Monthly Archives: September 2021

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.

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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.

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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.

Afghanistan evacuation kicks up tough emotions for veteran clients and counselors

Compiled by Bethany Bray September 10, 2021

On Aug. 30, the United States withdrew the last of its military troops from Afghanistan. News outlets documented this historic moment with a grainy, green-tinged, night-vision photo of a lone soldier boarding a C-17 cargo plane at the Hamid Karzai International Airport. The man in the photo — Army Maj. Gen. Chris Donahue, commanding general of the 82nd Airborne Division — was the last and final American service member to evacuate from Kabul, Afghanistan, ending a war that began nearly 20 years ago.

Major General Chris Donahue, commander of the U.S. Army 82nd Airborne Division, XVIII Airborne Corps, boards a C-17 cargo plane at the Hamid Karzai International Airport in Kabul, Afghanistan on Aug. 30. (U.S. Army photo by Master Sgt. Alex Burnett/Defense.gov)

This war has claimed the lives of nearly 2,500 American service members and more than 47,000 Afghan civilians, and the United States’ involvement has been debated and discussed for years — and by multiple presidential administrations.

Images and news reports from Afghanistan during the U.S. military withdrawal were chaotic, intense and, for many viewers, heartbreaking. Thousands of people flocked to the Kabul airport, hoping to be included in an evacuation flight out of the country before the Aug. 31 withdrawal deadline set by U.S. President Joe Biden. In the final weeks of August, close to 125,000 people were evacuated on 778 U.S. military and private airplane flights, an estimated 5,500 of whom were American citizens.

The sudden departure has left some to question what could have or should have been done differently — a conversation that will likely continue for years.

And for veterans and military families, it’s all deeply personal. The sudden withdrawal has stirred up difficult and intense emotions for them, and professional counselors who work with the military population are witnessing firsthand the toll it is taking on their clients’ mental health. For practitioners who are veterans themselves, this period has brought an extra layer of difficulty as they’ve needed to work through their own feelings to be able to help clients who are in the midst of similar struggles.

“It [Afghanistan] is definitely coming up in my work with veteran clients,” says Keith Myers, a licensed professional counselor (LPC) who specializes in treating veterans and their families at his private practice in Marietta, Georgia. “The most important thing I’m doing in therapy is acknowledging the events with clients, allowing them a safe space to feel whatever they need to feel and providing them with resources, if needed.”

“I had a former client send me a message a few days ago that went like this: ‘The Afghanistan stuff has been hard to watch. I have been very emotional [during] the few times I watched the news, especially with civilians clinging to that Air Force plane. My heart breaks for the Afghan people that helped the military and now are being left behind’,” says Myers, a core faculty member at Walden University. Another veteran client recently told Myers, “Alleviating suffering is never in vain, even if the final outcome isn’t permanent. A lot of mistakes were made there, but I don’t want a service member to think that their service and sacrifice there was in vain. Our work should be remembered and honored.”

 

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Counseling Today asked professional counselors who specialize in working with the military population, many of whom are veterans themselves, to offer some suggestions on how best help veteran and military-connected clients who are affected by the U.S.’s withdrawal from Afghanistan.

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The recent events in Afghanistan have affected military and veteran clients significantly. Many of them are experiencing a range of emotions: anger, sadness, frustration and hopelessness. The response can be as varied and unique as the veterans and family members experiencing them and is not just limited to those who served in Afghanistan.

Veterans who served in Iraq are experiencing something similar to what they witnessed in 2013-2014, when portions of Iraq were overrun after the military’s withdrawal from that country. Vietnam veterans, of course, are experiencing distress related to repeated comparisons to their own experiences.

For clinicians who are working with service members, veterans and their families, it might be necessary to help clients find alternative responses to the emotions they are experiencing.

For many veterans, the primary emotion that is being expressed is anger. Angry at the military and government for pulling out of Afghanistan, which can also extend to or rekindle feelings of anger and betrayal at their own leadership while deployed. Anger is the emotion that we experience when something we strongly believe in has been violated in some way. Helping the veteran understand and address the underlying core beliefs that they feel have been violated, such as “we never should have been there in the first place” and “all of the sacrifices were meaningless,” can be beneficial, rather than simply raging at current events.

Many veterans are also experiencing significant sadness, considering the lives lost and damaged during the conflict. This can be exacerbated by memorial moments and anniversary reactions, as we are emerging into the historical fall fighting season. For Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) veterans, the late winter/spring and late summer/autumn months are typically difficult as it was the height of fighting season in both conflicts, and many experienced losses of fellow service members during these months. The upcoming anniversaries of battlefield losses coupled with the current events could exacerbate feelings of sadness and grief.

These current events are ones that can cause grief at the loss of others or grief at the loss of their own capabilities to re-emerge. This “sacrifices were meaningless” self-talk can also demonstrate sadness; however, exploring whether or not the losses were in fact meaningless to the veteran themselves can be helpful in addressing this grief. It can also be beneficial to help the veteran realize how their behavior or outlook changed after the death of their fellow service member: Did they do things differently or convince their chain of command to listen to them?

I am also hearing a lot of confusion, both from clients and from those that I served with, including questions [such as] “Why were we there?” and “What was the point?” These were the same questions that we had while on patrol, sitting in the smoking areas or sitting on a mountainside. The same questions that service members asked while they were deployed. Many service members came to some measure of satisfaction as to why they were serving in combat in that particular time: whether to make life better for the population, to help a country stabilize or to simply take care of those around them.

It can be helpful to allow the veteran to explore how they rationalized their service while in country and to re-engage that rationalization now. The end does not invalidate what has gone before, so the reasons they gave themselves then can be helpful now. And one of the most powerful things that I have seen in the discussion lately is the simple fact of “we were there for each other.” In the middle of the suck, nothing matters but the people to the left and right of you — and that’s who and what we were fighting for, and no amount of current events can take that away from us.

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as an LPC in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families, and the executive director of the Colorado Veterans Health and Wellness Agency, a nonprofit that is affiliated with the Family Care Center. He writes and speaks about veteran mental health on his blog and podcast and is the author of the “From Combat to Counseling” column series at CT Online.

 

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I will sum up my reaction to recent Afghanistan events in two words: complex and jarring. While this subject is nothing new for many veterans who lived and experienced Afghanistan, the abrupt and dramatic details, images and public interests elicit a flurry of emotions and a surreal, isolated overtone.

Veterans’ minds and emotions are intense when watching petrified faces of people we actually knew, the Hindu Kush we saw on the horizon daily, the vehicles we traveled in, and the places we walked and lived. If you are speaking with a U.S. veteran about Afghanistan, here are some ideas and insights to help facilitate a meaningful interaction that may very well be the only one they have. These encompass every reaction I’ve directly heard from veterans (friends and clients) as well as my own.

  • Avoidance, anger and the need for peace: Avoidance and anger are great defense tactics that veterans lean on. It’s easier to have an angry rant or to avoid the subject altogether than to go deeper and search for meaning and healing. Counselors are often the only people to spur that journey to peace, so definitely open up the conversation and work your magic.
  • Complexity: People new to this subject don’t seem to grasp the complexity of the sociopolitical aspects of Afghanistan. There is no simple, clear, truly known explanation or answer to so many questions about what has gone on or is now going on. This makes it difficult to feel, think, articulate and resolve for veterans too.
  • Betrayal, confusion, frustration and embarrassment: Due to explicit language, I can’t share direct quotes, but to combine several, “We all wanted out of there but could it have maybe just been a little bit less of a giant ‘F you’ to everyone?” Veterans (and Afghans) are well aware that their lives are the pieces played on geopolitical chessboards, but it is even more upsetting when their individual experiences are completely ignored and/or erroneously lumped into strong opinions about governmental follies and intentions by friends, family and fellow citizens.
  • Deep compassion, concern, guilt, and helplessness: If you are watching media coverage and feeling deeply for people you’ve never met, just imagine if you knew them by name; laughed at their jokes; shared lamb kabobs their wife made for you; watched young girls boss the boys around; enjoyed broken language conversations and eye contact between burka adornments; placed money into a businesswoman’s hand; [and] listened to stories of “before the Taliban came” and fears of what will come again when the U.S. inevitably leaves.

The haunting possibilities, realities and unknowns leave many of us feeling helpless, angry, confused, misunderstood and isolated in our experiences and feelings. The unique and powerful thing counselors can offer is a strategic space to sort through the complexities and ensure the vital step of dispelling the “it was all for nothing” lie, which is often the sticking point for veterans.

Natosha Monroe is an Army veteran and LPC who specializes in treating clients with trauma and anxiety.

 

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The human spirit and soul are at stake for veterans across all wars who have been deployed in support of combat operations, engaged in warfighting and mobilized for humanitarian missions. The stench of death in field hospitals, tent cities and on the battlefield reminds us of how fragile human life can be for service members, veterans and military families. Healing during phases of a pandemic virus also complicates mental health issues. Providing military mental health requires that we restore the fragmented self, as we place the “in session” sign on our metaphoric exterior door. Thus, as a profession we should be mindful of counselor self-care and be in a mission-forward environment providing competent clinical military counseling services.

The military withdrawal from Afghanistan highlights the perfect storm that reflects a mental health tipping point in military mental health. This is reflected by Magellan’s Federal Military and Family Life Counselors (MFLAC) program which is recruiting for an immediate surge of mental health professionals to provide services on U.S. military bases. This is also seen in longer-than-normal wait times at VA clinics and with private Tricare providers.

The visual media played in real time has created a retraumatization for those who have experienced warfighting in hostile regions of the globe. Many in the military community have pre-existing political ideologies, a cultural belief system, [and] mental health and behavioral practices that help or hinder their coping and resiliency resources. Clients who enlisted after the terrorist attacks of Sept. 11th stated they wanted to “defend their homeland.” Thus, this cultivated some meaning and purpose to their chosen military career. However, many veterans I have worked with are jaded by their military service. As they transition to civilian life, their head is always on a swivel. They train to aggress not stress in the face of adversity because the life and safety of other unit members were dependent upon their quick and decisive actions and reactions. Consequently, current issues of mood regulation expressed as frustration, anger, anxiety, hypervigilance, substance use and other symptoms of an unhealthy nature have created a unique type of complex posttraumatic stress disorder (PTSD). Edward Tick, in his book Warrior’s Return: Restoring the Soul After War, eloquently describes complex PTSD as a moral injury that requires a transformative approach to healing, as opposed to “treating” the symptoms of PTSD and co-occurring mental health conditions.

Becoming a culturally competent clinical military counselor is difficult because training and development is sparse. The current literature in military psychology and counseling recognizes that the military is not one homogeneous group labeled as “the military culture.” Today’s military comprises men and women that identify with various racial and ethnic groups: Hispanic/Latinx, African American, Native American, Asian American, the LGBT community, as well as many other cultural groups. The military culture also reflects within-group differences through branch of service, enlisted versus officer rank, and the distinct military occupational specialties (e.g., infantry, special forces/operations, truck mechanic, logistics and embarkation specialists, communications officer, counterintelligence).

Overall, it is critical as professionals that we understand the unique cultural differences between military and civilian mental health assessment, diagnosis and treatment practices. Restoring the mind, body and spirit after warfighting requires a vision of optimal wellness, guided by transition services, that transforms the wounded warrior’s level of meaning and purpose relating to their military service.

Mark A. Stebnicki is a licensed clinical mental health counselor (LCMHC), professor emeritus at East Carolina University and author of the ACA-published book Clinical Military Counseling: Guidelines for Practice. He is the developer and instructor of the Clinical Military Counseling Certificate (CMCC) program through the Telehealth Certificate Institute. He is an active teacher, trainer, researcher and practitioner with extensive experience in military mental health, posttraumatic stress, chronic illness and disability.

 

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As a military spouse, mother, counselor educator and supervisor, and clinician, these recent times stress the importance of ethical self-awareness and boundaries at a whole new level.

As a military spouse, I understand the stress the coming and going of your service member can put on your relationship as well as your family dynamic. I can empathize with the military couple and family who does everything in their power to prepare to maximize quality time prior to your Marine/sailor/soldier’s departure, but despite all your efforts, you are still running around helping them pack last-minute items. In many movies, the actual stressors of these moments are not emphasized. I can understand the constant worry you have for your loved one when you are apart, whether it is a training or deployment.

Today, I think of the spouse who never wanted their Marine/soldier/sailor to leave but helped them pack. Today, I feel for the children who said, “See you later daddy/mommy,” and never will.

In recent research I have conducted with a colleague [soon to be published in the Journal of Multicultural Counseling and Development], we found that many mental health providers interested in servicing the military-connected population were or are currently military-connected themselves. With that being said, during this time, counselors working with this population are strongly encouraged to take some extra time and reflect upon the recent events. Awareness is key to ensuring best practices are offered to their clients. It is important for counselors to remember that they, too, are human. We need to check in with ourselves and be able to process the events of the world and their professional as well as personal impact on us.

For those of us who are military-connected, these recent events can be very personal as it affects us, our loved ones and our lifestyle. We need to be able to process the [withdrawal] event to ensure we do not create an environment supportive of countertransference. Remembering that counseling is a place which is intended to support our clients’ well-being first and foremost may be difficult when clients present with thoughts and beliefs that are contrary to our own. Ensuring we are at a place where we do not allow for our values and beliefs to impose upon our clients is imperative.

Furthermore, we may have clients that seek us out because we are military-connected. We, as counselors, need to remember this is a counseling relationship. Despite our personal need and desire for support and community at this time, we need to ensure we are at a point to keep our professional boundaries to ensure the well-being of our clients. If in the event, we are unable to do so, this is where we need to seek supervision and consultation. We need to ensure that our clients have continuity of care if we are unable to be fully present with them at this time.

Remember, we are human; the world impacts us too! We need to take a moment, process and find the support we need in this time in order to provide clients with the best care possible.

Nicole M. Arcuri Sanders is an LPC in New Jersey and Texas, LCMHC in North Carolina, licensed professional clinical counselor (LPCC) in California, a counselor supervisor and a core faculty member in counselor education and clinical mental health counseling at Capella University. Her area of clinical focus and research is the military-connected population; she has also presented at local, regional and national conferences to advocate for effective clinical services to meet this population’s needs. She has previously worked as a Department of Defense Education Activity district military liaison counselor, substance awareness counselor, school counselor, psychiatric assessment counselor, anti-bullying specialist and teacher.

 

U.S. Marines with the 24th Marine Expeditionary Unit process evacuees as they go through the Evacuation Control Center during the evacuation at Hamid Karzai International Airport, Kabul, Afghanistan, Aug. 28. (U.S. Marine Corps photo by Staff Sgt. Victor Mancilla/Defense.gov)

 

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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.

Yes, and … improv can be therapeutic

By Lindsey Phillips September 7, 2021

Two of the main rules of improv are that you must agree with the other person and add to the conversation. One of the most commonly used improv games “Yes, and …” illustrates these principles. 

Two people face each other. One person starts by voicing a single statement. The other person accepts this idea and builds on it by responding, “Yes, and …” For example, if someone says, “The lake is full of alligators,” the other person could respond, “Yes, and one of them is swimming toward us.” 

“In a lot of ways, improv is like a therapist,” says Andrea Baum, a licensed professional counselor (LPC) in Texas. “It’s giving that unconditional positive regard but also reflecting, tracking, and conveying empathy and understanding.” 

Baum discovered improv when she started looking for more playful counseling modalities. She decided that to enhance her role-playing, which she was using with clients, and to help herself focus more on being in the moment, she would take an improv theater class. In the process of having fun, she also observed several parallels with counseling. 

“I noticed that what I was trying to teach my clients to do, improv was organically doing,” she says. “Things like keeping them in the present moment, accepting themselves, finding their voice, expressing their authentic selves [and] connecting with other people. There were so many risks people were taking because they felt safe in [the improv] environment.”

Later, she learned about how improv could help caregivers better communicate with their loved ones, and this hit home for her. When Baum was 15, her father suffered a brain injury, which led to early onset dementia. Improv now served another purpose for Baum: “I started using these techniques that I had learned in improv with my dad, and our entire relationship just completely changed for the better. It was life-changing.”

Her experience with improv inspired her to partner with an improv educator and open Stomping Ground Comedy Theater in Dallas. She serves as the director of Improv for Life, a series of therapeutic improv classes and workshops that she designed for several populations with unique needs. 

Building connections 

In preparing to transition his counseling practice online a couple of years ago, Gordon Smith, a licensed clinical mental health counselor with a virtual private practice based in Asheville, North Carolina, began researching ways to build intimacy more effectively and efficiently in online spaces. His search led to him taking improv classes at the comedy club Second City. After participating in four online sessions, Smith was hooked. Immediately thereafter, he signed up for an improv group for counselors at the Improv Therapy Group, an organization that provides improvisation training with the goal of improving mental health. 

“I was immediately struck by how this modality allowed for practically instantaneous levels of trust, intimacy, risk-taking and laughter among total strangers,” Smith says. “I realized that I’d found what I was hunting for and was also having a really good time cutting up with a bunch of therapists.” 

Smith, who now serves on the Improv Therapy Group’s advisory board, has created improv groups tailored to working with gifted adolescents, adults and families. In a recent improv group, many of the participants reported that they felt mirrored and seen in the group in a way they didn’t often experience in their daily lives as neurodiverse individuals.   

Improv can also help disrupt toxic patterns in relationships, Smith says. He once worked with a family whose members all felt unheard and unseen by one another. The dynamic was so toxic that the family constantly argued in session, Smith recalls. While counselors can try to engage family members in therapeutic activities during therapy sessions, these activities may elicit only eye rolls or hurtful comments when the relationship is so badly damaged, Smith observes. He finds that the spontaneity of improv activities often interrupts these toxic patterns and opens the possibility of the relationship looking different. 

“All it takes is that first moment of spontaneity where something new happens and toxic patterns are disrupted, if only for a moment, which is what we’re going for in family therapy,” Smith says. Family members can explore how their relationship might look different by breaking out of an assumed role such as “mean mom,” for example. The mom can instead pretend to be “fun mom” for a few moments. Improv allows clients to play with the family narrative and “break” it in fun, nonthreatening ways, Smith explains.

Baum points out that mirroring is a great way to teach empathy and for people to connect with others. One of the first games she uses, especially when working with caregivers of people with Alzheimer’s disease, is having group members introduce themselves by saying their name and doing a silly gesture that expresses themselves in some way. The rest of the group then repeats this gesture three times before moving on to the next person.

When introducing improv games to clients, clinicians need to provide sufficient detail for how to play and show examples from across the spectrum. With the gesturing game, a counselor could exhibit both a small way to gesture, such as barely raising one’s hand, and a big way, such as jumping up and down and waving. 

“It seems like a simple icebreaker, but really we’re giving people the experience of being silly, being themselves, and then everybody accepting and supporting that by mirroring them,” Baum says. “There’s so much that benefits us when we mirror one another. We naturally mirror people when we’re connected to them. It helps us to listen and stay in the moment … and it’s a type of empathy … [to] really listen and repeat what you’re hearing.” 

Caregivers can also apply this skill in their own work, Baum says. They can mirror the ones they are caring for, matching their tone and volume of voice and what they are doing nonverbally. “That can help you connect and create mutual trust quickly,” Baum explains.  

Improv can also be a fun way to end a difficult processing session, says J. Claire Gregory, an American Counseling Association member who is an LPC and a licensed chemical dependency counselor in Texas. She presented on how improv can foster connection with clients and counseling students at ACA’s Virtual Conference Experience this past spring. 

One game she sometimes uses at the end of a process group is “Place, Hobby and Reason to Leave.” The game involves two people acting out a scene. One of the two leaves the room, while the others in the group determine a place (e.g., Texas), hobby (e.g., ballet) and reason to leave (e.g., stinging bees). The first individual returns to the room, and the second person acts out the place, hobby and reason to leave using only gestures and gibberish. The point of the exercise is to get the clients laughing and end the group on a fun note, Gregory says.   

Incorporating improv into counseling 

Comedic improv itself can be beneficial because it teaches communication, connection and acceptance in a supportive environment. So, counselors could recommend that clients who are struggling with social anxiety, confidence issues, self-esteem or relationship issues take a general improv class, Baum says. 

Therapeutic improv, however, differs in two ways: 1) It tailors the improv games to address a specific mental health need or population, and 2) it allows participants to process and apply the skills they learn in the games to their own lives. 

Alison Sheesley, an LPC and play therapist with a private practice in Denver, uses improv to create experiential activities that help group members learn skills needed to overcome some of the mental health issues confronting them. Although general improv classes are about being present, listening, being receptive, building connection and having fun, they are not as focused on helping participants connect what they do in class with their own personal lives, she explains. That’s one of the biggest differences between general improv and therapeutic improv. Sheesley’s focus is never on having clients be funny. She uses improv as a method for imparting life skills, but the humor often still happens intrinsically.

At Stomping Ground Comedy Theater, Baum has created therapeutic improv programs focused on anxiety, autism, caregivers, dementia/Alzheimer’s, kids and anxiety, health care professionals and physicians, and stress management. When working with an improv therapy group, Baum selects or adapts improv games based on the needs of the group population. 

One game she often uses for clients with social anxiety is to have them create a character — either someone they know or have made up — and imagine that character’s most distorted thought about themselves or the world. For instance, maybe the thought is “I’m stupid.” The person then acts out a scene with another person in the group who is also thinking their character’s most distorted thought. For example, the person whose character thinks they’re “stupid” may order a cup of coffee at Starbucks from the other person’s character, who is thinking, “The world is out to get me.” The first person may act nervous while ordering and stumble over their words, while the other person eyes them suspiciously.  

After acting this scene, Baum teaches the group how thoughts, emotions and behavior influence each other. They also learn to reframe thoughts using cognitive behavior theory. Baum asks the group how the characters could change their thoughts to neutral ones. They aren’t allowed to create a new thought, she explains. Instead, they must reframe the current one. The two members of the group assume these new, neutral thoughts and replay the same scene, noticing how things flow differently. 

Improv games such as this one have real-world benefits, Baum says. They give clients tools to communicate so that they won’t feel so lost or self-conscious, she explains. In the process, clients learn how to express themselves or how to position their hands or eyes when they first meet someone.

Monkey Business Images/Shutterstock.com

Baum has also used improv games to help people with dementia or Alzheimer’s learn how to better express their emotions. After playing the game, she briefly processes with them by asking, “How did that game make you feel? What did you learn from it? How could you use this in your life?” Her goal is to have clients come up with their own conclusions because then they are more likely to apply these lessons outside of session. 

Improv games are similar to techniques that many counselors already use, Smith observes. For example, clinicians may have clients externalize their feelings: “If your feeling could talk right now, what would it say?” That is a form of improv, he points out. This activity helps clients consider how their experience can go differently depending on subtle changes in how they think or act, he explains, which is in line with cognitive behavior theory.  

Reducing anxiety

Improv games work well with people who have anxiety, especially social anxiety, Sheesley says, because it allows them to lean into their social discomfort in a safe — and often humorous — way. Sheesley and her colleagues discussed how comedic improv therapy can treat social anxiety through group cohesiveness, play, exposure and humor in a 2016 article published in the Journal of Creativity in Mental Health. 

Sheesley, an ACA member who holds a doctorate in counselor education and supervision, runs a therapeutic improv comedy group in Denver that incorporates skills from acceptance and commitment therapy (ACT). At the beginning of a recent group session, she explained the concept of defusion, an ACT skill that involves creating space between a client’s sense of self and their thoughts and feelings to lessen their negative impact. This skill helps empower clients to make choices that align with their life values. Sheesley then asked group participants to identify a self-critical thought that contributed to their feelings of social anxiety so they could work on defusing it. In a circle, they repeated the self-critical thought multiple times using different silly voices, which is a well-known ACT defusion technique, Sheesley notes. 

However, she had the participants take it a step further by incorporating aspects of improv. They created characters to represent this self-critical thought and acted out how these characters spoke, walked, dressed and interacted with others. After getting comfortable in these roles, group members performed improvised scenes of inviting these self-critical characters to a party. One person pretended to be the self-critical character, while another person pretended to be the “self” that is negatively affected by this character. Sheesley instructed them not to reject the character but to treat it with acceptance, kindness and empathy. If she noticed a group member was not fully in the moment or was making a T sign (a sign Sheesley taught them to use when they needed a timeout), she would pause the improvisation to allow group members to process their feelings using a feelings chart. At the end of this exercise, group members told Sheesley they were able to view their self-critical thoughts and feelings through a different, more helpful, lens.

Improv can also help reduce anxiety among gifted individuals. This population often lives
in a state of overwhelm because of all the cognitive, sensory and emotional information they are processing, which can cause them to be more guarded and less trustful of the moment, Smith says. 

“The improv space allows for the rule for the room [to be] spontaneity and presence,” he notes. “It allows [gifted individuals] to come into the present and learn more about trusting … and feeling safe in the present. … They have time to practice going with their intuitive sense … and seeing how it works out in a no-stakes way.”

Smith once worked with a 13-year-old client who, like many gifted individuals, presented with asynchronous development (uneven intellectual, physical and emotional development). The client would overthink social situations, and by the time he figured out what to say, the moment had passed. His peers judged him negatively for his awkward and delayed responses. 

When the client first came to see Smith, these rejections had caused him such anxiety that he found it difficult to even open his mouth to speak. Their first few sessions together were only 20 minutes long because it was so painful for the client to talk. “His anxiety was so high,” Smith recalls. “I could see him so bottled up and having difficulty getting words out.” 

Smith knew the client enjoyed playing games, so he asked the client if he would play a game with him. The client agreed. Smith chose the improv game “Energy Ball” because he was also working on building the client’s emotional vocabulary. The game involves passing a ball that can transform into any feeling. Smith began the game by pretending to hold a ball of despair in his hands. Then, he threw it to the client. 

At first, the client played it safe by naming emotions such as happiness or fun, Smith recalls. He would also describe a feeling when he wasn’t sure of the emotional word, and Smith would “catch” the ball and name the appropriate feeling. But after about eight or nine passes of the energy ball, the client relaxed and started talking.

After playing this and other improv games, the client started doing hourlong sessions and grew confident enough to attend summer camp, where he made several friends. 

In improv, “everything that happens is a gift to be taken … and built upon versus some sort of threat. It’s just opportunity after opportunity after gift after gift,” Smith says. “And that can be a cognitive shift: The story I’m telling of what others are expecting of me or how they’re judging me … [changes] to ‘Well, here’s what they’re giving me.’”

Creating a safe space 

Counselors also need to cultivate a safe, supportive space when using improv. Baum and Gregory recommend establishing clear guidelines at the beginning. Gregory makes it clear that inappropriate or offensive words are not allowed, and she tailors her guidelines to the population. When she runs groups for individuals dealing with addiction, for example, she asks participants to avoid referencing drugs or drug use. 

The Stomping Ground theater has an oops/ouch policy, Baum says, that encourages group members to let others know if they are uncomfortable or offended by another’s actions or words.

“With improv, you can’t prepare for all things,” acknowledges Gregory, a doctoral candidate of counselor education and supervision at the University of Texas at San Antonio. “There’s going to be times where maybe a client gets over-triggered, but that can turn into an individual session” or learning experience, she says.

Smith had his own awkward moment in which he felt he crossed a line when acting out a scene in his personal improv group. The game involved group members destroying fear with an imaginary object. Smith picked up a “lamp” and proceeded to aggressively beat the fear out of it. At the end of the scene, he worried he had been a little too violent and may have triggered another group member, so he asked the group, “Was that too much?” 

The improv teacher responded in a supportive way, Smith recalls. She acknowledged that the performance could have been triggering, and she advised him to redo the scene in slow motion, which took the threat out of it. So, the group laughed while he slowly replayed the scene. 

Smith recommends that counselors also apply the “Yes, and …” principle to situations that create discomfort in their sessions. Acknowledge what the client was doing, he says, and show them another way to approach it to ensure that others feel safe. 

The need for proper training 

To successfully incorporate improv into their practice, Baum recommends that counselors take several improv classes and get training. She also stresses the importance of partnering with a highly skilled improv instructor. 

“The person who’s leading the group has to be able to build rapport and trust really quickly and in a playful way to get the buy-in,” she says. “If a therapist tries this once for the first time [without training], it could flop very quickly.” After doing improv for seven years, Baum says she just now feels she could lead a class by herself.

It was through an improv class that Sheesley met Stephanie Jones, an experienced improv coach and therapeutic improv consultant. Sheesley decided to partner with Jones and start an improv comedy play-based therapy group for social anxiety. Jones leads the improv activities, and Sheesley operates as a group facilitator, observing the group through a therapeutic lens. 

Before Gregory started using improv techniques with her in-patient group, she spent time training and discussing the ethical implications with her clinical director. She also sought consultation with other mental health professionals, all of whom advised her to continue learning by going to improv and psychodrama workshops. 

Smith has learned a substantial amount from Improv Therapy Group’s trainings, which allow him to play improv games with other mental health professionals and reflect on how best to use them with clients. Later in training, clinicians learn to create their own games tailored for the populations with which they work, he says. 

What counselors can learn from improv

Sheesley was working in a coffee shop in New Orleans when she first learned about improv from a friend. She started going to the local comedy theater and immediately loved it. Later, when she entered a master’s in counseling program, she noticed the parallels between the two. She recalls thinking, “Improv is exactly what we’re learning in my counseling classes about being receptive and present, listening and responding in the moment.”

She believes improv has also improved her skills as a counselor because it has given her confidence in her ability to handle whatever arises in session. “I’m much more accepting and less reactive to whatever comes up because I’ve practiced that in improv,” Sheesley says.

Smith agrees that in many ways, clinicians are already using improv skills by actively listening and being present with clients. Counseling sessions unfold naturally just like an improv scene, he says. In fact, some of the things he loves about both improv and counseling are “the immediacy, intimacy, uncertainty [and] mystery of how things are going to unfold,” he says.

Smith has also benefited from improv because he now has a deeper vocabulary to explain counseling concepts. He constantly uses “Yes, and …” with clients to build on what they are saying in session. Improv also allows him to crystallize therapeutic language in a casual way. For example, he can talk about “being in the moment” through these games and not from a Gestalt, psychoanalytic perspective. 

Baum thinks improv classes have made her more perceptive. “I’m able to read people really well nonverbally and verbally and pick up on cues. My intuition has improved on what might be going on with someone,” she explains. 

Gregory often found herself in her own head in sessions. She feared saying the wrong thing, and her focus on adhering to a specific counseling theory sometimes caused her to feel less connected with the client. Improv taught her how to step aside from that strictly clinical, structured mindset, she says.

Learning to be spontaneous and in the moment has allowed her to move past her own anxieties and fears to focus more on what her clients need. Spontaneity in improv “doesn’t mean being impulsive,” she adds. “It’s about being tuned in and being authentic to yourself and to the group.” 

Improv has also taught Gregory how to “fail.” She once tried an improv activity with a group, and it completely fell apart because no one wanted to participate. She had the group sit in silence for a few moments while she collected her thoughts about how to proceed. Finally, she asked the group what had happened, and she discovered some tension existed between two group members. 

“You’re going to fail with it,” Gregory admits. “There’s going to be times where you will try [an improv game] … and [clients] are just not really into it. And that’s OK because it leads to a different conversation, which can be therapeutic in itself.”

Learning to laugh again 

Gregory, Sheesley and Baum all agree that improv is a form of play therapy for adults. “At some point when we are becoming adults, we become self-conscious, and we stop playing. We stop expressing ourselves, and we start hiding parts of ourselves,” Baum says. “Improv is helpful because it’s a type of play that adults and children can have to express themselves.”

Sheesley finds that counseling frequently revolves around theories, mainly developed by white men, that are serious and often unapproachable. This isn’t the type of therapy that she wants to cultivate with her clients. She wants to make counseling a safe, playful space. “Laughter is just as therapeutic as crying, and yet we focus so much on crying as the ultimate cathartic expression,” she observes. She argues there is room for both. 

Smith recently led an improv workshop at a Supporting Emotional Needs of the Gifted mini-conference. He noticed one woman who looked like she wanted to participate but kept hesitating. So, he invited her to play in the next game. She reluctantly said yes, but a few minutes after playing, she was cracking herself up. 

Later, when they were processing the game with the group, she admitted that it was the first time she had laughed since her husband died two years earlier. “And it wasn’t because we were doing grief work,” Smith points out. “We were just playing and being supportive.” 

“Part of our job is helping people become aware of their own patterns, habits, scripts and narratives. … And improv is a way to disrupt those habits and patterns in a very safe way that allows for new perspectives,” Smith asserts. “So much of our work as therapists is just trying to help clients grow and broaden their perspectives on their own lives and to see opportunity and possibility. And that’s what [improv] is.”

People often think counseling must be serious all the time. They incorrectly assume that “if it’s fun, it’s suspicious somehow; if it’s fun, it’s not ‘real’ work,” Smith says. “We need to go to those other places that are sad and scary. [Yes,] those things can happen, and we can play.”

 

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@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.

Internet gaming disorder: A real mental health issue on the rise in adolescents and young adults

By Doyle L. Raymer Jr. September 1, 2021

I grew up playing video games and have followed their technological evolution through the years. As such, video games have been a big part of my life and remain so to this day. These games are a source of entertainment and relaxation, and they can even provide opportunities for social interaction and connection. They can contribute to improving a person’s cognitive skills, creativity, communication and reflexes. Many people use them as a healthy coping mechanism to decompress.

On the flip side, there is growing concern about the potential of negative mental health consequences associated with playing video games. Some of these concerns include gaming addiction, negative coping mechanisms, unhealthy lifestyles, loneliness and isolation, depression and even suicidal ideation.

As someone who still plays video games, I have met an alarming number of individuals who struggle with these concerns. In many cases, these individuals have no support system or don’t know how (or when) to seek professional help. My concern is that many counseling professionals are unaware of the devastating impact that gaming can have on a person’s life — just as any form of addiction can.

The evolution of gaming

As a gamer myself, I have always been fascinated by what draws people to play games and how games can affect and influence individuals, from their thoughts to their worldviews to their social identity. It raises a question: How does playing a game give meaning to one’s life?

Playing a game is not simply playing a game. A lot is going on in the player’s mind as they are playing, which often presents a hidden meaning behind gaming interactions. As the world continues to develop and evolve around technology, video games will also continue to develop and evolve. Video game addiction has grown at alarming rates over the past few years, and this trend will likely continue. For this reason, concern is growing in the mental health community around video game addiction and the gaming population.

Video games have been around for decades, and as time has gone by, their popularity has increased exponentially, as has the size of the gaming community. As of 2020, it was estimated that more than 2 billion people around the world played video games. In the U.S. alone, 160 million Americans engage in online gaming daily, making the gaming industry worth over $90 billion.

Video games have developed into esports and are being more widely recognized as electronic but real sports. Both share many of the same principles of competition, including professional players, recognized teams and huge audiences of fans. Stadiums fill with fans as professional esports teams face off, competing for prizes in excess of $1 million. In 2017, more than 250 million online viewers watched popular online games such as League of Legends and Overwatch, generating $756 million in revenue that year (for more, see Internet Gaming Disorder: Theory, Assessment, Treatment and Prevention by Daniel L. King and Paul H. Delfabbro).

In addition, many video gamers make a living playing games by streaming to online platforms such as Twitch to thousands of viewers. As the video game industry has developed, it has gained popularity and will continue to do so.

Mental health impact

As the popularity of video games has grown and the community of players has expanded, certain negative consequences and mental health impacts have become increasingly evident. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), internet gaming disorder was included in the section recommending conditions for further research. Gaming disorder was defined in the 11th revision of the International Classification of Diseases (ICD-11) as a “pattern of gaming behavior (digital-gaming or video-gaming) characterized by impaired control over gaming, increasing priority given to gaming over other activities to the extent that gaming takes precedence over other interests and daily activities, and continuation or escalation of gaming despite the occurrence of negative consequences.”

Internet gaming disorder was not classified as a unique mental disorder in the DSM-5 due to a lack of research in the field and debates regarding the recognition of behavioral addiction, but I believe recognition could help millions in need. At the same time, the opposing side argues that inclusion of internet gaming disorder in the DSM-5 would only generate unnecessary concern and lead to a stigma around such behavior.

Meanwhile, gambling disorder is recognized by the DSM-5 as a form of behavioral addiction, and it shares many similar characteristics with gaming disorder. So, I ask, why is this issue being ignored? Countries such as South Korea and China, where gaming addiction numbers are very high, have already recognized this as a serious disorder and developed treatment programs.

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Factors that can lead to addiction

Video gaming is a fun activity for many people, in large part because of the positive reinforcement players receive for the split-second decisions they make while playing the games. From clicking a mouse button or controller to moving a character, from slaying the enemy to leveling up, games provide constant and instant feedback to their players.

Games also contain online environments where real-time players can connect with other players or join a guild. This gives players a social identity and can provide feelings of self-worth. Many players experience a sense of meaning in-game because they are constantly presented with objectives to achieve or obstacles to conquer.

In addition, massively multiplayer online role-playing games (MMORPGs) provide players with endless opportunities, scenarios and outcomes from quests, intense guild battles, endless levels and intense competition to be the strongest player on the server. But such games motivate players to spend long hours playing a game that has no ending, potentially leading to poor sleep habits, unhealthy diets, isolation from others and the real world, and addiction.

Perhaps the most important factor leading to video game addiction is the increased dopamine levels experienced during play. This is where the concern originates because it can lead to maladaptive behaviors, unhealthy coping mechanisms and, potentially, addiction. Given the constant feeling of reward for in-game decision-making and the often-endless levels or possible outcomes in a game environment, gaming can become addictive. It can end up serving as an alternate reality and an escape from real life because the game provides the player with a “better” version of it.

According to the DSM-5, the presence of five or more of the following symptoms over the period of 12 months characterizes such behavior as concerning and maladaptive. These nine symptoms include:

1) Preoccupation with internet games

2) Withdrawal symptoms such as irritability, anxiety and sadness

3) Tolerance or the need to increase time in gaming

4) Unsuccessful attempts to stop gaming

5) Loss of interest in other activities

6) Psychosocial problems due to excessive gaming

7) Deceiving family members, therapists or others on the amount of time spent gaming

8) Use of internet gaming to escape or relieve negative moods

9) Jeopardizing or losing a significant relationship, education, job or career opportunity because of online gaming

Three stages

The process of gaming addiction occurs in three stages. In stage one, the game is played actively for fun. In stage two, games are no longer “fun,” but the individual still spends many hours playing to remove negative emotions such as stress, sadness and worry. In stage three, the game is no longer fun and no longer removes negative emotions.

During stage three, biological addiction occurs due to constant and persistently high levels of dopamine release, leading to a state of dopamine exhaustion. When dopamine exhaustion is reached, not only do games lose their potential for fun and pleasure, but so do other areas and activities. At this stage, individuals often find themselves feeling apathetic, directionless and without meaning in life. We can compare this evolution to alcoholism, in which the effects of alcohol decrease over time, requiring more alcohol to achieve the same effect.

Treatments and theoretical approaches

An effective way to reestablish normal functioning, regulate dopamine levels and improve quality of life is simply to take a break from gaming. During this period, which can take three weeks to two months, those who are addicted are encouraged to explore other activities and hobbies of interest as an alternative to gaming while dopamine levels reset.

What separates gaming from other addictions is that the addiction does not require quitting games forever. Instead, recovery focuses on learning to control time spent playing games. Strategies such as creating a schedule that incorporates healthy gaming habits into a routine while prioritizing other aspects of life have proved effective.

Much research is still needed about video game addiction to address the most efficient treatments and theoretical approaches for working with this population. When considering intervention strategies in counseling for gaming addictions, it is important to remember that no one-size-fits-all approach works. What works great for one individual may not work well for another. No single treatment has proved superior or most efficient yet. Cognitive behavior therapy has been the standard approach for many professionals, according to King and Delfabbro.

Professionals have also had positive results treating video gaming addiction with narrative therapy, especially with children and adolescents. As Alice Morgan writes in the book What Is Narrative Therapy? An Easy-to-Read Introduction, such therapy is effective because it “views problems as separate from people and assumes people have many skills, competencies, beliefs, values, commitments, and abilities that will assist them in reducing the influence of problems in their lives.” Narrative therapy might address strengths involving achievements in a game, such as being among the top players or leading the team to victory. It further explores these strengths and skills by incorporating them into real-life scenarios. It is equally important to assess the level of addiction as mild, moderate or severe by analyzing the severity of symptoms and the negative impact of gaming behavior.

It is important to establish trust and rapport during initial sessions. One effective way of developing rapport and trust with such clients, especially those who are resistant, is to mindfully disclose any experience the counselor has with video games. The counselor and client can find common ground through such shared interests and experiences. In contrast with substance abuse and alcohol addiction, the ultimate goal with gaming addiction is often not to eliminate gaming once and for all but rather to effectively control and reduce time spent playing video games. The goal is to normalize behavior that does not negatively interfere and affect other areas of life and overall physical and mental health.

As we rapidly move into technological and online environments in many aspects of our daily lives, video games will continue developing exponentially, and gaming communities’ growth will follow. Mental health issues are also rising among this growing body of diverse gamers. Using games as a coping strategy for other underlying issues can lead to an addiction, as real life is replaced with a virtual and more favorable one. Research in this area will continue to develop, and so will the emphasis placed on this issue and population by mental health professionals. More awareness of internet gaming disorder and the struggles faced by this population is needed to promote mental health and well-being.

 

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Doyle L. Raymer Jr. is a mental health counseling student at Walden University. As a gamer himself, he has a deep interest in internet gaming addiction. It is his deep desire to advocate and create awareness to help improve the overall mental health of members of the gaming community. Contact him at doyle.raymer@waldenu.edu.

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Related reading, from Counseling Today‘s October magazine: “Six steps for addressing behavioral addictions in clinical work

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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.