status and whether there were setbacks, describing how they coped and detailing what signs they will see when there is progress. To take advantage of the group dynamic, some of these questions could come from fellow members, or members could offer suggestions for what has worked for them. Ensuring that the group includes compliments from the leader and fellow members will help ensure that it is a positive and rewarding experience.

In addition, incorporating activities into groups helps children express themselves in a variety of ways. Fortunately, there are abundant solution-oriented activities to employ. An excellent resource for solution-focused activities with children is Pamela King’s Tools for Effective Therapy With Children and Families: A Solution-Focused Approach.

The following activities may be particularly useful:

  • Cartoon panel: Ask students to draw their miracle day using a six-panel cartoon or, alternatively, six resources/strengths they possess or six challenges they overcame with the names of the people who supported them and the skills they learned.
  • Mock interview: Prompt students to record a video interview of another student, or have them interview one another in a live video group stream. Prompts might include: What strengths did you use to overcome your challenge? How did you keep going and not give up? What advice do you have for others struggling with what you struggled with? Today, when you are being your best self, what are you doing well?
  • Rainbow questions: Have students pick three different Lego pieces that you supply (if meeting in person), or just ask them to name their top three specific color choices. Then, based on the colors selected, have them answer color-coded questions. For example:

Green: Imagine you are talking to your 5-year-old self. What is the wisest advice you would give yourself on how to handle being quarantined?

Orange: What did you do to help yourself get along with your family during quarantine?

Yellow: What is the nicest compliment you have received since the COVID-19 outbreak?

Dark Blue: Who supported you best during the quarantine? what did they do?

Black: What will your friends notice when you are your best self?

  • List it: Ask students to take a piece of paper and draw a line down the middle. On one side write challenges, and on the other side list strengths, resources and trusted advisers who help them with those challenges.
  • Face mask: Have students draw an outline of their face (or body) on each side of a page. On one side, ask them to draw or list what others see in them. On the opposite side, have them draw or list the strengths and resources they possess that others don’t know about.
  • News reporter: Have students interview key people in their lives and learn what those individuals see as their strengths, skills and resources. Ask students to elicit examples and stories, then write up the information as a newspaper piece.

Morning meetings

According to the Responsive Classroom approach, the goal of a class morning meeting is to “set the tone for respectful learning, establish a climate of trust, motivate students to feel significant, create empathy and encourage collaboration, and support social, emotional and academic learning.” Morning meetings are an easy opportunity to incorporate dialogue about the crisis in a way that can make evident to individual students their best hopes, personal resources, and instances of the preferred future being present.

Best hopes for the school year can be asked individually or as part of a group, such as, “What do we need as a group to end this school year well?”

Questions about resources and strengths could include, “When things were difficult, what was most helpful? What is something you tried that helped you to cope that you had never done before? Imagine you get in a time machine, go one year in the future and COVID-19 is finished. Look back to right now and describe something you are proud of in how you handled all of this Who was helpful to you? What would that person say if they were here describing something you did well? Whom do you admire and why? How are you like that person?”

Lessons

Solution-focused lessons can incorporate scaling as well as movement. Best hopes or goal setting can include floor spots that are numbered 1 to 10 (or write numbers on separate pages). Students can take turns standing by their number and then taking a step forward and describing what they will be doing when they are one number higher. Alternatively, a number line from 1 to 10 can be drawn and hung on the wall in class, and students can put a Post-it sticker on the line where they are. For a video chat, they can simply say their current number.

Picturing their preferred future and their resources can be done through letter writing. Students can be asked to think about what they would like to be doing in their career and life in 20 years. Have them imagine they are living that life and they find out that they can get messages back to the past. Ask this successful adult who is living their hoped-for life to describe to their younger self the challenges they faced, the internal assets that helped most and the people who were supportive. Then have them give their best advice on how to navigate the next 20 years.

Students can also interview each other to learn about one another’s recent challenges and resources, including who has helped them, what was most helpful and advice they have for others.

The ongoing pandemic requires that school staff members adjust how learning occurs. Solution-focused techniques allow school counselors to be brief, flexible and powerful in their support of students facing an array of social, emotional and learning challenges.

 

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Mark M. Jones has been an elementary school counselor in Arlington, Virginia, for four years. Before that, he was a trial lawyer for 30 years. Contact him at mark.jones2@apsva.us.

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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.