Monthly Archives: October 2020

Healing attachment wounds by being cared for and caring for others

By Adele Baruch and Ashley Higgins October 29, 2020

Those who work with individuals who have been traumatized have noted the need for these clients to reestablish connection to their own internal worlds. In these cases, clients often become frozen or, depending on the depth of trauma and the immediate response to that trauma, have an outwardly focused, hypervigilant, fight-or-flight approach to their experiences.

Cases of troubled attachment are based in this kind of fight-or-flight response, whether it is rooted in large T trauma (i.e., catastrophic accident or abuse) or small t trauma (i.e., multiple experiences with neglect or mistreatment). This leads to an inability for these clients to securely attach to others.

Building safety via action-based attunement

In cases of troubled attachment, the first task in counseling is to build safety through a focus on empathic, attuned responses associated with the client’s primary pathway of learning (for more, see David Mars and the Center for Transformative Therapy Training Center).

In a chapter titled “The creative connection: A Holistic expressive arts process” in the book Foundations of Expressive Arts Therapy (1999), Natalie Rogers defined empathy as “perceiving the world through the other person’s eyes, ears, and heart.” She noted that this understanding is conveyed through both our words and body language: “The body language, although usually unconsciously given and received … offers a sense of safety and comfort.” As we offer this opportunity for empathic co-regulation, we concurrently engage grounding approaches to enable a return to safety if anxiety is too high.

Along with grounding approaches, it is often useful to initiate action-based responses that are shared by the counselor to promote collaboration and attunement. These can range from the very simple to the more complex.

The following are offered as examples:

Expressive arts: Both the client and counselor respond to a piece of music with line and color. Then each person can respond to the other person’s artwork through line and color. Notice that there is no interpreting of the art experience, only the sharing of a visual response to music, and then sharing one’s experience of that response.
Breathwork: The counselor may model and practice basic and simple breathwork alongside the client to help the client access more internal quiet and space.
Role-plays: Engaging in simple role-plays can offer alternative action-based responses to challenging interpersonal situations

The choice of action-based approaches will depend on the needs and inclinations of the client, but these approaches are all in the service of conveying empathy and expanding interpersonal resonance. As Allan Schore (2013), a neuroscientist who has looked at brain activity during attachment experiences, would describe it, these approaches create opportunities for right brain to right brain communication (the foundation of attachment experiences).

As the client and counselor create together with these practices, the client builds a repertoire of action-based responses. The client may then begin to engage some of these action-based responses when triggered by a reminder of a traumatic event. This increases the client’s sense of internal safety.

Building resilience via attachment rupture and repair

Once safety is developed along with basic attunement and the capacity to choose constructive action, there is an opportunity to build a more robust and mature attachment via the counseling relationship. This can be achieved through a process of both intentional and unintentional rupture and repair of that attachment bond developed in counseling.

In her book chapter “Dyadic Regulation and Experiential Work With Emotion and Relatedness in Trauma and Disorganized Attachment” (originally published in Healing Trauma: Attachment, Trauma, the Brain, and the Mind, 2003), Diana Fosha articulated the way that counselors may, with great care, begin to interpret and confront with the expectation that this may create temporary ruptures in empathy. This empathy can be carefully repaired and restored in session through the articulation of feeling and the expression of understanding. A hypothetical example:

Counselor: “I wonder if you returned to your medical books with such great fervor last week because your partner has been asking for increased intimacy, and that is scary for you.”

This confrontation may be experienced as a temporary break in empathy, but if the counselor and client can sense and articulate the client’s immediate experience during that break, it can lead to a deeper understanding of that experience. That deeper understanding may lead to a more mature connection and, potentially, to the experience of a return to empathic attunement. These experiences, over and over again, may become internalized, leading to a more empathic connection to the client’s internal self.

Client: “When you say that, I feel like you are trying to push me to experience things I am not ready to experience after my last horrible relationship. You don’t really care about me. … You just want to see me move on.”

Counselor: “I hear you saying that my view about using your studies to keep a distance feels as if I am pushing you, and that feels as if I don’t understand how scary that is. Do I have that right?”

Client: “Yes, that’s right. You don’t really understand how scary it is.”

Counselor: “Can you tell me more about how scary it is?”

The repair may not occur immediately, but with careful listening, engagement and articulation, the feelings of fear and vulnerability may become more accessible. That experience makes a repair of empathic breaks caused (both intentionally and unintentionally) in a mature relationship inevitable. As Fosha explained, the experience of repair, in the context of confrontation and deeper understanding, provides evidence that differences or misunderstandings may eventually result in deeper connection.

This experience can lay the groundwork for both a greater capacity and patience for real-world attachments, as well as greater internalized empathy. Through this, the client experiences more ruptures and the relational commitment necessary for repair.

Building self-regulation via emotional flexibility

In addition to internalized empathy, resilience in attachment ruptures and repair also creates a sense of safety — safety to dwell near emotions and to work to translate vague sensations to words. This requires the development of a sense of “unconditional friendliness,” as John Welwood has described it (Toward a Psychology of Awakening), toward the emotions that come up during rupture and repair. As counselors, we model this friendliness to emotions when they come, both during periods of attunement and during experiences of rupture.

As clients become more experienced with the naming of feelings in both easy and difficult interpersonal situations, this encourages greater self-reflection. With practice, this leads to a “self” system capable of modulating a range of affects, with emotions that may be integrated into adaptive responses.

Schore noted in Affect Regulation and the Repair of Self (2003) that through this process of self-regulation, the client “develops the ability to flexibly regulate emotional states through interactions with other people.” It is through this increased flexibility in the expression of emotion that the client can productively practice emotional regulation in the real world.

Building agency via helping others

It is very useful for clients to see themselves not only as the one who is helped but also as one who helps others. George Vaillant reminds us that it is not so helpful to give into the understandable wish to “mother” or “father” our clients, as it is important for them to develop and internalize their own “parenting” capacities with others.

Often, clients who have been traumatized multiple times become frozen in the role of “helpee,” but by helping, they are developing an active response to others, often in the face of anxiety. Action in the face of triggered anxiety creates new neural pathways for responses to triggering events (as detailed in “A call to action” Overcoming anxiety through active coping” by Joseph LeDoux and Jack Gorman).

Additionally, as clients listen to and fashion adaptive responses to others, they further practice emotional flexibility and regulation. It is wonderful to exercise a developing sense of self with an empathic counselor; it can be even more rewarding to exercise these abilities with someone who may not have as much to give and who might challenge and stretch our adaptive responses — within reason. Early entry into the community as helpers and participants is often best done in a supportive environment, such as a peer support group or a well-structured community initiative or a learning environment.

Helping and prosocial behaviors foster more confidence in helping. Ervin Staub cites multiple studies that show that children and adults become more helpful once they start helping. This increased comfort with helping is generally positively received in peer milieus, and the person helping experiences a sense of being valued — and, if all goes well, a sense of community.

We suggest that the ability to practice responding, in a helpful, emotionally regulated way in the real world, is as important as counseling is on the path toward mature attachment.

Four examples of helping opportunities

The following are four brief examples of milieu settings that provide opportunities to help and observe others, as well as to articulate feelings that develop while participating.

Example 1: Roots of Empathy

Schools in Canada and New Zealand have developed a program for young children called the Roots of Empathy. In this program, a group of children is selected to host a parent-baby dyad in their room each month. Before each visit, the class prepares for the new developmental stage of the baby and the dyad. During each visit, children are encouraged to closely observe the way that the baby communicates, almost always with an open-hearted curiosity to their surroundings, and how the parent reads their baby’s needs.

After the visit, the children participate in discussions, artwork, drama and journal writing about what was learned. The natural generosity of children is expressed when they use art, music and drama to present gifts to the baby and parent. The visits continue one time per month throughout the year.

In this context, difficult questions arise, such as, “What if you were once a bully?” and “If no one ever really loved you, can you still be a good father?” As the children discuss observations of the parent-child dyad, they gain insight into their own emotions and those of others, leading to greater empathy.

David was 9 years old and had a form of autism. His parents shared with the program leader that David had never been invited to a birthday party by any of his classmates until the year that Roots of Empathy came to his classroom. That year, he was invited to three birthday parties. (For more, read Roots of Empathy: Changing the World Child by Child by Mary Gordon.)

Example 2: The Courage and Moral Choice Project

A program focused on the cultivation of empathy for older adolescents is the Courage and Moral Choice Project, developed in our Maine schools. With this project, students listened to stories of helping under catastrophic conditions, such as during Hurricane Katrina. They participated in group discussion after hearing these stories, where they were able to share their own stories of times when they, or someone in their neighborhood or family, took a risk to help someone.

Students were encouraged to express their own stories, and the stories of others, through art, song, essays and poetry. Those works were shared with the larger community at a school board meeting and a university conference. After presenting at a conference, one student approached a second student involved in the presentation and apologized for harassing and bullying her during her earlier years of school. The second student forgave the first student and expressed understanding that those years were rough ones for both of them.

Example 3: Active bystander training

Many student life programs have established active bystander training to support university students in preparing to step up when they see a peer harassed or bullied. Ervin Staub originally developed active bystander training for schools and government agencies to prevent a sense of isolation should an individual experience a violation.

The training promotes a sense of awareness on the part of community members, but more powerfully, it suggests a pathway to a sense of agency should a person experience the pain of knowing a friend or community member is being targeted.

Example 4: Transformative Couples Therapy

One final example of integrating attachment cultivated in counseling work and connection in natural support systems is David Mars’ transformative couples therapy (TCT). TCT is an approach to couples work in which partners may deepen their attachment to each other by providing empathic support as they work through the unexpressed feelings from experiences that may have left them in fight-or-flight mode. TCT offers examples of how prior individual counseling work may be augmented in a collaborative environment.

These opportunities are mentioned to provide examples of the kinds of programs that encourage empathic connections, self-expression, listening and a sense of agency. These integrated experiences support the work done in counseling toward the development of the capacity for mature attachment.

Conclusion

When working with individuals who have experienced either “small t” or “large T” trauma, it is essential to engage them in action-based responses that provide a healing alternative to the fight, flight or freeze reaction. Building agency in the form of fostering connections to their inner world (via safety developed through grounding and attunement) and outer world (via repaired ruptures in therapeutic alliance, and engaging as the “helper”) is critical.

For the client to establish connection to their inner world, safety is built in a therapeutic alliance focused on empathic, attuned responses and action-based grounding techniques. This allows for the clinician to challenge the client, creating mild ruptures in empathy that can be repaired to build a more mature attachment through the return to empathic attunement. These breaks and repairs provide practice for a greater capacity and patience in real-world situations. Greater patience increases clients’ empathy and connection to their internal world and an internalized safety to sit with uncomfortable sensations and experiences, thus increasing both internal and external resilience and agency.

In tandem to building internal resolve, balance provides the client the ability to further increase their agency. This is best accomplished by encouraging the client (the person originally helped) to help others in the context of a well-structured environment. With the balance of being “the one helped” and “the helper,” the client develops and internalizes their “parenting” ability, allowing individuation from being the “parented.”

Greater internal and external connection and competence heals attachment wounds both inside and outside of the clinician’s office.

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Adele Baruch chairs and is an associate professor in the University of Southern Maine’s counselor education department. She practiced couples and individual counseling for 15 years before starting to teach. She has focused her scholarship on healthy adaptation and has developed an action research project on courage and moral choice in Maine. Contact her at adele.baruchrunyon@maine.edu.

Ashley Higgins is a clinical counselor at the Glickman Family Center for Child and Adolescent Psychiatry at Spring Harbor Hospital in southern Maine. As a licensed professional counselor, her primary areas of clinical interest include integrative and strengths-based modalities for treating attachment trauma; family systems; and wilderness therapies. Contact her at amhiggins@mainebehavioralhealthcare.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.

How (not) to isolate during the COVID-19 pandemic

By Bethany Bray October 28, 2020

The coronavirus pandemic has steeply curtailed social gatherings, travel plans and in-person events for most of 2020. And that has raised something of a perplexing scenario for counselors and other mental health professionals: When almost everyone is isolating themselves physically to some extent — and will be for the foreseeable future — how do you identify that a client might be isolating in the “classic” sense, which is typically viewed as a red flag that someone might be struggling with their mental health?

“As I’ve gone through the last six months, my view on what isolation looks like has definitely changed,” says Sean Nixon, a licensed clinical professional counselor outside of Boise, Idaho, who works with children and families. “I used to think of isolating as a person who is off by themselves, not engaged or interacting with anyone. But now, [for] a lot of people who I’ve worked with in my practice, there’s this forced, constant isolating. Even now that they can leave the house, to walk up and give someone a hug, as you might have done six months ago, is not the norm.”

Nixon, like many clinicians, has needed to shift his thinking about what isolation looks like in clients during the COVID-19 pandemic, and respond differently as well. When screening for isolation and depression, one of the primary indicators counselors look for is a loss of interest or lack of participation in activities that a person once enjoyed. But throughout the pandemic, many clients haven’t felt safe playing group sports or participating in activities or hobbies that typically involve others. Plus, many of these activities haven’t been available anyway because of widespread cancellations and closures.

“Now, when asking those screener questions, I have to consider the person’s situation. … We have to screen more — are we seeing an increase in depression, an increase in stress because of the pandemic, or are we dealing with both here?” says Nixon, a member of the American Counseling Association who works as a pediatric mental health therapist in an outpatient setting for a medical system.

Nixon says he has also broadened his scope of thinking about isolation to look for it both in individuals and entire family units. Not only are families feeling isolated from friends and outside activities that they used to enjoy, but they are sometimes isolating themselves from each other within the household during this stressful time, he explains. This can range from physical withdrawal, such as shutting themselves in their bedrooms, to spending too much time using digital devices as an avoidance mechanism.

Signs of isolation in families with children often become apparent when youngsters express a constant desire to play with or do one-on-one activities with a caregiver, he says. At the same time, many parents are expressing that they feel overwhelmed or that they feel guilty about needing to spend time sequestered away from their children as they work from home.

“From parents, I’m hearing [in sessions] how they just need a break and are feeling like their children always want their attention. They’re trying to find balance while they still have work commitments and are trying to explain to younger children that ‘Mom and Dad aren’t just home; we’re home and we have work to do.’ It’s definitely a strain and struggle on parents,” says Nixon, who is also a licensed marriage and family counselor.

“A lot of times, the previous concept of isolation was as an individual problem,” he continues. “But [as the pandemic worsened] I was working with family units who were limited on where they could go, and I started to see stress and overwhelming emotions that came with being around each other 24 hours a day, seven days a week. As that continued to build, for some families, it helped them grow closer together. For others, it was increasing their dysfunction and tearing them apart faster.”

What to listen for

Ryan Holliman is a licensed professional counselor and supervisor (LPC-S) and a counselor educator who counsels adult clients one day per week at a free medical clinic in Dallas. Forging a strong bond with clients and getting to know what is and isn’t normal behavior for them is always important for clinicians, but that’s even more the case now, he says.

Many of Holliman’s clients have personality disorders and struggle with maintaining long-term relationships. During the COVID-19 pandemic, Holliman has found he needs to assess clients more regularly and rigorously for isolation, including asking focused questions about their relationships and the resources they rely on when experiencing stress.

“Isolation is now a lot more nuanced,” says Holliman, an ACA member and an assistant professor at Tarleton State University. “You have to listen for different things [such as] if they are being proactive about developing social networks and accessing those networks, or are they letting COVID-19 dictate the terms of their social life? … Most relationships right now are facing a lot of stress [because] we’re placing all the emotional weight on a few places.”

Holliman has increased his check-ins with clients about their relationships with friends and family, asking them to rate these relationships on a scale. He asks, “How happy are you with the relationship, and how happy do you think the other person is with the relationship?” The aim of this exercise is to ensure that clients are continuing to grow, not stall, in their relationships during this trying time, he explains.

“With COVID-19, it’s easy [for clients] to say ‘good enough is good enough’ and lapse into complacency. But I tell clients, ‘That’s not what I want for you.’ It would be easy to say, ‘It’s a crisis, it’s a pandemic, and this is as good as it’s going to get.’ But as counselors, we are called to be dealers in hope,” he emphasizes. “Help [clients] move toward hope and [see] that there can be more.”

Among the college student population, many individuals are exhibiting typical signs such as having trouble sleeping or feeling overwhelmed that suggest they are struggling and feeling isolated — but exponentially so, says Elizabeth Bambacus, a student engagement and summer studies administrator at Virginia Commonwealth University (VCU). She runs a peer mentoring program for first-generation college students, a population that is already susceptible to feeling out of place and experiencing self-doubt. Her program pairs freshmen first-generation students with upperclassmen first-generation students for support, guidance and friendship.

Bambacus says many of her students have talked about feeling like their academic programs are much harder this fall. One student recently remarked that she wouldn’t be upset if she threw her laptop across the room and it broke. In another conversation, a male student told Bambacus that he hadn’t been outdoors in four days.

“We [would] generally have students who pop in [to our office] and say hi and random drop-ins wanting to chat about everything from ‘I’m worried about an assignment’ to ‘I just had a big argument with my dad, and it’s impacting my ability to focus.’ But there isn’t much opportunity for that now,” say Bambacus, who has a doctorate in counselor education and supervision. “It’s just not the same because everyone is avoiding everyone.”

VCU’s campus in Richmond is open, but a majority of the school’s classes are being held online. While some students are staying on campus, many have chosen to live at home or by themselves in apartments off campus, Bambacus says. Most of the ways that students would typically be personally interacting with others, from staying after class to ask a professor a question to getting involved in student clubs and group events, are off the table this fall.

Another big indicator of isolation among students is avoidance behaviors, such as not engaging with peer mentors and neglecting assignments or otherwise letting their academics slide. Bambacus observes that many students, including those who have a prior history of being responsive, aren’t responding to her emails this semester. “College students in general aren’t great at this,” she says, “but I have noticed an uptick.”

Many students this year are also experiencing a resurgence of anxiety and depression that were previously under control, Bambacus adds. Students with those diagnoses are always at risk for isolating behaviors, but this year, that is acutely so. As they begin to feel disconnected, their anxiety spikes and they get behind in their classwork, leading to a vicious cycle, she notes.

“I see students get overwhelmed, get behind in classes, and that’s triggering too — that feeling of doom. ‘Oh no. It’s happening again.’ With all of the anxiety and depressive thoughts, how can anyone do their homework or study for a test? That requires so much mental energy to do that, and the shame in not being able to do that — beating yourself up for not being able to focus for more than 30 seconds at a time — it’s just a cycle.”

Adapt as needed

In addition to checking in more frequently with clients and listening for the different (and potentially new) ways that isolation is affecting them, Holliman is focusing on self-talk. These past few months have left many clients prone to a downward spiral of self-critical thinking, he says.

Many of his clients talk about being “stuck in their own thoughts,” he notes. “When you’re at home all the time, that’s a real struggle to fight that.”

That is all the more acute for clients dealing with reduced income or job loss during the recent economic shifts caused by COVID-19, he adds. Feeling trapped financially can lead to increased feelings of isolation, he says, particularly when added to the social isolation and self-doubt that have gone hand in hand with the pandemic.

“Clients may just need to hear, ‘This is not a normal situation, and you’re handling it,’” Holliman says. “Drawing from compassion-focused therapy, I ask [clients], ‘How are you talking to yourself? What’s the tone of voice you use? Do you give yourself credit for managing your mental health during all of this?’ We all need to give ourselves credit.”

Normalization is an important therapeutic tool right now, says Nellie Scanlon, an ACA member and LPC in the counseling center at Slippery Rock University (SRU) in Pennsylvania. Scanlon, a temporary faculty member at SRU, started a support group this fall for students to talk about the loss, isolation and other feelings they have experienced during the pandemic. The group meets weekly via Zoom.

Like Bambacus, Scanlon says she is seeing an uptick in symptoms of depression and anxiety among the college student population she sees. “Many clients are using the phrase ‘It’s fine’ when they really mean they are not fine. I have been encouraging clients to allow themselves to feel what they are feeling and process those feelings in session. So often, we are expected to be OK and move on without acknowledging that our feelings of loss and loneliness are normal responses in times of crisis such as the current pandemic,” says Scanlon, who successfully defended her dissertation and earned her doctorate in counselor education at Duquesne University earlier this fall.

“I also remind clients that they are more resilient than they realize,” she says. “I ask clients to remember a time in the past when they were successful at bouncing back and talk about it. It seems to be personally impactful for them to recall when they have been resilient in the past, and that increases their confidence level to adjust to current life circumstances.”

Of course, there are also some tried-and-true interventions for addressing isolation and loneliness that counselors are no longer finding helpful or appropriate to use during the pandemic. The professionals interviewed for this article agree that counselors should put exposure therapy and similar techniques on the shelf for now. They say it simply isn’t appropriate to encourage clients struggling with depression, social anxiety, obsessive-compulsive disorder or other diagnoses to interact with others in person at this time as a way to stave off isolation.

Bambacus notes that many of the go-to suggestions she would typically give to college students to boost their mental wellness, such as calling a friend to get together, going to a campus event or party, or simply getting out of the house to sit at a coffee shop for an hour, are not advisable at this time. She has been forced to consider other ways that she might help students make connections and avoid isolation. “This is definitely bringing out the creativity in us all right now — along with frustration,” Bambacus says with a chuckle.

“I think this is a real struggle given the current social restrictions in place due to the COVID-19 pandemic,” agrees Scanlon, the chair-elect of ACA’s North Atlantic Region and immediate past president of the Pennsylvania Counseling Association. “I have been encouraging clients to connect with others in a meaningful manner that is effective for them. … Needless to say, there still appears to be an overwhelming loss of personal connection with others because we are limited due to the pandemic in the how, what, when and where of connecting with others.”

Creative connections

Psychoeducation can be a helpful tool in situations in which clients assume that they can’t be social during the pandemic or even push back against that line of thinking, Holliman says. By making themselves aware of out-of-the-box options, counselors can be ready to offer suggestions. For example, Holliman notes that his local library offers book clubs that meet over Zoom.

“There are a lot of unique ways for us to connect with one another,” Holliman says. “Limited options doesn’t mean no options, and that’s something clients really need to hear. There are ways [to find connection], but you have to be creative. The counselor needs to be a creative co-creator of options.”

For many clients, especially those in recovery, the pandemic actually offers more options for attending 12-step meetings and support groups because so many of them are meeting online now, he says.

Holliman found psychoeducation to be a powerful tool recently when working with a woman with bipolar disorder who was estranged from her family and struggling with isolation. She ended up in the hospital due to dosage issues that led to toxicity from one of her medications. In a session following her hospitalization, the client confided in Holliman: “Other than you, those doctors in the hospital were the first people I’ve talked to in a long time.”

Holliman said he knew even prior to this session that relationships were a challenge for the client, but her hospitalization served as a tipping point and an indicator of how acute her isolation had become during the pandemic. During the session, Holliman spent a good deal of time normalizing the client’s experience with bipolar disorder, emphasizing that supports were available and connecting her with resources, including online support groups for individuals with bipolar disorder. Holliman told the client, “You may feel alone, but you don’t have to be alone.”

“She had no idea there were others like her out there,” Holliman says. “She made the comment, ‘I thought we all just ended up in asylums.’ She didn’t realize [there were supports]. She had just assumed, ‘This is how life goes.’”

Clients with bipolar disorder are at higher risk for isolation because of the rapid mood fluctuations of their disorder and the impact that can have on their close relationships, often causing these clients to become estranged from friends and family members, Holliman notes.

This client has engineered a significant turnaround since her hospitalization, according to Holliman, including rekindling her relationship with her parents. “Things aren’t perfect [in this client’s life], but they are better,” he says.

Bambacus also emphasizes the need for creativity to help clients find ways to avoid isolation during the pandemic. This fall, she started offering online office hours and helped organize a series of faculty talks (also held online) for her first-generation students on nonacademic topics such as impostor syndrome.

At the same time, she is encouraging her upperclassmen mentors to organize events for students in the mentoring program, with a focus on staying connected. If the event is in person, students must hold it outside and limit it to a small number of attendees. Other students are planning virtual events, such as game nights and a live “cooking show” in which students demonstrate how to make their favorite recipes over video chat. Still others are doing low-risk volunteer work, such as writing letters to older adults or doing a trash pickup outdoors.

Bambacus has also been checking in with students more frequently. For those exhibiting withdrawal or avoidance behaviors, she sometimes includes a gentle reminder that she needs to hear back from them.

“I’m watching everyone a little more carefully,” she says. “Especially students who put on a brave face, they often appreciate check-ins. … I am watching students who are more susceptible to slowing down during the semester and struggling and those who have taken breaks [withdrawn from enrollment] previously because of their mental health. Often, the first sign they are struggling is unresponsiveness. I get creative with my emails and give them a deadline, such as ‘I need to know by Friday.’ Once they respond, then I say, ‘Hey, you’re there. Let’s talk!’”

This fall, she has been emphasizing self-care and wellness among her students, including the importance of physical activity, eating and sleeping well, getting outside and turning off the news. She is also pushing the message that it is OK to ask for help when you are struggling. Even something as simple as encouraging students to call their friends and family members instead of texting, so that they actually hear one another’s voices, can foster stronger connection, she says.

“There’s so much healing in knowing that you’re not alone in your feelings of isolation, so create opportunities for clients to see that other people are in the same boat,” Bambacus says. “Maybe that means running more groups and offering those types of services. It can be held outside or virtually. [It’s] just having that space where clients can see that this is not just happening to them and that other people are surviving ‘in spite of’ and offering them some hope and options. Isolation is such a devious thing because it makes you think that you are the only one — you’re not just alone; you’re the only one who’s alone — and that’s just not true.”

Families and isolation: A group effort

For families struggling with isolation, Nixon is focusing on ways they can be intentional about prioritizing connection, both within and outside the family unit. With all the stressors families are facing during the pandemic, it is easy to lapse into bad habits, he notes. “When you get resolved to ‘this is how life is going to be,’ you kind of go through the motions,” says Nixon, a board member of the Association for Child and Adolescent Counseling, a division of ACA.

Step one of being intentional often involves creating and maintaining a daily schedule in the household, Nixon advises. He suggests setting times for family members to focus on work or school and times to focus on connecting as a family, including designated times to put away all electronic devices.

Family time should include activities that prompt family members to interact and engage with one another to minimize isolation and boost mental health, Nixon says. This could include everything from getting outside and playing in the yard to coloring or drawing together, playing board games, having an indoor dance party or engaging in a scavenger hunt. (For more ideas, see the article “Supporting families with engagement strategies during COVID-19.”)

The lack of in-person celebrations during the pandemic, especially surrounding birthdays, has been hard for young clients and families. Nixon has helped clients find new ways to connect with family and friends to mark special occasions, including blowing their celebratory candles out during video chats and organizing walk-by or drive-by “parades” of well-wishers.

Similarly, many of Nixon’s adolescent clients are missing the in-person interactions they would normally have with friends and peers through school and extracurricular activities. Here, intentionality also helps fill the void. Nixon asks adolescent clients to identify what they enjoyed most before the pandemic. The answers usually involve hanging out with friends, watching movies or playing video games together. One of the ways his clients have adapted is by setting a specific time to watch a movie simultaneously with friends (each in their own home) and then texting or video chatting with one another as they watch.

Nixon also encourages family clients to identify substitutes for things they enjoyed doing together before the pandemic. He uses a whiteboard in sessions to visualize clients’ ideas and prompt dialogue.

“I get their perspective and talk about what their preference and focus was before the pandemic. Was it being together at mealtimes? Then be intentional about that now. Or if sports were really important, organized sports may not be an option, but they can play as a family or set time aside to sit down and review tapes from past games and analyze them,” says Nixon, a past president of the Idaho Counseling Association. “Identify what was important to [clients] before, and help them realize that it’s still important and how to find a new context for it.”

Counselors can guide clients to find new rituals by identifying the core reason they enjoyed certain activities before the pandemic. Ask “why do families do what they do, and what meaning do they give to it? Then try and find something else that will give them the same meaning in a different context,” Nixon advises.

For one family on Nixon’s caseload, family meals were very important, and they found connection by going out to eat in restaurants together. This became more challenging when many restaurants closed their dining rooms throughout the spring and summer.

Nixon helped the family reframe this ritual and brainstorm ways they could re-create the aspects of eating out that they most enjoyed. After breaking it down, the family identified the core features they enjoyed as trying new restaurants and experiencing new cuisines together. The family had a self-imposed rule of never eating at the same restaurant twice in one month or having the same type of cuisine twice in one week, so they were always looking for new places to try, Nixon says.

“For them, what was meaningful was … the adventure of trying something new and ordering with the intention of sharing it with someone at the table,” he says. “The intention was to be adventurous, to try something new and to share that together.”

Once they came to this realization, Nixon suggested the family experience new foods together by learning to cook them at home. Their initial reply? “We don’t cook,” Nixon recalls.

Undeterred, Nixon suggested the family search the internet for ideas and how-to videos. The family started small, making an appetizer, and found it was easier than they had assumed it would be. From there, the activity blossomed into setting aside one night per week to replicate dishes together that they had previously enjoyed at restaurants.

“They didn’t want to mess up and fail, and they didn’t want to waste time and money [on specialty ingredients]. But they found that nothing was ever a failure, just as with going out to a restaurant that they didn’t like. It was the trying that they enjoyed,” Nixon says.

Now, even with restaurants reopening, this family continues with its at-home cooking adventures. They set aside the money they save by eating at home to splurge on an occasional restaurant meal that they previously would have considered a treat.

“The opportunity that this family has taken to take a step outside of their comfort zone has brought them closer together,” Nixon says. “They have found that family members have skills that they did not completely see before, and they have found that small changes have always impacted the family. In the past, the small changes were seen negatively, [but] now they see the opportunity and positivity that can come within the family.”

Looking ahead

Nixon says he has been contemplating the long-term effects the COVID-19 pandemic might have on mental health, especially with the increased physical and social isolation that will return for many people during the winter months. As cases of COVID-19 continue to rise in the U.S., combined with the arrival of the traditional flu season, it is possible that states or localities may reimpose some of the stringent lockdown measures, such as school and business closures, that happened back in the spring.

It is possible that counselors might witness an uptick not only of isolating behaviors but also feelings of hopelessness and suicidal ideation among clients, Nixon says. With that in mind, he is increasing his screenings of clients for safety, harm and abuse, plus making sure that he shares resources such as crisis hotline numbers.

“I have been thinking about that a lot lately: how to help families and clients with the potential for an extended stay at home and the long-term aspect with winter coming on,” Nixon says. “How can families be intentional [to avoid isolation]? What’s important to [a client’s] family, and how do you continue to keep that ember burning?”

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Contact the counselors interviewed for this article:

Elizabeth Bambacus: bambacuses@vcu.edu
Ryan Holliman: ryanholliman@gmail.com
Sean Nixon: seanjnixon@gmail.com
Nellie Scanlon: aniela.scanlon@sru.edu

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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.

Advice for counselors who want to work with military clients

By Lindsey Phillips October 27, 2020

Clinicians often tell Taqueena Quintana, a licensed professional counselor (LPC) in Washington, D.C, that they find it difficult to start working with the military population as a civilian counselor. They want to know how she managed to do it despite not having any personal military experience.

Quintana was first introduced to the military population when she was a counselor at a substance abuse agency. Some of her clients were veterans, and because she hadn’t been trained to work with this population, she started doing her own research.

Then, later as an adjunct instructor of counseling, she had the opportunity to teach a course for combat veterans, and she noticed how their mental health challenges directly affected their personal and professional lives. For example, one student suffered from memory loss because of a traumatic brain injury he received during service. He excelled when he spoke in class, but he had difficulty completing written assignments, which affected his employment and academics.

Through these experiences, Quintana discovered she enjoyed working with veterans, so she decided to do it full-time by working as a counselor on a military base. Now she owns Transformation Counseling Services, a private practice where she works with military populations.

Connect with professionals who work with this population

Quintana, an assistant professor of counseling at Arkansas State University and a deployed resiliency counselor for the Navy, acknowledges that she wouldn’t have been successful in working with military clients without support from her mentors, supervisors and colleagues. Early in her counseling career, she would go to ACA conferences and attend every military presentation she could – not only to learn more about military mental health but also to make connections with others working in this field.

Quintana also advises counselors to find supervisors and mentors who are connected to the military branches they want to work with. One of her supervisors is a Navy spouse and another is an Army veteran. In addition to providing her with advice on counseling military clients, they refer her for possible job opportunities.

Now Quintana is in a position to support other counselors who want to work with this population. She volunteers with the National Board for Certified Counselors Foundation’s mentor program, which matches counselors who have similar interests and career aspirations. One of her mentees choose Quintana specifically because of the work she has done with the Army. “You seek people in those [military] positions to help you get there yourself,” Quintana says.

Keith Myers, dean of clinical affairs and an associate professor of counseling at Richmont Graduate University, recommends counselors join the Military and Government Counseling Association (MGCA), a division of ACA, or ACA’s Veterans Interest Network, which provide them with access to journals, newsletters and trainings. The Center for Deployment Psychology is another great resource for trainings and education, he adds.

U.S. Marine Corps photo by Lance Cpl. Brendan Mullin/defense.gov

Gain experience with military-connected organizations

Quintana found creating her own knowledge base and foundation in working with this population to be helpful, professionally. “A lot of times, employers want to see that you have some sort of knowledge or experience in [the area in which] you’re working,” she says. “It doesn’t mean you can’t find opportunities. It just means that you have to intentionally position yourself in these spaces where you can gain these opportunities (paid or unpaid).”

Myers, an LPC with a private practice serving veterans in Marietta, Georgia, suggests counselors get involved with military-associated organizations such as the Wounded Warrior Project (which offers programs and resources for wounded veterans who served on or after 9/11) or Give An Hour (which provides free mental health care to veterans and their families).

Tanya Workman, an LPC and the training director for the licensed professional mental health counselor training program at the South Texas Veterans Health Care System’s Frank Tejeda Outpatient Clinic in San Antonio, recommends clinicians look for opportunities at military hospitals and clinics such as the Steven A. Cohen Military Family Clinic at Endeavors, a Texas-based provider that provides mental health care to veterans and their families regardless of their role while in uniform or discharge status. They can also volunteer at the Veterans Crisis Line, which connects veterans in crisis and their families with a U.S. Department of Veterans Affairs (VA) responder, she adds.

There are also training programs geared toward graduate students. The VA’s Office of Academic Affiliations offers a training program for master’s-level counseling students, says Workman, an ACA member and Army veteran. Some of the VA offices are providing internships for these students as a way to train more mental health professional in the specific mental health needs of the military service members and veterans, she explains.

One job position available to counselors is a deployed resiliency counselor, Quintana says. These counselors work for the U.S. Department of Defense or the Navy (but they do not have to be a military member themselves). As Quintana explains, the counselors go on tour with the unit and provide mental health counseling to service members during their deployment.

Find experience outside the VA

“The VA is not the only facility in which [counselors] can work with veterans and active-duty military,” Quintana stresses. “There are organizations and agencies [such as the American Red Cross, Catholic Charities and Salvation Army] that offer opportunities for counselors to position themselves to work with veterans and active-duty military.”

A military family life counselor is another job position that counselors may want to consider, Quintana continues. In this role, counselors are sent to bases in the states or overseas and provide solution-focused, nonmedical counseling to service members and their family. It’s a contracted position with organizations outside the VA and U.S. government and does not require previous experience working with the military, Quintana says.

Myers, an ACA member whose clinical specialties include veteran issues, trauma and combat-related posttraumatic stress disorder, agrees that counselors don’t have to look for organizations that are strictly veteran service providers. Veterans seek help from many different organizations such as psychiatric hospitals or residential treatment centers, he points out.

Myers actually discovered his passion for working with military clients when he took a job at a rehabilitation hospital that had an outpatient service for veterans with traumatic brain injury and mental health issues.

A good fit

Adrian Marquez, a licensed mental health counselor and owner of the private practice Calm in the Storms in Melbourne, Florida, created and serves as the director of programming for The Sheepdog Program, a mental health and substance abuse program for veterans and first responders. He carefully and meticulously selects counselors for this program because he knows the job can be demanding at times. But it’s also rewarding, he adds.

He looks for counselors whose personality would fit in well with the military culture, but that doesn’t mean they must have military experience. For example, one clinician Marquez hired is a world record-holder marathon runner. When Marquez, a retired Marine master sergeant and Marine Raider, discovered the counselor had trained for marathons to the point that his toenails fell off, he knew that this counselor understood what it was like to push yourself beyond your limits. He had the endurance mindset that so many veterans share.

According to Marquez, “It’s finding the right personality, the right character and the people that are willing do [this work] with the right heart.”

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Related reading:

See the “From Combat to Counseling” column series at CT Online, including one on this topic, “Getting started in counseling military clients.”

See Counseling Today‘s November magazine for an in-depth feature on working with military and veteran clients, “Counseling in the trenches.”

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.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.

Addiction: Paving the way to recovery

By Laurie Meyers October 26, 2020

When the outside world looked at Julie Bates-Maves’ client “James,” it saw a 60-something “junkie” who had wasted 20 years of his life shooting up heroin. But in James’ community of people who used heroin, he was a respected man — an authority figure who could be trusted.

Throughout his two-decade addiction, James had established himself as a safety expert, recounts Bates-Maves, a member of the American Counseling Association. It might seem incongruous to use the word “safety” when speaking about heroin use, but safer injection practices can save lives. James derived great satisfaction from helping his peers reduce their risk of contracting HIV or hepatitis by teaching them never to share needles and demonstrating how to clean their own. He also taught others how to inject without missing the vein.

James’ process of giving up heroin took about a year, but he did well with overcoming the physical addiction, says Bates-Maves, a licensed professional counselor (LPC) whose master’s degree is in rehabilitation counseling with a concentration in alcohol and substance abuse counseling. The hard part was when James was alone and feeling lonely. He struggled with feelings of uselessness, and he knew where he could readily find validation. Among other users, all James had to do was offer to lend his expertise. There was always someone willing to take him up on his offer.

“He had not found respect in virtually any other area of his life,” Bates-Maves says. That meant that in trying to give up heroin, James would also have to leave behind the solitary piece of his world that made him feel worthwhile.

Once Bates-Maves understood that using heroin was tied to James’ sense of self, she realized they needed to examine what it was about the behavior and the attached relationships that provided him with a sense of meaning.

“It was a lot of picking each other’s brains and saying, ‘Let’s try to dissect this,’” she recalls. They set about trying to uncover the actual source of the sense of meaning that James derived from using heroin. “Is it truly tied to the syringe and the bleach and the cotton and the heroin?” she asked him. “Or is it that somebody is listening to you because they think you know something that they don’t?”

Ultimately, James realized that he didn’t actually need the heroin. “I just need someone to look at me and think I’m smart and that I have something to offer,” he told Bates-Maves. So, they worked together to identify another way for James to find a sense of meaning and feel as if he had something to offer others.

Earlier in his life, James had pursued a welding career. For various reasons, he had abandoned that path long ago. But now, he was ready to pick it up again.

With Bates-Maves’ help, James got re-enrolled in a tech program for welding. By going back to school, he acquired a skill set that not many people possess, built new relationships and experienced a sense of validation. He was able to say, “Hey, I’m 62, but I don’t have to check out of the game, and I don’t have to stay stagnant in everything I’ve done,” Bates-Maves explains. “I can add new things to my life, and by adding more to my life, I can add to other people’s lives.”

“So,” she adds, “it became sort of a sense of altruism for him of wanting to give to the world and then to feel good about doing that.”

James had been addicted to heroin for 20 years and recognized that over that time, he had hurt and taken a lot from others, particularly his family. “He had kind of felt like a leech for a long time, and now it was finally time to be able to give that back and repay,” Bates-Maves says.

James was a watershed client for Bates-Maves. His story was the one that changed how she viewed substance abuse counseling. James’ narrative hadn’t been just informational — it had been existential. It made her realize that counselors need to have those types of discussions — about the search for meaning, about the grief and loss that come with substance abuse — with all clients in recovery.

Bates-Maves and the other counseling professionals interviewed for this article say that when therapists center treatment solely on elimination of the substance and everything associated with it from the person’s life — without considering the myriad factors that contribute to use, abuse and the drive to reuse — they are actually hampering clients’ recovery.

The need for grief work in substance abuse therapy

“We oversimplify the picture of addiction,” Bates-Maves says. “We do that as a world broadly, and we definitely do that in the counseling profession sometimes. …We think of it as the erosion of a life — it’s only somebody moving backward, it’s only someone being stuck. And we get stuck in that narrative.”

Counselors often focus on getting clients “unstuck,” which is certainly not without worth, but it is limited, says Bates-Maves, an associate professor of clinical mental health at the University of Wisconsin-Stout. “I’ve worked with many clients who … loved being stuck [in addiction],” she says. They loved the feeling of being someone else, the ability to lose sight of negative things, the ability to create an optional numbness.

Addiction sets the stage for a lot of destruction in people’s lives, but it can also serve as a kind of desperate sustenance for users who see no other way to cope with life, Bates-Maves says. The bald truth is that substance abuse also adds things to life, and that’s something counselors don’t talk about enough, she asserts. Counseling is a profession that focuses on concepts such as identity and a person’s sense of meaning, yet counselors often neglect to explore how these concepts tie in to addiction — what clients are actually getting from their substance abuse, what makes it attractive or useful to them, she says.

When presenting on the role that grief and loss play in addiction, Bates-Maves has frequently heard from audience members that the clinics in which they work have told them not to talk about the “good stuff” that substance use brings. She says the usual company line is, “You can’t have them celebrate the high or tell those so-called glory war stories. That’s encouraging their desire to use.”

“We’re so blinded by this fear of people going back to use,” Bates-Maves says. “What if the glory days were the only time people felt powerful, or what if when they’re high, it’s the only time they don’t feel intense [emotional or physical] pain? What if it’s the only time they feel confident enough to engage with another human? … Those are central treatment issues, and they can come out of the quote-unquote ‘positive experiences’ in addiction. There’s a lot to let go of when you’re trying to get to recovery. There’s a tremendous amount of loss, and [we’ve] somehow largely missed that as a field.”

Bates-Maves feels so strongly about the necessity of counselors having these conversations with clients as part of the recovery process that she wrote a book, Grief and Addiction: Considering Loss in the Recovery Process, which was released at the end of September.

“Addiction … ravages your life,” Bates-Maves says. “Nobody likes that.” Even so, she continues, counselors need to encourage clients to think about the things they risk losing when they determine to confront their addiction.

“Even if they’re good losses — things you want to go away — it’s still a massive change that you’re undertaking,” she tells clients. “You deserve to feel sad and frustrated and sorrowful … and relieved.”

Even though the changes people go through in recovery need to happen, clients deserve to know that it’s OK for them to miss the things they leave behind. “You can miss it forever and still change,” Bates-Maves says emphatically.

“When we start to try and shove people forward to recovery without looking at the rearview mirror at all, we’re going to miss the things that will chase them down later,” she explains.

Bates-Maves believes Kenneth Doka’s model of disenfranchised grief perfectly explicates the losses sustained by people struggling with addiction. In the recovery process, these clients typically must abandon coping methods and even relationships that are unhealthy. As such, these things are often deemed “unworthy” of grieving over.

Similarly, many clients in recovery have lost friends to stigmatized deaths such as overdose, suicide, hepatitis and AIDS. Other clients may have chosen abortion or had a miscarriage because of their addiction. Once again, these individuals can be made to feel that they aren’t allowed to grieve those losses, Bates-Maves says. In particular, family members — and the courts — tend to convey the message, “You dug your own hole.”

But everyone has losses from predicaments that are primarily self-created, Bates-Maves argues. “I have this grief all the time where I’m the one who caused the problem, but I’m still really mad that I have it,” she says.

Emotions that are denied usually just fester and show up in other ways, Bates-Maves says. “Just let people” — including those struggling with addiction — “be angry. Let them be sad. Just because we’re the creators of our own misery does not mean we don’t deserve to be miserable about it,” she says.

Counselors can offer clients support as they learn to acknowledge that their current reality — whatever stage of addiction or recovery they’re in — is incredibly tricky and comes with myriad, and often confusing, emotions, Bates-Maves says. What counselors shouldn’t do is tell clients that what they’re feeling is wrong or try to “cheerlead” them into a different emotional state, she continues.

People sometimes picture coping as having overcome a difficulty so that it no longer has any emotional effect on them, Bates-Maves says. “I think it’s really important for all of us to remember that’s not what coping is. Coping isn’t getting over something. … It’s living with something. It’s getting through it as you’re in it.”

“My job as a counselor is not to make the pain go away, because I can’t,” Bates-Maves continues. “It’s not to force the transformation of pain. That’s a hope, but sometimes that can take longer than my relationship with [the client].”

So, what is the other side of grief? What is the goal of grief work? Bates-Maves describes it as learning to walk with and carry your pain in a way that doesn’t sink you. “You want the pain to be manageable so that you can live life with it there,” she says.

Bates-Maves recommends a variety of methods to help clients, including those walking through addiction and recovery, with their grief and pain. One method is containment — the idea of compartmentalizing the pain and building psychological space for it. She says this is particularly useful for pain attached to situations that are unlikely to be resolved anytime soon. Some clients make actual physical boxes, write down their thoughts, feelings or whatever it is that is causing them distress, and lock it up, but the container need not be literal, Bates-Maves explains.

The intent of the exercise is not to lock the person’s pain up forever, but rather to put it aside so that the person can carry on with the other parts of their life. This acknowledges the reality that even when people are hurting badly, the demands of living go on. When a client has the time or desire, they can open the container, sit with the pain and feel whatever they feel. Being able to set aside the pain temporarily allows clients to care for their children, drive to work or even just relax by watching TV or listening to music without being confronted by constant intrusive thoughts, Bates-Maves says. Journaling is another way that clients can create a space outside of their own heads for their emotions, she adds.

In contrast, radical acceptance, a method that is the polar opposite of locking one’s thoughts away, can be very effective for some clients. “It’s this idea that we cannot always change things and we need to accept and acknowledge it and keep moving,” Bates-Maves says. With radical acceptance, clients learn that their grief and pain are valid but that they can feel those emotions and still keep moving alongside them.

Bates-Maves has also had clients who experienced intense and disturbing dreams about their grief. She would teach them “directed dreaming.” Clients would take five to 15 minutes before going to bed to create detailed mental pictures in their minds of what they wanted to dream about. With practice, people can learn to direct their dreams, Bates-Maves says.

For clients who frequently feel overwhelmed, Bates-Maves recommends belly breathing. She explains that teaching people to breathe more efficiently can reduce panicked breathing, which helps take the body from a state of distress to one of relaxation, or at least closer to it.

She sometimes helps clients transform their pain by learning to reframe how they view their losses. Certain clients realize that they will never feel differently about parts of their past but that they are OK with that. Some clients work through their pain by seeking connection with others. And some clients decide that they need to spend more time with themselves rather than with others, hoping to learn who they are without addiction.

Attachment, trauma and addiction

Many people with addiction have been primed to seek solace in substances or processes because of a history of trauma and a lack of healthy attachments, says ACA member Oliver J. Morgan, who has written numerous books on substance abuse and addiction. Caring relationships can help mitigate the effect of trauma in a child’s life, whereas a lack of those connections is traumatic in itself. Feeling cared for helps build healthy neural connections such as a fully functional stress response and the reward, reinforcement and motivation systems that contribute to emotional coping skills, he explains.

When someone finds it difficult to cope with stressors such as the lasting pain of trauma, dysfunctional relationships, loneliness or the everyday disappointments and frustration of life, they may turn to addictive substances or behaviors, says Morgan, a licensed marriage and family therapist who has been clean and sober for over 30 years but once was addicted to alcohol.

Over time, chronic use and abuse of substances or processes oversensitize areas of the brain related to dopamine so that they are easily triggered, he says. The brain then connects those areas to memory and environmental cues that themselves create desire. In other words, addiction causes the brain to react to cues that a client may not even know exist, Morgan says, creating what neurobiologists call “pulses of craving.”

“The brain organizes reward around memories so that we remember to repeat [the action],” says Morgan, a master addiction counselor. “It’s how we learn and how we fall in love.” A particular song on the radio, specific places or people, or even certain scents can serve as triggers.

That’s why he views all addiction counseling as relapse prevention. “From the beginning, you need to prepare people for the possibility, if not probability, of relapse,” says Morgan, a professor of counseling and human services at the University of Scranton.

He uses psychoeducation to explain the neurobiology underlying addiction and relapse — not just to clients, but to their families if they are willing to listen. Morgan believes this is essential to preventing a common scenario: A client relapses and their family says, “He told me he was going to stop and he didn’t. He lied to me.”

It’s not quite that simple, Morgan says. He explains to families that their loved ones mean it when they say they’re going to stop using, but they’re not anticipating that their brains are going to react to these cues. So, a relapse doesn’t mean that the client isn’t committed to recovery, Morgan says. The support of loved ones helps clients remain dedicated to the recovery process and keep believing that they can achieve it — even if they are momentarily derailed by a relapse.

Morgan, a member of the International Association of Addictions and Offender Counselors, a division of ACA, believes that relationships are the ultimate buffer against addiction. From the start of the recovery process, he helps clients begin forging new relationships with people who are clean and sober. They might develop these connections by finding sponsors or reaching out to strangers at Alcoholics Anonymous (AA), Narcotics Anonymous (NA) or other recovery group meetings and virtual gatherings.

Morgan also gives clients a laminated card with steps to take if they feel the urge to use. This can function as a kind of crisis plan or serve as a reminder to clients that they have tools to help prevent relapse. The first step is to acknowledge their urge but to remind themselves that it is just a feeling, not something that they have to act on.

Next, Morgan wants clients to reach out to someone whom they trust and can talk to. “The best way to deal with stress is to buffer with a relationship,” he says. The person or people clients reach out to could be a sponsor, recovery group members or Morgan himself. This gives clients a way to share the burden by verbalizing their feelings and getting some advice. If none of this works, he tells clients to call him (assuming he wasn’t the person they reached out to initially).

Because the urge to use is triggered by external and internal cues that clients may not even be aware of, Morgan urges counselors to walk these clients through their past. He asks clients to think about times when they were using or wanted to use. What was happening in their lives at the time? What were their favorite songs? The broader the exploration of everything in their lives, the more likely it is that potential relapse triggers can be identified.

“Sometimes,” Morgan says, “you have to wait for them to come into session and say, ‘I really wanted to use’ [to discover their triggers]. That’s why it’s important to let them have access [to you] when it happens [between sessions] so that you can walk them through it. ‘Where were you? What happened? Who was with you?’”

Once the client and counselor have identified triggering situations, they can work together to come up with better ways to handle them. In his own life as someone who was addicted to alcohol, Morgan uses humor. “I make a joke out of it and talk about it widely,” he says.

When Carol Sloan Goodall, a licensed clinical addictions specialist, led group work at a local recovery center, she frequently had clients form smaller circles to identify three external, three internal and three sensory triggers. Group members also had to come up with three ways to cope with each trigger.

“I was often pleasantly surprised to see how many different realistic coping skills they created and excited to see the clients impressed and motivated by these ideas,” says Goodall, a licensed clinical mental health counselor in private practice in Charlotte, North Carolina.

Common external triggers involved people, places and things. Internal triggers usually involved emotions but sometimes also included cravings, chronic pain or illness. Sensory triggers were just that — input from the five senses, such as smells, tastes and sounds.

The coping skills that clients came up with were varied. One client described avoiding temptation by changing their route upon realizing that their drug dealer lived on a particular street. Another client felt like their home was a trigger, so they rearranged the furniture and changed the color of the accessories to make it appear new and different.

“One client said he carried a dryer sheet in his pocket and sniffed it when triggered by scents reminding him of drug use,” Goodall recalls. “Another client stated that the perfume cards you spray in department stores served the same purpose.”

Goodall also suggested that when confronted by triggers, clients could distract themselves with sensations such as snapping a rubber band on their wrists or holding an ice cube.

Morgan is a believer that practicing mindfulness can help clients identify and even anticipate triggers. He teaches clients to sit down and find a place on which to focus — a spot on the wall, a beam of sunlight, a candle. Then he instructs them to just “be” in that moment and observe what is happening around them in the here and now, to cultivate awareness and to notice if the urge to use is creeping up. He also finds this mindfulness practice helpful for coping with anxiety and creating a sense of calm by just being in the moment, letting one’s thoughts and emotions float by, and then letting them go.

The necessity of reducing in-person meetings during the pandemic has in some ways made it easier for those in recovery to get support. Groups such as AA, NA and other recovery organizations swiftly moved their meetings to digital platforms. People can access virtual meetings or keep in touch with other group members through social media, email or phone. Counselor clinicians have also had to become more comfortable with virtual counseling. Morgan sees this as a positive because he thinks not having to show up in person to access resources is easier for many people who are seeking help with substance abuse. It’s less uncomfortable for these clients, Morgan says, because they don’t quite have to put themselves out there completely.

Going from prison to the outside world

Julia Thielen, an LPC located in South Dakota, works at an intensive outpatient facility with a particularly challenging substance abuse population: clients living in a post-prison transitional facility after being incarcerated for as long as 10 to 15 years.

These clients are not only working toward recovery, but also coping with trauma and trying to navigate a world that they don’t recognize or understand, Thielen notes. They have records, have spent years without employment, are often estranged from their families, have often lost friends to causes such as overdose, and struggle to form a sense of identity. Life has generally moved on without them. The things these clients may have once wanted — steady jobs, families, a house of their own — now feel largely out of reach to them, Thielen says.

Those around these clients often want to sugarcoat their circumstances and make them feel better, but what they really need, Thielen says, is someone to hear them out and help them set realistic goals. “Yes, you are past 30, so having a house before then is not going to happen. But is it possible to achieve that by 40?” she asks them.

For clients who have spent a particularly long time in prison, just getting a job is challenging, Thielen says. They lack a history of employment and have to disclose that they spent time in prison. They need help finding any form of employment just to reestablish a work history so that further down the line, future employers at potentially more attractive jobs might be able to see them as responsible and hard-working, she explains.

In addition to teaching these clients emotional self-regulation skills such as deep breathing, Thielen and her colleagues instruct them in basic life skills. Many of these individuals spent their adolescence and young adulthood in prison, so in essence, they have skipped a developmental stage, she says.

Thielen’s clients regularly talk about the challenges of finding healthy friends and activities. “One of the big things they are lacking is any kind of support or stability in their lives,” she says. Getting these clients involved with AA, NA or another recovery group is one way to help them establish friendships with people who don’t use or who are also in recovery.

Many of Thielen’s clients don’t know what healthy friendships look like, so she spends a significant amount of time helping them identify red flags from their past relationships, such as behaviors that led them toward addiction or contributed to them staying addicted. Often, Thielen says, these friends from clients’ former lives would call in sick for the client when they were hungover, pay their fines for misbehavior or help them come up with excuses for their probation officer.

Another piece of the puzzle is to help these clients articulate what values they would like potential friends to possess. Often, the easiest way to do this, Thielen says, is to ask them what values and beliefs they would like to instill in their own children and to look for those same characteristics and qualities in others when forming new friendships.

But most of Thielen’s clients still have strong ties to the people they previously used with. These aren’t “healthy” friendships, but many of these clients have no one else in their lives upon being released from prison. In many cases, their families and any friends they had who weren’t fellow users have given up on them long ago. From the perspective of some clients, the people who were their fellow users and have maintained contact have “been there” for them, and the clients want to reciprocate. But spending time with these friends — who may not be interested in stopping their own substance use — is the most common road back to addiction and, often, reincarceration.

Some clients can have the hard conversations and cut ties with the people who are linked to their past substance abuse and prison time, Thielen says. But that’s almost an impossible ask until they have formed new relationships. That is why getting them into some type of new community such as a self-help group, addiction recovery group or church group is critical, she says.

Another challenge is that although a transitional facility can offer support and shelter to those who have recently been released, the environment isn’t very conducive to learning responsibility, Thielen says. These clients learned to follow a particular set of rules in prison, and now they learn to follow another set of rules in the transitional facility, but they aren’t necessarily learning how to set a budget, how to cook a meal or even how to buy groceries for themselves.

Thielen and her colleagues attempt to set clients up with case managers and life skills coaches, but she acknowledges that some individuals are very resistant to this kind of instruction.

Prevention and intervention

Counselors do have opportunities to intervene — before addiction, before prison, before a life goes off the rails. Morgan notes that while the focus is typically on those who are physically addicted to substances, almost three times as many people are problem users. And it is these individuals whom counselors are most likely to see, he says.

Morgan asserts that addiction professionals don’t necessarily know how to deal with those individuals who are problematic users but have not reached the threshold for addiction. Recovery centers aren’t suitable for these individuals because they aren’t physically addicted, he says.

But professional counselors can help clients explore and recognize their problem use through exposure to motivational interviewing and the stages of change, Morgan says. Often, these clients have ended up in the counselor’s office because they’ve had trouble at work, at school, with their family or other relationships, or elsewhere. They may flatly deny any suggestion of “problem use,” but counselors can suggest exploring what is going on in these clients’ lives.

“If they’re willing, that already puts them into precontemplation,” Morgan says. Counselors can take that recognition that something’s not quite right and say, “Let’s look at what change looks like,” he suggests. “Let’s stop drinking, drink less or drink less harmfully.”

“We have to pay attention to moments of opportunity,” he stresses. “Someone gets pulled over for a DUI — that’s a moment of opportunity.” If someone is overdrinking and prone to accidents around the home, every visit to the emergency room is an opportunity, Morgan continues. Some hospitals are already using motivational interviewing for brief interventions in the ER, and the success rates have been impressive, he says.

The problem is that for too long, the message has been that when people with substance abuse problems are ready, they will seek help, Morgan says. But most of the time, they’re not going to come in on their own, he asserts.

“We have to raise the bar,” Morgan concludes.

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

International Association of Addiction and Offender Counselors (iaaocounselors.org)

IAAOC, a division of ACA, is an organization of professional substance abuse/addictions counselors, corrections counselors, students and counselor educators concerned with improving the lives of individuals exhibiting addictive or criminal behaviors.

Counseling Today (ct.counseling.org)

“Hidden in plain sight” by Laurie Meyers
“Standing in the shadow of addiction” by Lindsey Phillips
“Grief, loss and substance use” by Susan Furr and Derrick Johnson
“Healing the healers: Counselors recovering from familial addiction” by Suzanne A. Whitehead
“Group counseling with clients receiving medication-assisted treatment for substance use disorders,” by Stephanie Maccombs
“Informed by trauma” by Laurie Meyers
“Suicide, substance abuse and medical trauma” by Bethany Bray

Books (imis.counseling.org/store)

A Concise Guide to Opioid Addiction for Counselors by Kelvin Alderson and Samuel T. Gladding
A Contemporary Approach to Substance Use Disorders and Addiction Counseling, second edition, by Ford Brooks and Bill McHenry
Addiction in the Family: What Every Counselor Needs to Know by Virginia A. Kelly
Treatment Strategies for Substance and Process Addictions by Robert L. Smith
Introduction to Crisis and Trauma Counseling edited by Thelma Duffey and Shane Haberstroh
Coping Skills for a Stressful World: A Workbook for Counselors and Clients by Michelle Muratori and Robert Haynes

Webinars and article for continuing professional development (https://imis.counseling.org/store/catalog.aspx#)

“Opiate Addiction and Chronic Pain: Overview of Counseling Approaches” with Geri Miller
“Opiate Addiction and Chronic Pain: Ethical Practices for Counseling Clients Who Live With Chronic Pain” with Geri Miller
“Opiate Addiction and Chronic Pain: Hope, Resilience and Self-Care Strategies for Counselors and Clients” with Geri Miller
“Substance Abuse/Disruptive Impulse Control/Conduct Disorder” with Shannon Karl
“Developmental Approaches in Treating Addiction” by Ford Brooks and Bill McHenry
“Complicated Grief: An Evolving Theoretical Landscape” by Laurie A. Burke, A. Elizabeth Crunk and E.H. Mike Robinson III
“Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Misuse” with Amy E. Williams and Kristin Bruns

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

Substance use disorders and addiction
Grief and loss

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@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.

Fear and anxiety at the ballot box

By Laurie Meyers October 22, 2020

Word began to filter out late morning on Tuesday, Oct. 13, the last day that Virginia residents could register to vote in the 2020 general elections. A severed fiber-optic cable had brought down the commonwealth’s voter registration portal. Officials said the cut was an accident caused by roadwork; skeptics on Twitter had “accidentally” trending. Paper registration was still available — if postmarked or dropped off at local voter registration offices.

By midafternoon, after an approximately six-hour outage, the site was back up. A federal judge ordered an extension of the deadline to compensate would-be voters for lost time. Everyone would still be able to register to vote. All’s well that ends well, right?

And yet. To many people, the snafu seemed like just one more alarming plot twist in the tale of an election season — and year — so fraught with unprecedented crises that it would most likely evoke reader skepticism if found within the pages of a novel.

The U.S. national elections are already set to serve as a proxy for the country’s stance on climate change, universal health care, racism, police brutality and (dueling visions of) democracy. The maelstrom of events that is 2020 has brought everything to the forefront in Technicolor. The death of George Floyd under the knee of a police officer. The ensuing protests against police brutality and the continuing demands for an end to racial injustice. The spread of violence by white supremacist groups. Record-breaking wildfires in California and Oregon. An incredibly active — and ongoing — hurricane season. The death of Supreme Court Justice Ruth Bader Ginsburg and the rush to appoint her successor. All of it amidst a pandemic unlike any other seen in the past 102 years.

When most Americans started staying home in March in hopes of bringing down the levels of infection by the novel coronavirus, they most likely didn’t expect that almost everything about COVID-19 would become partisan. The degree of threat posed by the virus. Whether to close businesses and restrict community movement. To mask or not to mask? In some quarters — albeit fairly fringe ones — the very existence of the novel coronavirus became a partisan matter. Now, less than one month before the election, more than 225,000 Americans are dead — a total that includes a disproportionate number of Black, Indigenous and people of color — and voters have spent months wondering about the best way to cast their vote.

In response to voter anxiety about going to the polls in person, most states expanded absentee mail-in voting by allowing anyone to use COVID-19 to justify their request. But the U.S. Postal Service, which had been preparing for the surge, was subject to organizational and equipment changes that made the mail less timely. So, many voters worried: If they requested an absentee ballot, would it arrive in time? The requirements for mail-in ballots vary from state to state, leaving some voters baffled and bemused. A process that is usually fairly straightforward has become yet another tangle to unravel in a year that has been fraught with knots.

“Our ability to cope with uncertainty is maxed out,” says licensed professional counselor (LPC) Keri Riggs, an American Counseling Association member with a private practice in Richardson, Texas. The pandemic has also effectively put most of our previously established timelines in question.

“We can’t make plans,” Riggs, whose areas of specialization include depression and anxiety, says. “The thing about the election is that we have a theoretical deadline.” We’ve always thought we understood when voting for the election was over, but this year, we can’t even have a sense of certainty about when it might end and when an undisputed winner in the presidential election might be declared, she says. Part of this year’s election anxiety is tied to not being able to rely on that usual deadline as an endpoint to at least one source of uncertainty.

With the exception of the contested vote count in Bush vs. Gore in 2000, modern Americans are used to learning who the winner of the presidential election is on election night or the morning after. But because so many people are voting by mail this year and it will take time to process those ballots, the votes amassed on Election Day will not be the final tally.

“If there is a contested election, it could drag on for a very long time,” Riggs points out. “Everything has already been dragging on for a very long time.”

And it’s not just about the endpoint. Many voters see this election as more than a mere partisan contest; to these voters, it is something upon which the future of bigger picture issues such as climate change, immigration and racial justice rests. In fact, a recent Pew Research Center survey found that 83% of registered voters say it really matters who wins the presidency. These results are an increase from the 74% of voters who said the same thing four years ago and the highest share of voters saying this in two decades of Pew Research Center surveys. In keeping with the anxiety surrounding the election, approximately 50% of survey respondents said they expected that voting will be difficult.

The stories that we tell ourselves play a critical role in how we cope with stress, anxiety and the seeming chaos around us, Riggs says. Too often, clients focus on the “what ifs” of a doomsday future that may or may not come to pass, she explains.

“The Islamic theologian, Sufi mystic and poet Rumi once said, ‘The words you speak become the house you live in,’’’ notes Ryan Thomas Neace, an LPC who is the founder and CEO of Change Inc., a St. Louis counseling practice that focuses on healing and personal growth in the face of pain. A similar dictum is contained in the Hebrew Scriptures, “The power of life and death is on the tongue,” he continues. “In other words, what we say matters.”

Neace is not denying that voters are facing weighty issues as they cast their ballots, but he maintains that the narratives we construct are not solving anything. Instead, people get caught in the trap of thinking that constant worry and panic are somehow equal to civic engagement or political purpose.

Clients can break their “doom” loops with present-moment awareness, Riggs says. For example, when fear of the future and visions of disaster threaten to take over, she has clients practice telling themselves that they and everyone they love are safe in that moment.

Riggs also advises clients to consume social media and news in moderation and to take breaks. She urges clients to channel their energy into productive action, either by engaging in the political process with a campaign donation or volunteering at the polls, or via a smaller personal outlet such as journaling or even cleaning the bathroom.

Riggs says it is also essential to exercise self-compassion and what one of her clients calls “grace.”

“We need to give ourselves and each other grace — the benefit of the doubt,” she says. “We’re not all on our A-game.”

Neace reminds clients that it is OK — indeed helpful — to tell themselves resilience-building stories such as, “There’s a lot at stake here, but we’re going to get through this together, no matter what.”

President Donald Trump and former Vice President Joe Biden, pictured in a nationally-televised debate on Sept. 29.

Fear of racial violence

“There is a lot of evidence that there are a number of groups that actively want to hurt and disenfranchise Black Americans,” says Harrison Davis, an LPC in Atlanta who specializes in depression, anxiety, resentment and helping people overcome personal obstacles. These groups have come out of the shadows and appear to feel empowered by what they — and many Black Americans — perceive as support from the police and from forces within certain parts of the government and judicial system, he says.

The clients and community members he’s spoken to say their sense of security has diminished over the past year because they feel betrayed by people they believed were their allies. Some of his Black clients have told Davis that instead of standing by them in the fight for racial justice and an end to police brutality, some of their white neighbors and friends supported these law enforcement actions and were actively critical of the ensuing protests.

On top of this vulnerability, some of his Black clients have expressed concern that President Trump has not committed to a smooth transition of power if he loses, while white supremacists are threatening violence or even war, Davis says.

Some clients have an almost panicky need to prepare for an emergency — as if by doing so they can keep their darker fears from manifesting, he continues. This sense of catastrophe is fueled not just by the election, but by the many deaths the coronavirus has brought to the Black community.

Although the threat is real, his clients’ response — living in a constant state of anxiety and panic — is neither healthy nor sustainable, Davis says.

Like Riggs and Neace, when working with clients struggling with election anxiety, Davis zeroes on how much news and social media they are consuming. Not only are clients being bombarded with a sense of overall catastrophe—they are engaging in conversations that are often vitriolic and damaging.

“When I grew up, you would just watch the polictical coverage on the TV networks,” he says. Now, everyone can watch a developing story or scandal in real time. So Davis asks clients to notice how they are responding as they track this torrent of information. “Is it causing you to tense up?” he asks. “Lose sleep?” Clients also report irritability and constant worry–not just about the election, but everything. Right now, the constant urgency and concern of news and social media has such a marked effect on clients, that Davis has moved away from recommending that they balance their use. Instead, he has them do a complete detox.

“Channel that energy into positives instead of arguing with people,” he urges clients. Rather than trying to convince others of their viewpoint, they could be helping people register to vote or get to the polls on Election Day. Davis also encourages clients to find hobbies and outlets that have nothing to do with politics or current events.

On a deeper level, he finds that clients are struggling to accept the world as it is. They may have believed that we had grown as a nation and society over the past decade but now may see that things haven’t changed significantly. One way to cope with that reality and find greater peace is to identify ways to help the community, Davis says.

In his own life, Davis’ father, who was an activist in the civil rights era, told him and his siblings that they might have thought things had changed, but they really hadn’t. Black Americans are still engaged in the struggle for racial equality that has been denied them for generations.

That doesn’t mean that clients need to live in fear, Davis says. Living like that only gives power to those who want Black people to be afraid. He urges clients to find a space where they feel like they belong and to be thoughtful about who they invite into their inner world. They may not yet be able to change the world, but they can control elements of their world by removing unsupportive friends or by leaving environments which make them feel triggered or unsafe—such as social groups or toxic work environments.

A number of his clients are very spiritual, Davis adds. They find strength through the Bible, which holds many stories of people who experienced tragedy and injustice but prevailed by relying on faith and their community.

Power and connection amid chaos

Although many of us view the cacophony of the election cycle as something to endure while keeping our sanity in check, ACA member Laura Brackett is encouraging clients to find their personal power in the chaos.

The year 2020 and the years leading up to it have been traumatic in myriad ways, and exploring personal power is a constant component of trauma work, she says. “The beauty of it is that personal power takes countless forms,” says Brackett, the director of community engagement at Change, Inc., in St. Louis. “For some clients, this has meant outward action in the form of voting, protesting and becoming active in the community. For others, it has meant embracing their own emotional reactions and how that is influencing their behavior and empathy toward self and others.”

Often the process involves a combination of both external and internal work, she says. Brackett’s goal is to encourage clients to embrace their personal power without losing sight of how its expression affects others.

“If there is one thing this year has shown us, it’s that we don’t live in a vacuum,” she says. “Our words and actions have real impact on others. I want to help my clients see this interconnectedness and learn how they can best live within it in a way that is compassionate as well as empowered.”

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Related reading, from ACA’s Department of Government Affairs and Public Policy: “Counselors Are Voting in 2020”

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@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.