Monthly Archives: September 2021

Voice of Experience: Three pieces of anger

By Gregory K. Moffatt September 23, 2021

He was court mandated, and to stay out of jail, he was required to engage in several months of anger management counseling, among other things. I was his choice as a counselor.

An incident of road rage had resulted in this outcome. The other driver had recklessly cut my client off on the interstate. His temper flared, and he pursued the other driver, eventually bumping her car and nearly causing an accident. The other driver was a young mother on her way to work with two children in car seats in the rear of the van. She called the police, who pulled my client over and arrested him.

My client didn’t have a single mark on his police record prior to this incident and said he had never done anything else like it in his 38 years of life. In our early sessions together, he was as befuddled by his behavior as the frightened young mother must have been on the highway.

Leremy/Shutterstock.com

Anger is a fascinating emotion. It is completely visceral. You can’t “decide” to be angry any more than you can decide to fall in love with someone. Instead, in a way, anger attacks us out of the blue, as it had done to my client.

People express anger differently depending on a variety of factors, including personality, coping skills, history and context. Regardless, we are all its victims at one time or another, and sometimes this emotion deceives us. In fact, anger can be much “safer” for us to express than other emotions. A counselor once told me that depression is really hidden anger, and while that may often be true, I believe the opposite is also true. It is sometimes easier to be self-righteous and angry than it is to admit that your heart is hurting.

I’ve had clients who have threatened others with weapons, engaged in violent road rage, and even some who have killed their workmates. Very few of these people planned their behaviors ahead of time. They acted spontaneously in the heat of passion (pardon the cliché).

I have witnessed anger many times in my clients, and I’ve recognized some things that help me manage it. Early in my career, “anger management” involved a set of techniques such as deep breathing and the development of varied coping skills. While those are certainly important areas on which to focus, I was missing a piece of the puzzle at the time that is also critical in managing anger.

Anger has three common components or pieces, and if we help our clients address these three issues, they will have new tools for coping in a variety of situations.

The first component is loss of control. When all of our tools for coping are expended, we are reduced to primitive behaviors. Think about how illogical (yet common) it is to push an elevator button repeatedly. In the midst of our frustration, we push the button again and again, even though we know it won’t help. This is where the use of deep breathing (or another relaxation technique) is very helpful.

My client had been feeling a loss of control at work and a loss of control at home. When the other driver’s behavior caused him to feel a similar loss of control that day in heavy traffic, he tried to retake control by “punishing” her for her reckless driving.

A second component of anger is that the precipitating event is perceived as personal. My client perceived that the other driver was doing something deliberately to him (as if she had planned specifically to make him angry) when, in fact, she was simply in a hurry and wasn’t thinking. The irony in road rage is that we depersonalize the other driver and at the same time perceive their behavior to be a personal and intentional attack on us.

Finally, the third component is a belief that one has been wronged — that life isn’t fair. My client believed that “other drivers shouldn’t be so careless.” In a way, he was trying to make the world fair by righting a wrong. That thinking is quite illogical but very common in road rage incidents.

The rage my client experienced had occurred partially because his defenses were down. He had just wrapped up a very bad day at work, his home life was at a low point, and in the safety of his car — his own domain — he let his normal coping skills fly out the window.

After weeks of counseling work, my client went on about his life a much healthier person. By looking at these three pieces of anger, he was able to learn to recognize cues and apply anger management techniques. I hope he’ll never see the back seat of a police car again.

 

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

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

Assessment, diagnosis and treatment planning: A map for the journey ahead

By Bethany Bray September 22, 2021

Clients impart so much about themselves, verbally and nonverbally, in counseling sessions that it will overwhelm clinicians who don’t organize the information and use it to create a structured plan for their work together, contends Nathaniel N. Ivers, associate professor and chair of the Department of Counseling at Wake Forest University.

Fully understanding a client’s situation, symptoms and needs and then matching them with a diagnosis (when appropriate) and a treatment plan that will help them heal, grow and thrive are core aspects of professional counseling. Counselors learn these skills, at least conceptually, in graduate school but gain true understanding of them through their direct work with clients. 

Practically applying that knowledge is “where the rubber hits the road,” says Ivers, a member of the American Counseling Association. Examining a client’s concerns in depth — moving beyond surface-level questions such as “How did this week go?” or “What do you want to talk about?” — is the most integrative and effective way to devise a rich treatment plan and pinpoint a destination that the client and practitioner will work toward together in therapy.

Ivers acknowledges that counselors who are busy with full caseloads may be resistant to the idea of dedicating time to create a comprehensive, integrative plan for each client. But as he tells his students: The more you do it, the easier it will get.

“Eventually, you won’t have to write out a full, multipoint case conceptualization plan for every client,” says Ivers, a licensed professional counselor in Texas and a licensed clinical mental health counselor in North Carolina. “But when you eventually have … trouble figuring out [a case], that’s when you need to fall back on it — put pen to paper and conceptualize a full plan.”

When teaching these concepts to students, Ivers often shares a quote from psychologist Donald Meichenbaum, professor emeritus at the University of Waterloo in Canada and one of the founders of cognitive behavior therapy: “A clinician without a case conceptional model is like a captain of a ship without a rudder, aimlessly floating about with little or no direction.”

An important responsibility

The three components of assessment, diagnosis and treatment planning are intrinsically linked and provide a “map” for counselors to offer evidence-based treatment that best fits the client, says Shannon Karl, an ACA member who is a professor and field-based clinical coordinator in the Department of Counseling at Nova Southeastern University in Florida. Not only is the process vital to establishing a foundation for counseling work with a client, but it also creates a pathway for the individual to access appropriate treatment services from counselors and interdisciplinary professionals.

Assessment, diagnosis and treatment planning are important responsibilities, and mastery of these skills is often closely tied to clinician confidence, Karl says, so it’s understandable that new professionals may worry if they are getting things right. She urges counselors who feel this way to remember that their mentors are there to advise and support them. Similarly, counselor education and supervision programs are meant to help trainees through this learning curve, she says.

Even so, both novice and experienced counselors should seek continuing education, peer consultation and mentorship in these areas throughout their careers, stresses Karl, co-author of the ACA-published book DSM-5 Learning Companion for Counselors. It is imperative for counselors to keep these skills sharp and up to date, not only because they are integral parts of the counseling process but also because diagnoses and related criteria are constantly changing and evolving.

Karl was on an ACA task force formed to study the updates and changes introduced in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013. She was dismayed, she says, to see how long it took many counseling practices to update their procedures to reflect the changes made between the fourth and fifth editions of the DSM.

Karl urges clinicians to stay informed and up to date by attending workshops, conferences and other continuing education events; consulting regularly with professional peers; seeking mentorship or supervision; joining professional Listservs; and reading counseling journals and other publications. Remaining active with state and local counseling organizations will also help practitioners stay abreast of criteria and processes that vary state to state, she notes. Leadership within the counseling profession must ensure that funding for continuing education on assessment, diagnosis and treatment planning is prioritized, especially for counselors in economically disadvantaged or rural areas and settings where practices or clinics are short-staffed, Karl adds.

“One thing we can do at all levels is make sure that clinicians have access to free or reduced-cost continuing education, workshops and seminars. Accessibility is important,” says Karl, a licensed mental health counselor whose area of focus is childhood trauma and DSM-5 disorders. “It’s important for professional counselors, regardless of work setting, to be able to best serve their clients, and one way to do that is to be active in learning regarding assessment, diagnosis and best treatment planning. We can’t help others heal in isolation.”

Danica Hays, author of the ACA-published book Assessment in Counseling: Procedures and Practices, notes that counseling graduate students often take only one class each on assessment and diagnosis. Continuing education, in addition to competency gained through experience, is needed to round out counselors’ knowledge, she says.

“With the amount of material to cover, [counselor graduate education] lessons are often distilled to case conceptualization and treatment planning as simply following a recipe,” says Hays, a professor and dean of the College of Education at the University of Nevada, Las Vegas. Gaining comprehensive knowledge that includes “other ways of knowing — often from scholars and practitioners of color — can be incredibly helpful to ensure clients are not harmed by an incomplete and/or distorted story told on their behalf,” she adds.

Client driven

Tracie Keller, a licensed professional clinical counselor and supervisor in Ohio, has found that teaming directly with the client to identify goals and build a treatment plan strengthens the level of trust and rapport between clinician and client, which in turn improves treatment outcomes. She chooses to highlight this collaborative approach on the website for her group practice in Columbus, Ohio, by including the following statement: “We believe that treatment planning is a process that both the therapist and the client determine together.” 

Keller tries to think about the process from the client’s perspective. She notes that if she went to a medical doctor and the doctor prescribed a treatment plan and medication without bothering to tell her that she had the flu, she’d question what was going on and whether the doctor valued her input.

Keller, who specializes in treating clients with eating disorders and trauma-related concerns, says a prescriptive approach has never really worked for her. “[Clients know] themselves the best,” she says. “For me, it [collaborative treatment planning] is something that helps build a lot of trust. It’s not just prescribing ‘this is what I want you to do,’ but instead walking alongside [clients] to execute the goals they want. … If the client doesn’t buy in, [counseling] won’t be successful.”

Hays notes that involving clients in case conceptualization and treatment planning also allows for better cultural understanding and responsiveness. Counselors have a significant responsibility to get a client’s story right, she says, and “getting the story right involves co-constructing it with the client in a way that honors their cultural experiences as well as points of trauma and resilience.”

“Really good assessment is committing to gather a client’s story with that client, engaging in basic helping skills to affirm what the client is sharing as they share it, incorporating multiple qualitative and quantitative tools in the process, and proposing and evaluating treatment approaches with the client,” Hays asserts. “Thus, assessment may not involve many questions but [rather] more space within sessions for the client to share their stories, with the power and voice to confirm or disconfirm an evolving conceptualization of those stories.”

When Keller begins working with a new client, she listens carefully as they talk through their history and symptoms. Possible diagnoses and issues to work on in counseling often become apparent to Keller as she listens, but she stores those ideas away for the time being. Instead, she prompts the client to think of treatment goals, asking questions such as “If you could change anything in your life through our work together, what would that be?” or “What would you want to be different in your life after our relationship concludes?”

Clients presenting with symptoms of an eating disorder might respond with statements such as “I don’t want to fight my body anymore” or “I’m sick of hating my body,” Keller says. In this example, Keller and the client might work together to create a goal of improving the client’s body image in counseling. Later, once the client has made some progress on that goal and established a stronger therapeutic relationship with Keller, she will circle back to some of the issues that revealed themselves in the initial assessment session and try to tie those issues into the client’s treatment goals. If the client mentioned purging behavior or restrictive eating in the initial session, for example, Keller might gently raise the idea that this behavior could be something to work on as part of reaching the client’s goal of obtaining a healthy body image.

Because Keller accepts insurance at her practice, she diagnoses all of her clients to submit for reimbursement. Keller lets each client know that she will share their diagnosis with their insurance company, and she dedicates time to explaining the diagnosis to the client and how she arrived at that decision. Depending on the client, she sometimes takes out her copy of the DSM-5 in session and looks through the diagnosis criteria with them.

“I talk about it from the start because they’re in a very vulnerable space [at intake], and it’s important to be really transparent about what their diagnosis is and what it means,” Keller says. She never moves forward with a treatment plan or diagnosis unless a client agrees to it.

After talking through the diagnosis with the client, she explains the methods and tools she uses (such as cognitive behavior therapy or eye movement desensitization and reprocessing) to treat that particular diagnosis and how she will tailor her approach to help the client meet the treatment goals they have identified.

A large portion of the initial goal-setting and therapeutic work with clients is frequently focused on reducing symptoms, Keller notes. As treatment progresses, she works with clients to shift or change treatment goals to move beyond symptom management and to focus on the issues that lie beneath their original presenting concern.

For example, a client with chronic depression might first identify goals that involve improving their mood and alleviating their symptoms. Later, as their symptoms lessen and the client is feeling better, they could be ready to focus on past trauma or relationship issues that they didn’t have the bandwidth to tackle earlier, Keller says. 

She finds this process often happens organically; the “win” of seeing symptoms lessen often motivates clients to identify additional goals. “It’s cool because you have a lot of trust and past success in therapy [at that point] to go off of, and the client often wants to dig deeper and make greater changes,” Keller says.

Client treatment plans need to evolve and stay flexible because clients’ needs will change throughout therapy. Keller notes that it is common for individuals with eating disorders to experience periods when their symptoms worsen, sometimes to the point of needing hospitalization or inpatient care. Whenever this happens, Keller works with the client to shift their treatment plan and identify different goals for the near future, and then they repeat the process after the client has been discharged or their situation has otherwise improved.

Assessment shouldn’t be limited to the initial and concluding sessions with a client. As Keller points out, an important part of this process is being attuned to a client’s needs and blending assessment work into each session. She says that she continually listens for short- and long-term treatment goals.

“As you go on through treatment, you’re getting information [from the client] with each session,” Keller says. “As you walk with them, you’re learning more and more: how they relate to you, how they relate to other people. You can’t ignore that information. It will guide you. I’m constantly assessing and holding that information.”

Keller acknowledges that her understanding of the treatment planning process has expanded over time. “Now it’s a process that is pulled up in my mind during every single session — not just at intake and conclusion,” she says. “Even if I don’t verbalize it with the client, I’m thinking of every conversation through the lens of their goals. It becomes an unspoken but ever-so-present aspect of the work, and it moves it along.”

Diagnosis: A love-hate relationship

Many professional counselors have mixed feelings about diagnosis. On one hand, it can be a tool that connects clients with the mental health care they need. On the other hand, it can be viewed (both by clinicians and clients) as a “label” that follows clients throughout treatment and, in some cases, life.

Keller says she understands both sides; however, she values diagnosis and finds it useful. Diagnosis is a tool that allows her to understand how she can initially help her clients, and it guides her interventions and therapeutic approach as treatment progresses. It can also remove financial barriers to mental health care. Counseling can be expensive, and insurance companies typically require a diagnosis for reimbursement. So, Keller views diagnosis as a way of providing treatment access for clients who wouldn’t be able to afford counseling without insurance coverage. 

The key, Keller says, is to be fully transparent with clients and include them in the diagnostic process, especially for diagnoses that can carry a stigma, such as personality disorders, substance use disorders and eating disorders. In some cases, counselors may need to offer psychoeducation to dispel inaccuracies or stereotypes about a diagnosis.

“I can have a love-hate relationship with it [diagnosis] at times,” Keller admits. “It can have a stigma and the burden of sharing it with insurance. … Oftentimes in therapy, we end up having to process and unpack a lot, [including] what they [clients] have heard and experienced in carrying that diagnosis. If I can be involved in that process with them and acknowledge the stigma, I can help them.”

Ivers says there can be limits to diagnosis, including when clients develop a sense of dependency on their diagnosis or use it as a “crutch.” But as a whole, he finds that the process of diagnosis generally encourages counselors to seek out best practices, research and resources to help and support their clients.

“We have to be cautious that we don’t reduce people to their diagnosis,” Ivers warns. “But for others, finally receiving a name for the cluster of symptoms they’re experiencing can be a relief. It also can open them up to treatment and connect them with you [their counselor] or other practitioners who can help for their specific concern, [including] prescribing medication.”

Karl agrees that one benefit of diagnosis is that it often helps connect clients to interdisciplinary treatment. Even if a counselor is not required to assign diagnoses to clients, they need to have a “comfortable awareness” and foundational knowledge of the diagnosis process and be able to triage clients to connect them to further treatment if needed, Karl says. Screening skills and competency regarding diagnosis are also a requirement for counselor licensure in many states and therefore something to keep oneself updated on through continuing education, she adds.

Diagnosis also requires counselors to know how to use the DSM. Karl advises clinicians to become comfortable with looking things up in the manual and knowing where to turn when they have questions or need more information, rather than trying to memorize its contents.

Additionally, there are certain conditions mentioned in the DSM that counselors would not be involved in diagnosing, such as neurodevelopmental disorders. Because counselors will often be included in treatment plans for clients with those types of diagnoses, however, they still need to be proficient enough to have an understanding of any DSM diagnosis and its best treatment practices, even if they do not diagnose the client themselves, Karl notes.

Trying to remember all the nuances of the diagnoses in the DSM is “setting yourself up for failure,” Karl says. The DSM-5 contains more than 1,000 pages and hundreds of diagnoses. Even if clinicians were able to remember everything the manual contains, revisions and updates are made to the information regularly. For that reason, Karl urges counselors to focus on having a core knowledge of the manual, being comfortable enough to use it as a resource and adapting with it as it changes.  

Potential bias

Counselors are human beings with individual personalities and worldviews, so there is always a chance of potential bias creeping into assessment, diagnosis and treatment planning. To avoid this, clinicians must diligently reflect on their biases and really think about their assessment questions and diagnosis processes, says Ivers, who presented the session “Using Case Conceptualization to Navigate the Turbulent Waters of the Human Condition” at ACA’s 2018 Conference & Expo.

Ivers stresses that counselors need to critically examine why they are asking what they are asking — and what they are not asking. “If a client is acknowledging some of the cultural struggles they’re facing and we skirt those issues and do not focus on them,” he says, “what we’re telling them is that it’s not therapeutically important.”

“Case conceptualization is a tool, and when used effectively, it can be extremely helpful,” Ivers notes. “But when used ineffectively, it can be hurtful and damaging. In the case of culture, it can actively discriminate and misalign. It can [cause a clinician to] try and fit a client into a mold.”

Clinicians must also keep in mind that assessment and diagnostic tools can have an innate bias. Models often have a “cultural flavor” and are based on what is traditional (or Westernized) rather than on what is deviant or nondominant, Ivers says. He teaches Jon and Len Sperry’s case conceptualization method to his students at Wake Forest. One of the benefits of the model, Ivers says, is that it allows for flexibility and modification based on a client’s cultural factors. (For more information, read Jon and Len Sperry’s Counseling Today article “Case conceptualization: Key to highly effective counseling.”)

“There are evidenced differences in how symptoms are expressed culture to culture and, thus, individuals do not neatly fit in diagnostic or treatment ‘boxes.’ Fostering one’s competency is embracing these tensions,” says Hays, who is an ACA fellow.

She points out that research shows there are disproportionate rates of mental health issues among people of marginalized statuses. “The question has been whether differences in diagnostic rates — based in case conceptualization — are actual differences among cultural groups or whether they are a result of faulty assessment and diagnostic processes on the part of the counselor,” Hays says. “The answer is likely a little of both. Counselor cultural bias does substantially shape assessment and treatment, and experiences of privilege, oppression, trauma and resilience shape what symptoms are presented.”

Keller acknowledges that the potential for practitioner bias in assessment, diagnosis and treatment planning is one of the messiest aspects of professional counseling. What she finds invaluable in this realm is seeking feedback through regular consultation with professional peers as well as attending counseling herself. 

Personal counseling and professional consultation allow Keller to process things, identify her “blind spots” and work through her own biases, “so they don’t come out in the counseling room,” she says. “The last thing I want is for my stuff to affect [my client’s] stuff.”

Ivers admits it is “inherently reductionistic” to take all the information that a counselor gleans from a client through the therapeutic relationship and organize it into a treatment model and plan. There is no way to keep from losing data as the counselor processes all the information, he says.

“Therefore, it’s important to remain flexible and be aware that there can be blind spots,” Ivers advises. “You’re never going to get it 100 percent right, and that’s why we [counselors] are always reassessing and modifying a treatment plan. But you’re hopefully on the right path.”

A career-long learning curve

It’s not easy to competently assess what a client needs and then match those needs with an accurate and responsive treatment plan that will help the person to heal. Therefore, counselors find themselves continually developing and strengthening these skills over the entire course of their careers. 

Keller says it remains her goal to grow her skills in assessment, diagnosis and treatment planning over the decades to come with the mission of better serving her clients. “To be an effective counselor is to trust and to be OK with always learning and pushing ourselves to grow,” Keller says. “If I stop doing that, I probably shouldn’t be practicing anymore. Counseling is a process that I have to be willing to grow and change and evolve with — just as clients do. [Counselors should] trust that wherever you’re at in your professional journey, it’s OK — and it’s good even — to be learning.”

fizkes/Shutterstock.com

 

Wrestling with a client’s previous diagnosis

It’s not uncommon for counselors to see clients who have received a prior diagnosis from another clinician. If the client comes via referral, the counselor may have case notes that include the diagnosis in writing. In other situations, a client might report to the counselor that they were told they have a certain diagnosis. This introduces the possibility that the client might have misunderstood or misremembered clinical terms that they heard from the other practitioner or found on the internet.

So, what happens if the counselor, after getting to know the client, disagrees with the previous diagnosis? It’s a common scenario, says Shannon Karl, a licensed mental health counselor and professor at Nova Southeastern University. She urges counselors to remember that individuals grow and change, so a diagnosis shouldn’t stay static. A previous diagnosis may no longer be relevant or applicable for a client, especially if it’s more than a few years old.

Counselors need to come to their own conclusions about a client without allowing a previous diagnosis to color their assessment, Karl says.

Danica Hays, a professor and dean of the College of Education at the University of Nevada, Las Vegas, suggests that practitioners ask the client questions to get additional information about a past diagnosis, including how (and by whom) it was made, how the client feels about the diagnosis, the extent to which the client still identifies with the diagnosis, and how or if they feel that the diagnosis led to finding support to address their symptoms.

“Given the inevitable role of bias in clinical decision-making, counselors should always be cautious when a client presents a treatment history in which they were diagnosed a particular way,” Hays says. “It is important that counselors not quickly jump to a diagnosis based on what has been diagnosed before. This is a clear example of the improper ways that cognitive tools are used to yield misdiagnosis and client maltreatment.”

A counselor’s role also includes ensuring that a client feels heard and trusted when they talk about previous diagnoses or conditions that they think they have but that have yet to be diagnosed, adds Tracie Keller, a licensed professional clinical counselor.

“I try and hold that [information] with respect and honor, but at the same time, I do my own assessment and treatment plan based on what I’m hearing,” says Keller, who owns a counseling practice in Columbus, Ohio. “I use that as a jumping-off point to garner further questions, [as] a starting point to dig deeper.”

Karl once worked as a mental health counselor in a pain clinic where she had the freedom to have an initial session with clients before she opened and reviewed the individual’s records. “Clients really valued that I wanted to take a few minutes to hear it [their mental health history] from them,” Karl says. “They knew they had the chance to share their story with me without any filters.”

Karl acknowledges that this will not be possible for most counselors. However, she urges clinicians to find ways to hear a client’s backstory in their own words, even if they know the client’s diagnosis and case history before the person walks in the door.

“We need to preserve the ability to hear clients’ stories from them,” Karl says. “Keep in mind that we are not defined by our diagnoses; we grow and evolve in positive directions. What was happening previously doesn’t mean it’s happening now. Be aware that assessment is a continual, ongoing process, and a diagnosis is never set in stone. If we come from that lens, it helps us see clients for who they are as opposed to what they’re tagged with.”

 

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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.

African Americans and the reluctance to seek treatment

By Patricia Bethea Whitfield September 16, 2021

Amid talks of how African Americans have been disproportionately impacted by the COVID-19 pandemic and speculations about their hesitance to be vaccinated, the Tuskegee experiment has been cited numerous times as a kind of landmark explanation of why African Americans are reluctant to seek treatment. In the Tuskegee experiment, African American men were recruited for what they thought was a medical treatment but was actually a study of untreated syphilis that continued long after penicillin was a recognized intervention for the disease. In fact, the men were never treated, and many went on to infect their partners as well. As unethical as this research is now recognized to be, the reluctance of African Americans to trust systems and seek treatment is actually rooted closer to home, in the long history of mental health abuse and failed mental health intervention for African Americans. 

Today, African Americans face numerous challenges that affect their mental health, including high rates of unemployment, poverty and incarceration; health disparities and disability; the emotional and psychological impact of the pandemic; and the steady uptick of police shootings in the African American community. All of these challenges are complicated by the intergenerational trauma of slavery, the very mention of which often arouses an almost visceral reaction even 150-plus years after it ended. In fact, Africans were brought to this country as slave labor and, along the way, laws were passed to ensure that they and their descendants would continue to be enslaved forever. Over time, the color of their skin was equated with servitude and privation in a way that has persisted for over 400 years. Slavery is our common history, and if it is a shame, it is our common shame. 

Now there are new mental health challenges in the emerging myths that discount the history of African Americans and slavery. The first myth is that slavery is a hoax, meaning that Blacks were never enslaved in this country. The second myth is that Blacks were enslaved but slavery was really not that bad. In the first myth, the discounting of history is insidious. It is meant to befuddle and confound in the same kind of gaslighting experienced by the lead character in the movie of the same name (Gaslight). In this case, the myth is intended to create doubt of perception and historical memory such that Black people are being told, “You think you went through hell, but it did not happen.” In an era of turbulent racial tension, the second myth of slavery as a harmless social good conveys a tone of slavery reconsidered for African Americans, and recent voter restriction laws help to flesh out the second boogeyman as a political reality. This historical revisionism retraumatizes, angers and reactivates centuries-old intergenerational fight-or-flight strategies for coping, including confrontation (rallies and marches) and withdrawal. 

According to the Centers for Disease Control and Prevention (2017), non-Hispanic Blacks are more likely than non-Hispanic whites to report feelings of “sadness, hopelessness, worthlessness, or that everything is an effort all or most of the time.” The U.S. Department of Health and Human Services (HHS) Office of Minority Health reported that suicide was the second-leading cause of death among African Americans ages 15 to 24 in 2019, and the death rate from suicide for African American men was four times that of African American women. African Americans have one of the highest rates of poverty in the United States, and according to the HHS Office of Minority Health, African Americans living below the poverty line are twice as likely as other individuals to report psychological distress. In 2019, the Substance Abuse and Mental Health Services Administration reported that among adults who experienced mental health issues in the past year, non-Hispanic Blacks were significantly less likely to receive mental health treatment than non-Hispanic whites (8.7% compared with 18.6%). 

Despite the evident need for mental health counseling, many African Americans are reluctant to seek treatment. Some of this reluctance may be rooted in the reality that, historically, African Americans have had their mental health abused and their mental health treatment administered with a liberal dose of discrimination and bias. Initially, it was assumed that African Americans could not be mentally ill. The general notion was that a person had to own property and actively engage in business and civic affairs to experience mental illness, and because African American slaves “had nothing and nothing to worry about,” they could not be mentally ill. In fact, when both the 1840 and 1850 U.S. census found such low rates of mental illness among slaves, it was concluded that slavery actually protected slaves from the known diagnoses of the time. 

Science rushed to support pro-slavery views. Physicians and scientists promoted the notion that slavery was such a good thing that a slave would have to be mentally ill to want to leave it. Thus, drapetomania emerged as the first race-based diagnosis. Samuel Cartwright, a physician, coined the term in 1851 to describe a “disease” that made slaves develop an irrational urge to run away from slavery. He also identified a second physical and mental abnormality, dysaethesia aethiopica, thought to attack Black people who had too much freedom. This condition was purported to make them sabotage their work, break things and become confrontational with others. 

While early attempts to label African American behavior seem antiquated and almost laughable today, they have had a profound impact on the regulation of Black behavior and the transmission of intergenerational bias. Over time, resistance to oppression and free labor stereotyped African Americans as “lazy” people who did not want to work, and for their most vociferous resistance to slavery, they were often labeled “deranged.” In this way, race and control were conflated with mental illness in the lives of Black people, and that was just the beginning. Slavery in the United States ended in the mid-1860s, and the usefulness of Blacks for free labor and reproduction of more slaves ended with it. Slavery left a lot of broken families who were never able to reconnect. Employment was nearly nonexistent, and Jim Crow laws codified new subservient behaviors for Black people, who had to go to the back door for service and step off the sidewalk to let white people pass. From 1882-1968, 3,446 Black people were lynched in a campaign of terror, according to Tuskegee Institute. 

Also in the late 1800s, Francis Galton coined the term “eugenics,” the notion that only certain people should be able to reproduce. Herbert Spencer supported this idea with his now famous “survival of the fittest” theory or social Darwinism. Eventually, the concept of eugenics was adopted and applied for various purposes: the genocide of the Jews by Adolf Hitler, in immigration policy and, ultimately, in the forced sterilization of people considered mentally defective, including persons with disabilities. According to the Equal Justice Initiative (2013), in addition to persons with disabilities and prisoners, “thousands of poor Southern Black women were sterilized without their knowledge or consent.”

The notions of Galton and Spencer further fueled views on miscegenation, or biological race mixing, and the legal prohibitions against intermarriage. The supposition was that by outlawing mixed-race unions, the white race would remain the strong, pure race, while mixed-race individuals, called “mulattoes,” would meld into the Black race. It worked. By definition, mulattoes disappeared nearly a century ago after the U.S. census dropped that category and mixed-race individuals were forced to self-identify as Black and intermarry with Black people. Legally, the prohibition on mixed-race marriage lasted until the Supreme Court struck it down in Loving v. Virginia in 1967. But in the dominant discourse, it has lasted much longer. 

Well into the 20th century, the realities of Black mental health were minimized in service to age-old views on the dangers of Black people having too much freedom — namely, that it would cause them to lapse into ruin and insanity. Mental health treatment and facilities were fledgling and limited notions for everyone at the time, but for Black people, institutionalization was dismal. Because of segregation, Black people who were mentally ill were housed separately from whites, to the point of being lodged on the grounds or in overcrowded spaces, forced to work in the facilities, and often hired out to support the institutions.

In some cases, individuals were institutionalized for other disorders, other disabilities were mistaken for mental illness, and people were confined on the word of an employer. Despite passage of the Civil Rights Act of 1964, some states continued to provide discriminatory mental health services in which African Americans were more likely to be labeled as aggressive, less likely to engage in talk therapy, more likely to be segregated on pharmaceutical interventions and, in the case of African American men, more likely to be labeled as schizophrenic and restrained. 

Consequently, many African Americans remain skeptical that mental health professionals are here to help them, and they are often right. According to a fact sheet published by the American Psychiatric Association in 2017, African Americans are less likely to receive “guide-line consistent” care, more likely to use the emergency room or a primary care provider for intervention, and less often included in research. In a 2013 study from Earlise Ward, Jacqueline Wiltshire, Michelle Detry and Roger Brown, African Americans were found to be generally reluctant to consider psychological problems, were concerned about the stigma associated with mental illness, and were “somewhat open” to mental health services, although they preferred “religious coping.” A 2015 study by Janeé Avent, Craig Cashwell and Shelly Brown-Jeffy found that in Southern Black communities, the faith leader or “preacher” is often a front-line source of support for church members experiencing mental health distress. 

To attract Black people to mental health counseling, we must address old prejudices around the flawed construct of race, lingering biases in mental health treatment, and the lack of access to mental health services for those living in poverty. We could recruit more counselor education students from marginalized groups, and we could address the shortage of African Americans among counselor education faculty. According to the 2017 CACREP Vital Statistics Report, African Americans make up just 14.52% of counselor educators, and of that number, 4.11% are African American men. We could ask ourselves hard questions about why counselor education textbooks have been silent about what has happened to African Americans in mental health treatment, and when we do that, we could decide not to put that dialogue in a separate section of the book. 

We could have an integrated discussion about the segregated history of mental health treatment in this country. We could stop saying that Black people “drop out” of treatment and start a conversation about why African Americans are skeptical of our labels and our notions and potions as they relate to the historical regulation of Black behavior. Finally, it is late — but not too late — to do due diligence in the clinical assessment of people who bought and sold human beings and, in many cases, perpetrated horrific acts of violence against them. The victims who resisted oppression were labeled “mentally ill,” but we have yet to label the perpetrators of these atrocities. 

For these reasons, the myths that deny the injustices of slavery or that slavery ever even existed are not benign. African Americans have lived for more than 400 years in a kind of psychological fun house with mirrors that reflect everything in exaggerated shapes. The message: “Your life experience does not matter.” 

Ultimately, viewing enslaved people as less than human, recklessly labeling them and then wantonly disregarding African American mental health for two centuries formed the justification for the Tuskegee experiment. So, if African Americans are reluctant to seek treatment, the reluctance has less to do with race and more to do with trust. That is what the reluctance is about. Happily, that is what counseling is about too.

pixelheadphoto digitalskillet/Shutterstock.com

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Patricia Bethea Whitfield holds a doctorate of education and is an associate professor and coordinator of the CACREP-accredited mental health counseling clinical program in the Department of Counseling at North Carolina A&T State University, where she teaches “Counseling Poor and Ethnically Diverse Families.” She is a member of the North Carolina Counseling Association Executive Council, president of the North Carolina Association for Specialists in Group Work, and past president of the North Carolina Association of Marriage and Family Counselors.

 

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

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

Humility wins

By Ellie Rose September 15, 2021

Guess what? If you have ever been in or are currently in therapy yourself, Carl Rogers might not have been a good fit for you. Neither might have Bessel van der Kolk or Irvin Yalom.

The clout that some of these big names in therapy possess is generally well-earned. Who doesn’t appreciate the advances in thinking on things such as unconditional positive regard, trauma or transference that these experts have provided?

As counselor clinicians, we are fortunate to have a wealth of brilliant minds who have gone before us before we ever step foot in our first theories classroom. But it is OK that we are not them. Inside the walls of a therapy office, there is not a single human on this planet who is (or would have been) the best therapist for everyone.

One of the ways that I market myself as an associate-level clinician still working toward independent licensure is this: leaning into humility. Rather than feeling less than those who already have 20 years in the field, a doctorate-level education or an alphabet of special certifications, I focus on fully occupying my space in this little corner of the world where real and meaningful change can happen for my clients.

Humility is powerful. And accepting all that you are and all that you are not is far more of a strength than a deficit when it comes to attracting and retaining clients. Here are some tips to challenge your thinking on fully embracing what you bring to the therapy table:

1) Accept that you won’t be a good fit for everyone; you will be an excellent fit for some. My website FAQs include the question “Why should I pick you?” My answer leads off with “Maybe you shouldn’t …” before I expand on how important it is to find the right fit in therapy.

Do not be anxious about all the things you are not as a counselor; rather, stand tall in exactly what you are. Even if you are just an intern at the cheapest university in America and receive subpar supervision, you still bring an entire lifetime of experience to your clients. Your very person is a gift.

If you had an abusive childhood, bring it. If you face constant household moves from a military lifestyle, bring it. If you’re happily married or are in the middle of a high-conflict divorce, bring it. Are you a parent? An artist? Do you have attention-deficit disorder? Bring it. All the elements of your very person are tools. They are uniquely yours and uniquely perfect for certain clients.

2) Sell the confidence you have in the client, not yourself. During the first intake session, I am very open with clients that I am not necessarily everyone’s cup of tea. I give them permission to fire me. And I validate the challenge they currently face in going out on a limb with a new therapist. I let them know that I have myself had a string of therapists with whom I didn’t really connect before I finally found the right one.

I look them in the eye and say something like this: “If this doesn’t feel right here, or if you aren’t connecting with what’s happening in this room, by all means, let’s talk about it. I might not be the right person for you, but I trust that the right person is out there, and I will offer some names for you that might be a better fit for your needs.”

Clients have responded really well to this. Some tear up just at that moment of me recognizing how scary it is to start dissecting a lifetime of pain with a stranger. Others thank me for giving them permission to be direct. Candidly, there are very, very, very few clients who don’t come back. In being given the freedom to choose what is right for them, clients will typically stop wondering if you might just be a smarmy businessperson trying to make a buck off them.

Imagine going to a car dealership and, right off the bat, the salesperson indicates that they want you to get the most out of your car-buying experience. Then, they acknowledge that they might not have what’s right for you but will help you find the place that does. Wouldn’t that feel great and immediately earn your trust? When you meet with a professional who is willing to recommend that you take your business elsewhere if warranted, that can lead to a substantial leap in rapport building with that person. When you do this as a counselor, it demonstrates to the client that you are perfectly confident in what you do offer and aren’t desperate for their business. Note: Even if you are desperate for their business, the client won’t benefit at all by knowing that.

3) Consider risking your own time. I found the therapist I’m currently seeing after I had interviewed a few others and was feeling weary in the hunt. Someone recommended him to me, and he stood out to me initially for one reason: The first session was risk-free. No, I’m not talking about the industry standard “free 15-minute consultation”; I mean that he offered an entire session at his expense to see if it would be a good fit. The catch was that if clients wanted a second session, they would book it and then pay the fee for the first session as well as the second. If he was terrible, no loss to the client; they could walk away.

I was immediately struck by his boldness and figured he must feel confident about what he was offering, so I gave it a shot. It paid off. I scheduled a second session right away and gladly paid the cost of the first. That was nearly two years ago, and I still see him regularly to this day. It was a marketing technique that served as a really attractive selling point for me as a client. Some variation of this might work for you too.

4) Be comfortable saying, “I don’t know.” You don’t need to be an expert on everything to be a great counselor. You don’t even need to be an expert on anything specific to be a great counselor! While establishing a niche can be a smart career move and might be personally fulfilling to you, it’s also OK to be a general clinician who handles only things such as anxiety, depression and grief. Evidence has consistently shown that it is not the specialized skill that produces the highest rates of success; rather, it’s the therapeutic alliance … and this is something that exists far beyond textbooks and continuing education workshops.

If a client asks you a question that you don’t have the answer to, say so. Offer to find answers for them or with them. If a client wants a particular type of therapy that is not in your wheelhouse, say what you know and what you don’t, and let them know if you are (or aren’t) willing to learn about the type of therapy they are seeking. Most of all, if you are asked for a very specialized service such as eye movement desensitization and reprocessing or brainspotting and you aren’t trained in it, PLEASE don’t pretend that you are and go home to binge on YouTube videos in hopes of faking it. State clearly your scope of practice and stay within it — while constantly trying to improve on your own time.

acidmit/Shutterstock.com

As a consumer, I am deeply appreciative of those experts who admit the limitations of their knowledge and don’t pretend to have all the answers. This deepens my trust in them. My general physician does this, which is why I would endure scheduling inconveniences just to see him; his word is gold. When you are confident in what and who you are, there is no reason to feel threatened by what you don’t know.

I remember the first time I worked with someone who had a chronic medical condition. She was nervous upon intake and asked what kind of experience I had in this particular area. I told her plainly that I knew nothing more than a couple of paragraphs out of my textbook regarding her condition but that I was honored to give her space to process her own pain and deepen my learning alongside her. During the same intake, I tried to defer by offering to find her names of people with special training in that area if she preferred someone with more experience. She declined, saying that she had a good feeling about me, and we worked through several fulfilling months together. This type of scenario has repeated many times in my young career, but I add the following caveat: There are certain situations or disorders that I insist on referring out because it would be detrimental to the client not to have the right kind of training for their needs in those cases. This brings me to my final point.

5) Never stop learning. Mandated continuing education credits are just the bare minimum. Competent professional therapists immerse themselves in the worlds of counseling, psychology and the human condition. This doesn’t mean reading every new self-help book that gets cranked out, but it does mean being diligent about exposing yourself to books, media, people and experiences that will not only deepen your skill set as a clinician but also deepen your own authenticity. This is especially relevant when you are dealing with couples, families and other unique populations.

Our world has been changing fast. Mental health therapists don’t need to know it all or specialize in everything. That would be an impossible feat. But we do need to constantly be updating our own knowledge and beliefs and fully developing our personhood to humbly bring best practices into the presence of our clients.

 

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Ellie Rose is a licensed mental health counselor associate, national certified counselor and private practice business owner in Vancouver, Washington. She works with individuals, couples and families through a therapeutic lens that encourages her clients to lean into reality, find meaning, and develop skills in handling the onslaught of life’s challenges. She is also a mother, reader, writer and speaker who can be contacted at ellie@ellierosetherapy.com or found on Instagram: @ellie.rose.therapy.

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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.

Trauma stabilization through polyvagal theory and DBT

By Kirby Reutter September 14, 2021

From my perspective, polyvagal theory has thus far provided us with the best working model of how trauma affects the brain and the body. According to this model, trauma has an impact on both branches of the autonomic nervous system (sympathetic and parasympathetic), which includes both branches of the parasympathetic nervous system (ventral and dorsal). 

The sympathetic branch of the nervous system is associated with physical and emotional acceleration (such as increased fear, anger, breathing and heart rate); in the case of danger, this means “fight or flight.” In contrast, the parasympathetic branch of the nervous system is associated with physical and emotional deceleration. More specifically, the ventral branch of the parasympathetic nervous system is associated with social engagement, while the dorsal branch is responsible for “rest and digest” functions and, in the case of extreme threat, “freeze.” Freeze occurs when the organism either mentally dissociates or, in even more extreme cases, faints.

When presented with danger, the various branches of the autonomic nervous system are affected in a specific order. The first branch to be affected is the ventral sub-branch of the parasympathetic nervous system, which is responsible for social engagement. In other words, when presented with threat, functions related to social connectivity — laughter, smiling, empathy, attunement, the ability to provide validation — go offline. If the danger persists, the next branch to be affected is the sympathetic nervous system, which results in fight or flight. When neither fight nor flight can mitigate the threat, the dorsal sub-branch of the parasympathetic nervous system is activated, resulting in freeze (some sort of either mental or physical collapse, such as dissociating or fainting). The following actions summarize this sequence:

  1. Danger is sensed.
  2. Social engagement goes offline (ventral parasympathetic nervous system).
  3. Danger persists.
  4. Fight or flight is triggered (sympathetic nervous system).
  5. Danger cannot be mitigated through fight or flight.
  6. Freeze response activates (dorsal parasympathetic nervous system). 

The two pedals

Think of the sympathetic nervous system as the accelerator and the parasympathetic nervous system as the brakes. As we drive down the highway, we need both of these functions. If the drive is smooth, sometimes we will gently accelerate and sometimes we will gently brake. The same process applies to our physical, mental and emotional functioning. If the “drive” is smooth, our mind and body enjoys a gentle oscillation between accelerating and braking. 

This is even reflected in our heart rhythm. A healthy rhythm is indicated by a consistent repetition of fast/slow, fast/slow, fast/slow. The reason for this gentle pendulation is so that the entire organism, at a moment’s notice, can either further accelerate or further break, as needed. A heartbeat that is either consistently fast or consistently slow or irregularly fast/slow is not a healthy rhythm because these circulation styles cannot allow for the gentle oscillation between accelerating and braking that is required for a smooth ride.

Let’s return to our driving analogy. If you are driving down the highway and a truck carelessly swerves right in front of you, you will probably have all of the reactions represented by the polyvagal theory: You may swear and flash various fingers (social engagement goes offline), you may suddenly accelerate, or you may slam on the breaks. But after the danger is averted, you will most likely return to your baseline of gently oscillating between accelerating/braking as needed — until the next threat again requires more extreme action.  

Now let’s assume you have experienced so many roadside perils that you decide never to let down your guard. You are poised at every moment to yell and scream at other drivers, unpredictably accelerate and unpredictably brake. If you are really frazzled, you may even attempt to accelerate and brake simultaneously. Over time, this becomes your new default driving style, regardless of the driving conditions: cuss everyone out, suddenly accelerate, suddenly brake. (You may have noticed that in some major cities, this sort of driving is common.) Do you see how this will lead to a wild ride? Even if the driving conditions would otherwise have been relatively smooth, they won’t be anymore. And even if no danger would otherwise have been present, now there is. You are off to the races …

A breakdown in dialectics

This driving metaphor describes what happens to people who have experienced chronic trauma: too much accelerating, too much braking, and loss of social engagement to boot. This leads to a vast variety of responses that are either “too much” or “too little,” resulting in a host of life complications. This tendency toward too much or too little especially affects the following domains:

  • Awareness
  • Thoughts 
  • Emotions 
  • Reactions 
  • Relationships 

For each of these domains, it is possible to have either too much (overuse of the accelerator, or sympathetic nervous system) or too little (overuse of the brake, or parasympathetic nervous system). Too much awareness leads to hypervigilance, whereas too little leads to dissociation. Too much thinking leads to obsessive rumination, whereas too little leads to impulsive decision-making. Too much emotional stimulation leads to overwhelm, whereas too little leads to numbness. Too much reactivity leads to even more crises, whereas too little leads to paralysis. Even relationships can be either too much or too little, resulting in either overdependence or under-dependence on others.  

In short, trauma results in all of the following possibilities: over-awareness versus under-awareness; overthinking versus under-thinking; overemoting versus under-emoting; overreacting versus underreacting; and over-relating versus under-relating. Because both the sympathetic and parasympathetic nervous systems have been hijacked, the driver is constantly over-accelerating and over-braking in each of these domains — and often doing both at the same time.

bestber/Shutterstock.com

Restoring balance 

Dialectical behavior therapy (DBT), which was developed by Marsha Linehan, is all about reconciling “dialectical dilemmas” (binary extremes resulting in dysfunction) by teaching specific behavioral skills to forge a “middle path” between those extremes. In particular, DBT teaches the following five skill sets: mindfulness, distress tolerance, emotion regulation, dialectical thinking and interpersonal effectiveness. These skill sets teach the middle path between each of the dialectical dilemmas mentioned in the previous section.

As long as clients are existing and operating at these extremes, it is extremely difficult for them to do even basic counseling — much less trauma work and much less life. That is why DBT as a treatment model is entirely skills focused. DBT teaches the foundational skills one needs to optimize counseling, stabilize for trauma work and then thrive in life — “building a life worth living,” in the words of Linehan. Among dozens of skills that could be highlighted, I would like to present five simple acronyms to help clients find — or forge — each of these middle paths.

The RAIN dance: One path to mindfulness 

Mindfulness, by definition, is always a combination of both awareness and acceptance. The RAIN dance helps clients increase both awareness and acceptance of intense emotions and other triggers in a highly practical and applied manner. RAIN stands for Recognize, Allow, Inquire and Nurture.  

The purpose of this acronym is to help clients know precisely how to apply mindfulness in a real-life situation. Let’s suppose you want to help a client become more mindful of their anger. First, teach your client to recognize their anger — and especially where they notice it in their bodies (e.g., clenched jaw). Next, teach your client to allow their anger (instead of judging or resisting it, which will make it only more difficult to manage in the long run.). Then, teach your client to inquire about their anger — with curiosity, empathy and maybe even humor. (Fear and anger are neurologically incompatible with empathy, curiosity, and humor.) Finally, teach your client to engage in some sort of nurturing (i.e., self-soothing) behavior to release the anger in an appropriate manner (such as taking a long walk through the woods). The emotional energy will need to become appropriately discharged, especially if the intense emotion has resulted from a fight-or-flight response; otherwise, this energy will simply become frozen — and then continue to resurface when triggered. 

The basic idea behind this skill is simple: Learn to “dance” with your emotions rather than avoiding, resisting, suppressing or judging them.  

TIP the balance: One path to distress tolerance 

DBT distress tolerance is all about learning to cope in the moment without making it worse. It is about replacing impulsive, addictive, risky or self-injurious behaviors (in other words, any behavior that leads to even more of a crisis orientation) with more-effective coping strategies.  

One of my favorite distress tolerance skills has to do with finding ways to TIP the balance. Because there is such a direct and obvious mind-body connection, often the quickest way to shift your mood is to quickly shift something in your body. If you can “tip” your body chemistry, you can also “tip” the balance on your emotions. There are three ways to quickly TIP your body chemistry: Temperature, Intense exercise and Paced breathing/Paired muscle relaxation (this refers to tensing your muscles as you inhale and relaxing your muscles as you exhale). 

Although each of these techniques is effective on its own, they can be even more effective when done together. For example, one way I personally TIP the balance in my own life is by riding my bicycle. This activity helps me to quickly change my body temperature, involves intense physical exercise, and helps me synchronize my respiration (inhale/exhale) with my musculation (tense/relax) through the cyclical nature of pedaling.

Sow your SEEDS: One path to emotion regulation

Whereas distress tolerance refers to short-term coping in the moment, emotion regulation refers to a long-term lifestyle change that will ultimately support much healthier emotionality. When I teach emotion regulation skills to clients, I use an extended garden analogy. For example, if you want to have a healthy garden of flowers, would it make any sense to scream and swear at the flowers? Ignore the flowers? Shame the flowers? Coerce or manipulate the flowers? Of course not. Your flowers do not need to be controlled — they need to be cultivated. 

The same concept applies to our emotions. Instead of trying to control them, we need to care for them — like beautiful, delicate flowers. (By the way, it makes me cringe every time that I hear therapists — and even DBT practitioners, no less — paraphrase emotion regulation as “controlling your emotions.”) There are several things you need to do to care for a real garden: plant the right seeds, do some weeding, check the soil, continue to care for the garden even when you feel like giving up, and fertilize. Each of these activities represents a specific way to care for our emotions as well. Here, I will simply introduce the first one: You need to plant the right SEEDS.  

Planting the right SEEDS refers to five ways of taking care of your physical body: Symptoms, Eating, Exercise, Drugs and Sleep. If you want to have a healthy garden of emotions, you will need to plant each of these seeds by addressing physical symptoms, finding healthy eating patterns, getting moderate exercise, monitoring which drugs enter your body, and getting adequate sleep. After helping my clients develop a specific plan for each of these “seeds,” I often have them provide me with a quick SEEDS report at the beginning of each session, as part of their weekly check-in. 

Working the TOM: One path to dialectical thinking  

Dialectical thinking is all about letting go of the extremes, learning to think more in the middle, learning to be more flexible with your cognitions, learning to see things from someone else’s perspective, learning to see things from multiple perspectives in your own head, and learning to update your beliefs when presented with new information.  

When I teach dialectical thinking to clients, I use a very simple process: We work the TOM, which stands for Thought, Opposite and Middle. First, we identify the original problematic thought. Next, we identify the complete opposite extreme of that cognition. Finally, we brainstorm a possible belief somewhere more in the middle.  

Let’s assume a client has the original problematic thought of “I am not good at anything.” The complete opposite extreme would be: “I have never once made a mistake. I am absolutely flawless. I am the most competent human specimen that has ever existed.” And something more in the middle might be: “There are some things I am OK at, but there are also lots of things that I need to work on.”  

The purpose of this exercise is to help clients quickly identify a cognition that is most likely much more accurate than the original belief. Clients may not always be able to come up with a middle thought on their own, so it is completely fine to help them at first. Eventually, however, it is better if clients can generate their own middle thoughts because whatever they produce will inherently be more believable than whatever you come up with. Even if the client insists they do not believe the middle thought that they generated, chances are that part of them does — because those words came from their mind. Regardless, your job is not to try to convince your client that the middle thought is more accurate; it is simply to plant the seed for that thought and then let it germinate on its own.
In fact, the more the client wrestles with the middle thought, the more they are thinking about it, therefore reinforcing the new cognition.  

DEAR Adult: One path to interpersonal effectiveness 

Whereas all the other skills mentioned so far are about self-regulation, interpersonal effectiveness inherently involves both the self and someone else. Therefore, interpersonal effectiveness inherently subsumes the other skill sets. After all, you can’t possibly deal with another person if you can’t even deal with yourself yet. 

Here, I would like to introduce perhaps the most comprehensive of the interpersonal effectiveness skills: DEAR Adult. D stands for Describe: First, describe the situation that needs to be addressed. State only the facts, and truly focus on the situation, not the person. Next, Express how you feel about the situation. Use “I feel” statements. Once again, truly express how you feel about the situation, not the person. Sometimes it can be helpful to use a “float back” and express how you have felt about similar situations previously so that both you and the other person understand that there might be more history beyond the current situation. If you want to be especially dialectical, also use this E to Empathize with the other person’s perspective.  

Now you are ready to move on to A, which stands for Assert. When asserting, use “I need” statements. In particular, explain what you need in positive terms, not negative ones; explain precisely what you need the other person to do, not what they should stop doing. If you want to be even more dialectical, also use the A to Appreciate the other person’s perspective and even Apologize for your role in this situation.  

R stands for Reinforce. You want to end on a positive, upbeat note by reinforcing both your request and the relationship itself. In my opinion, the best way to reinforce both is to explain how what you are requesting is a win-win proposition. You simply want what is best for both parties. Therefore, you are willing to further negotiate and compromise as necessary.  

Finally, you want to do all of this using the Adult Voice, which is the dialectic (the middle ground) between the Parent Voice (yell, lecture, berate) and the Child Voice (whine, pout, throw a tantrum). The Adult Voice is when you communicate in a manner that is calm, composed and collected.

Summary 

Ongoing trauma results in overstimulation of both the sympathetic and parasympathetic nervous systems (accelerator and brake), resulting in a variety of responses that are either “too much” or “too little.” The five skill sets taught in DBT help restore the balance between these extremes by providing a middle path, which includes reactivation of the social engagement system. That’s why when I am explaining DBT to my clients, I usually dispense with clinical jargon and simply refer to this model as “developing balance therapy.” In this article, I have briefly introduced five skills (among legion) as examples of these middle paths: RAIN dance as a form of mindfulness; TIP the balance as a form of distress tolerance; sow your SEEDS as a form of emotion regulation; work the TOM as a form of dialectical thinking; and DEAR Adult as a form of interpersonal effectiveness. 

To be clear, DBT was not designed to resolve the original trauma. Myriad models have been developed for trauma processing. Some models focus more on verbal processing and are generally referred to as “top-down models.” Other models focus more on somatic processing and are generally referred to as “bottom-up models.” Some clients prefer verbal forms of processing, some clients prefer somatic forms of processing, and most clients can benefit from both, so it is not necessary (in my opinion) to engage in endless debate or pointless turf wars on this point. My recommendation is simple: Be trained in at least one form of trauma processing that is mostly top-down and at least one form of trauma processing that is mostly bottom-up — and become proficient in both. (Another dialectical dilemma resolved.) 

However, no form of trauma processing can be completely effective when the individual is actively in crisis, experiencing ongoing danger or constantly dysregulated. That’s where DBT comes in. DBT (which I like to call “developing balance therapy”) provides the necessary skill set to help individuals sufficiently stabilize or self-regulate in order to then proceed with deeper trauma work.  

If you would like to learn more about how to use trauma-focused DBT with a variety of trauma-based disorders, I recommend the following resources to get started:  

  • The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming Trauma and Post-Traumatic Stress Disorder by Kirby Reutter, 2019
  • “DBT for Trauma and PTSD” (DBT Expert Interview series at psychotherapyacademy.org/dbt-interviews)
  • Survival Packet: Treatment Guide for Individual, Group, and Family Counseling by Kirby Reutter, 2019
  • “The Journey From Mars: Brain Development and Trauma” webinar (youtube.com/watch?v=WSFqHS_axOc)

 

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Kirby Reutter is a bilingual clinical psychologist and licensed mental health counselor who contracts with the Department of Homeland Security to provide mental health services for international asylum seekers. He has provided four trainings for the U.S. military, is a TED speaker and is the author of The Dialectical Behavior Therapy Skills Workbook for PTSD: Practical Exercises for Overcoming Trauma and Post-Traumatic Stress Disorder. Contact him at Kirby.reutter@gatewaywoods.org or through his website at drkirbyreutter.com.

 

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

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