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Counselors Audience

Understanding adult ADHD

By Donna Mac November 20, 2017

Many people ask, “Isn’t ADHD something that kids grow out of?” When people think of attention-deficit/hyperactivity disorder (ADHD), they usually picture a child “bouncing off the walls” and then being unable to follow directions to stop that behavior.

In mainstream society, we don’t see adults bouncing off the walls, so it makes sense that people wonder if ADHD is something that is “grown out of.” In addition, ADHD usually isn’t diagnosed for the very first time during adulthood. Because the onset of ADHD typically is prior to age 4, it is usually first diagnosed in childhood. Therefore, people don’t tend to think of ADHD as an “adult condition.” Rather, they might assume that it’s isolated as a childhood condition.

It is important to remember that ADHD is actually a genetic condition. It affects the brain’s neurotransmitter system of dopamine and norepinephrine, brain waves and connections, and the actual structure of the brain, specifically the frontal lobe and prefrontal cortex, cerebral volume, caudate nucleus and gray matter/white matter. In addition, certain environmental factors can further exacerbate a person’s symptomology. Regardless, ADHD is actually a “brain condition,” which means that it can also affect adults.

Going back to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, there was a chapter that included mental health diagnoses that were all first diagnosed in “infancy, childhood or adolescence.” ADHD was one of the diagnoses included in that chapter. Therefore, some people figured those disorders were not likely found in adults. However, the chapter’s title didn’t specify that those disorders weren’t found in adults; rather, it indicated that they were typically first noticed in childhood.

When the fifth edition of the DSM (DSM-5) was written, the task force offered more clarification for those disorders, so that the entire chapter was actually eliminated and the diagnoses in that chapter displaced. Due to the revision, ADHD was moved to the new “Neurodevelopmental Disorders” chapter, to more accurately reflect that the disorder is related to the biology of the brain.

In writing the DSM-5’s revisions for ADHD, there was also a symptom threshold change for the adult qualifiers. The purpose of the change was to reflect the substantial evidence of clinically significant ADHD impairment in adults within social, occupational and educational settings, in addition to difficulties with maintaining daily living responsibilities. To qualify for an ADHD diagnosis according to the DSM-5, an adult needs to meet only five symptoms, instead of the six required for children, in either of the two presentations (hyperactive/impulsive and inattentive/disorganized).

 

Growing out of ADHD?

At this point, it has been well-established that adults can have ADHD, so the question now becomes: Is it possible for a child with ADHD to experience symptom reduction (or elimination) as he or she transitions to adulthood? The answer is tertiary: yes, no and sometimes!

As children with ADHD grow into adolescence, research does show that up to two-thirds will experience a noticeable reduction in motoric restlessness or hyperactivity. Because of the manner in which the brain develops during this period, there can be an opportunity for rewiring in which the neurons proliferate and then are pruned back to complete the development of the frontal lobes.

With this particular symptomology of hyperactivity and motoric restlessness being reduced or eliminated, however, it is still possible that the person’s other ADHD symptoms may remain. The remaining symptoms are likely the ADHD core symptoms of impulsivity, impaired attention and lack of intrinsic motivation. Research shows that these symptoms will likely continue to some degree — possibly still to a clinically significant degree — but they might also be less impairing than they were for the person during childhood.

So, to answer the question of whether adults can experience ADHD symptom reduction or elimination, here is a recap:

  • Some symptoms in adults will dissipate completely.
  • Some symptoms will lessen.
  • Some symptoms will remain the same.
  • Some symptoms will change by being expressed differently than they were in childhood.
  • Sometimes, the symptoms will remain, but they will appear less impairing because the adult has developed strategies to manage the symptoms.

As we examine how adult ADHD symptoms can be expressed, think about ADHD as a brain disorder stemming from an inability to self-regulate and executive functioning deficits. These functions allow us to plan, change flexibly from one course of action to another, inhibit actions (impulse control) and modulate affect. Executive functioning also includes organizational skills, emotional control, working memory and short-term memory, time estimation and time management, focus and attention, problem-solving, verbal reasoning, intrinsic motivation, task initiation and shifting gears. If a deficit is present in any of these areas, think about how much more difficult an already stressful job would be, in addition to how one might struggle with maintaining relationships, raising a family, completing daily living responsibilities and remaining connected in the community.

 

Childhood vs. adulthood scenarios

With all of the possible ADHD deficits stemming from its different presentations and with different degrees of impairment, these symptoms can be expressed in adults in a variety of ways. The scenarios below showcase how ADHD symptoms might remain similar in adulthood as in childhood, or how the symptoms’ expressions can also change over time.

  • Think about a child with ADHD constantly getting out of her seat at school. That can be the same adult tapping her pen or shaking her leg at her desk at work.
  • Think about a child with ADHD constantly talking to her “neighbor” in school while the teacher is talking. That might be the same adult unintentionally getting her co-workers off-task during a meeting.
  • Think about a child with ADHD impulsively pulling a toy out of another kid’s hand, struggling to take turns and share. That sounds like the same adult struggling to “take turns” while he is talking and expressing ideas with his co-workers.
  • Think about a child with ADHD refusing to shut off her video game. That might be the same adult finding it difficult to get off of her social media accounts.
  • Think about a child with ADHD unwilling to compromise with friends, always wanting his own way instead. That sounds like the same adult insisting his wife watch “his show” or listen to “his radio station.”
  • Think about a child with ADHD carelessly rushing through her trumpet scales (a dreaded, nonpreferred task) in an attempt to get to the preferred part of her trumpet practice sooner, which is playing the actual song. That could be the same adult at work, carelessly rushing through writing a report, to more quickly get to the things she actually enjoys doing at her job.
  • Think about a child with ADHD always trying to get away with doing less at school (maybe by not “showing” his required math work). That might be the same adult also trying to get away with doing less at his job.
  • Think about a child with ADHD being dragged out of bed and taking “forever” to get dressed, eat breakfast and groom herself. That may be the same adult constantly being late for work or other appointments.
  • Think about the bedroom of a child with ADHD looking like a tornado hit it. That could be the same adult whose wife is nagging him because his dirty laundry is all over the bedroom floor, or whose boss is upset with him because he presents poorly at work with a disorganized, messy desk.
  • Think about a child with ADHD incessantly begging her parents for something to obtain immediate gratification for herself: “Take me to the pool. Take me to the pool! Puh-Lease!” That sounds like the same adult refusing to take “no” for an answer in other social relationships.
  • Think about a child with ADHD disregarding minor details with his schoolwork. That could be the same adult overlooking “minor details” in other areas of life, such as neglecting to wear his identification badge at work, forgetting to check the “change oil on this date” sticker in his car or, worse, forgetting to check the gas tank.
  • Think about a child with ADHD struggling to get started with her chores at home. That can be the same adult struggling to initiate, sustain or complete daily living responsibilities at home. For example, she may buy groceries, get them home and put the items away in the kitchen. However, the items needing to be placed elsewhere in the house (shampoo, body wash, etc.) remain in the grocery bags on the kitchen counter. After her husband nags her for a day to put the rest of the items away, she eventually moves the grocery bags upstairs to the bathroom and places the bags on the bathroom counter. After her husband nags her another day, she eventually takes the items out of the bag and puts them under the bathroom cabinet.
  • Think about a child with ADHD climbing the drapes in a banquet hall at a wedding. That could be the same adult craving a dopamine rush as she is darting in and out of traffic at high rates of speed. Remember, when it comes to dopamine, people with ADHD either don’t produce enough, retain enough or transport it efficiently. Dopamine is a “feel good” neurotransmitter (in addition to being the main “focus” neurotransmitter), so when individuals are recklessly impulsive, they are likely feeling understimulated and attempting to stimulate their dopamine level to “feel good.”

However, people with ADHD can be notoriously impatient. In the driving scenario above, it may not be about stimulation; it might be about her impatience. In a third scenario, this person could also be darting in and out of traffic because she is late for something because people with ADHD can also be notoriously late.

  • Think about a child with ADHD hyperfocusing on something — likely a preferred activity that seems irrelevant to others. Many times, this is because of norepinephrine. We require this neurotransmitter to help us pay attention to things that are either boring or challenging. When this neurotransmitter is not produced enough, retained enough or transported efficiently, as in people with ADHD, it can be a struggle to pay attention in boring and challenging situations. However, when people with ADHD really enjoy something, norepinephrine can actually be stimulated, and then they can hyperfocus.

Now think of the adult hyperfocusing at home on something that appears irrelevant. This person also then has a propensity toward becoming overwhelmed with all of the other dreaded, nonpreferred tasks on her “list of things to do.” She may use the hyperfocus ability with something that she enjoys as a misguided coping strategy to avoid the nonpreferred tasks. This further perpetuates her feelings of being overwhelmed with everything that she’s supposed to be doing and not getting accomplished.

  • Think about a child with ADHD struggling to pay attention to his teacher. That sounds like the same adult struggling to remain focused as he and his wife have a conversation at the dinner table. Then, the next morning, when he doesn’t get out of bed when he’s supposed to, she wonders why he didn’t get up early to take the dog to the vet. It’s possible that he wasn’t focusing on their conversation the previous night, so he didn’t actually know he was responsible for this. Or, he did know, but he struggled with time management. Or, he struggled with intrinsic motivation to get out of bed to get things accomplished for the day. Or, he was paying attention to the conversation, remembered it and was actually motivated to take the dog to the vet, but he forgot to set his alarm clock.

With this type of situation, it can be unclear why he didn’t get up that morning because it could have been from any number of ADHD symptoms — or a combination of some of them.

 

Other experiences

According to the Centers for Disease Control and Prevention, people with ADHD also experience other situations that I didn’t necessarily address specifically in the scenarios above. People with ADHD can experience:

  • More unplanned pregnancies and sexually transmitted diseases
  • Higher arrest rates and propensity for repeating offenses
  • More aggressive behavior (This does not mean that all adults with ADHD are aggressive. In fact, most are not. But the rates of aggression among those with ADHD are higher when compared with those in the general population.)
  • More speeding tickets
  • More shoplifting convictions
  • More money management issues, impulsive spending habits and credit card debt
  • More substance abuse (higher in unmedicated ADHD patients than in the general population)
  • More risk-taking behaviors
  • Higher rates of smoking (in unmedicated ADHD patients)
  • Higher rates of depression (especially among males) and anxiety
  • Comorbid diagnoses (more than half of those with ADHD have a dual diagnosis)
  • Low self-esteem due to perceived failures at school or work and due to struggles in relationships

In looking at all of the different issues and scenarios related to ADHD and presented in this article, it is important to note that all adults will be late to an appointment once in awhile, lose something important, become overwhelmed with their “list of things to do,” interrupt during a conversation or even get a speeding ticket. These situations are all within normal limits as human beings. It becomes clinically significant only when a variety of these instances occur chronically and intensely and also interfere with the person’s functioning.

Adults with noticeable ADHD symptoms can sometimes manage these symptoms. This can be done in a number of ways:

  • An ADHD medication regimen
  • Psychotherapy to learn strategies to self-regulate
  • Neurofeedback to help strengthen connections in the brain
  • Holistic practices of consuming nutrients that promote proper brain functioning, including zinc, vitamin C, omega 3 fatty acids and protein
  • Exercise to increase blood flow in the brain, specifically in the neocortex where it’s needed to increase focus and decrease impulsivity

A combination of treatment modalities may be most effective so that adults with ADHD can continue to function well in their respective environments.

Because of the multifaceted origin of this disorder and the external variables each person experiences, ADHD symptoms can come across differently, so each person with ADHD (child or adult) will not present the same, even among the same presentation. Some individuals will have overtly noticeable symptoms. In the case of other individuals, outsiders may not even notice their symptomology, especially if they have learned to cope with their ADHD and self-regulate.

 

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Donna Mac is a licensed clinical professional counselor treating adolescents in psychotherapy who are transitioning to adulthood. She is also the author of the book Toddlers & ADHD, which can actually be applied across the life span. Find out more via her website, toddlersandadhd.com or email donnamac0211@gmail.com.

 

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

Bringing Syrian hospitality into your counseling practice

By Shadin Atiyeh November 8, 2017

In a small village resting in a valley watched over by a medieval castle, the women made their morning rounds. At each house, they were met by the same ritual. A warm greeting with a kiss on each cheek, an invitation to sit and at least three rounds of offerings: sweets, coffee and fruit. This is an obligation, to express hospitality to guests, but the host treats it as an honor and a joy.

Between each offering, conversation flows about family members, friends and occurrences in the village. The host asks intentionally about each person in the guest’s life. Silences are reserved to hold sadness, grief or political sentiments better left unsaid. These silences are broken with “May God help,” or “baseeta,” translating literally to “simple,” but used to acknowledge the futility of talking about a topic and moving on to the next one.

The Arabic language is vast but vague. One word can carry many meanings, but translated without context, it can lose all meaning. Another example is “Yalla,” which the women will use to indicate that they are ready to leave and move on to the next visit. It can mean “let’s go,” and “hurry up” or “come on.” The goodbyes are drawn out, with invitations to stay longer, kisses and hugs. The guests invite the host to visit them next time.

These morning visits serve multiple purposes. There is no one in the village who will not have a visit from a neighbor, a friend or a family member each day. There is no household task that won’t have a helping hand. There is no meal that anyone in the village will eat alone. There is no newcomer who is not welcomed with multiple visits from each neighbor offering food and conversation. There is also no misstep, family argument or fashion mistake that does not get aired out with the dirty laundry in rooftop conversations. In English, there are many words for aloneness, and each word can have either positive or negative connotations (e.g., solitude and loneliness). In Arabic, “wahida” has a mostly negative connotation: sadness, loneliness, pity.

The values of hospitality, community and honor are central to Syrian and many Middle Eastern cultures. Growing up as an American of Syrian Arab descent, my father told us one story to teach us true hospitality. This story did not involve a fellow Arab but rather a Jewish man who helped my father when he arrived in the United States from Syria at the age of 18. This Jewish business owner gave my father his first job in the United States and supported him in his first years.

When I visited Syria for the first time with my father, I experienced the hospitality and community that he knew. These values can be hard to find in the United States — a primarily individualistic culture where privacy is paramount and the belief that we must make it on our own is prominent. I can imagine the culture shock when my father came to the United States and possibly went a few days without a knock on the door from a neighbor. I felt a similar shock in Syria. I remember craving some privacy or solitude in which to think and read, some freedom from feeling scrutinized.

 

Bridging cultural boundaries

As a licensed professional counselor and approved clinical supervisor working with refugee populations, I try to hold on to an empathy for how culture shock feels and to encourage that empathy among my supervisees. I have an appreciation for my father’s story because I currently work at a Jewish agency expressing Jewish values by resettling Middle Eastern refugees. I have a firsthand experience of the power of this work to bridge cultural boundaries.

As the Syrian refugee crisis continues, refugees are forced to flee their communities and are placed in third countries for resettlement when there is no opportunity to return home. In the United States, a network of nonprofit agencies is responsible for meeting families at the airport, securing housing and providing basic services and cultural orientation. I have learned that we can accomplish these steps either by checking off the boxes or by approaching these refugee families with the same spirit of hospitality and welcoming that they most likely would afford to us. Doing so demonstrates respect and honor and eases the culture shock of being in a new country.

How could you incorporate hospitality into your counseling practice to make it more welcoming for those of Middle Eastern descent? You can follow some rituals that might help to evoke a sense of respect and suggest that your practice is a place to sit and talk.

Many therapists in the United States put effort and thought into how the room is set up. This traditionally involves a private and quiet setting, dim lighting, plants and the therapist’s chair facing a couch. You might have a table with drinks available, but it is important to insist that these clients partake because they would not think it appropriate to take a drink on their own or accept a drink on the first offer. Going through the ritual of making and pouring coffee for your client further demonstrates care and respect. Having a candy dish or sweets tray can also be useful, but it is important to hold the dish and offer it to these clients.

Giving gifts acknowledges the value of relationships to these clients, so you might consider giving small gifts at the first and last sessions. These gifts might be cards, representational items, journals, bookmarks or books. These gifts can serve a therapeutic purpose.

Artwork on the walls can include Arabic writing, such as the words “Ahlwan wa Sahlan,” meaning “Welcome and Health.” Some therapists have their name in Arabic next to the English writing on their doors. If your client speaks English as a second language, make an effort to learn some words that can communicate empathy for the difficulty of learning a new language and having an accent. One of my favorite moments with a client was when my position as the all-knowing authority was shattered by my broken attempts to speak French.

Be careful not to assume what language your clients speak. Instead, ask. Iran, Afghanistan and Somalia, for example, are not Arab countries and speak languages other than Arabic. There are also different ethnic groups such as the Kurds, Armenians, Jews and Chaldeans within Arab countries who may not speak Arabic as their first language.

Don’t expect your client to teach you about their culture. Obtain supervision and consultation and read from credible sources. Hisham Matar’s In the Country of Men is a novel that offers raw insight into the experience of a child growing up in Libya and being forced to leave. Bint Arab: Arab and Arab American Women in the United States, by Evelyn Shakir, portrays the diversity of Arab American cultures and the dissonance women of Arab descent experience living in the United States.

Poetry is another window into cultures and is a highly revered art in Arab traditions. Some famous Arab and Arab American poets include Nizar Qabbani, Adonis, Khalil Gibran and Maram al-Massri. These poems might also be therapeutic tools.

The Arabic language is also ornate, formal and elaborate. It is not enough to say, “Welcome”; you should say “Two welcomes.” When someone says, “Good morning,” the response should be more extravagant, such as “Morning of light.”

There are many sayings and poems that could hold the extreme sadness, loss and loneliness attached to leaving one’s country, home and community. Qabbani wrote: “My son lays down his pens, his crayon box in front of me and asks me to draw a homeland for him. The brush trembles in my hands and I sink, weeping.” My clients might spend a lot of time talking about how loss of homeland has affected their children, parents and other family members. I honor my clients’ positions in their families and allow them to discuss these other people in session because these family members might be extensions of self.

Your clients are the experts on their experiences of their culture and their perspectives on it. Many clients from racial or ethnic minorities might be walking into your office with the same questions: Will the therapist understand my culture? Will the therapist respect my culture?

As the counselor, you have the power to initiate a conversation about these unspoken questions, make these concerns explicit and address them. Respect and acknowledge differences while also connecting on commonalities such as the feelings of loss, guilt and shame.

Counselors working with this population must also acknowledge the political and social climate in which these refugees are entering the United States. Experiences and fears of discrimination and prejudice have contributed to increased anxiety, depression and traumatic stress among Arab Americans in the United States. Adding clients’ past traumatic experiences to these experiences can lead many to isolate themselves further.

Therapists in the United States inundated with negative images of the Middle East might be at risk of holding unexamined negative stereotypes and beliefs about Middle Eastern people and their cultures. The therapeutic space can become a place of risk for further harming vulnerable clients, or it can provide an opportunity to give clients a chance to experience understanding and support.

In bringing a spirit of Syrian hospitality into my work as a counselor, I am able to communicate a warmth and welcoming to my clients. As my clients walk a tightrope over an ocean — behind them loss and in front of them both danger and opportunity — I hope the therapeutic space offers rest and reflection. A good host is usually invited as a guest. I attempt to be invited as a guest into my clients’ lives so that I can work with them to build bridges over those oceans.

 

“Light is more important than the lantern. The poem more important than the notebook.” — Nizar Qabbani

 

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Shadin Atiyeh is a master’s-level licensed professional counselor in Michigan, national certified counselor and approved clinical supervisor. She is currently a doctoral student in counselor education and supervision and a department manager within a refugee resettlement and social services agency. She has five years of experience providing clinical services, case management and employment services with vulnerable populations, including refugees and other immigrants, survivors of domestic violence and sexual assault, and families experiencing homelessness. She also serves as a clinical supervision for counseling interns and prelicensure counselors. Contact her at shadin.atiyeh@waldenu.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.

A protocol for ‘should’ thoughts

By Brandon S. Ballantyne October 31, 2017

As a licensed professional counselor, I believe that cognitive behavior therapy (CBT) offers clients a natural platform to gain insight into the relationship between thoughts and emotions. Using cognitive behavioral techniques, I invite clients to explore the specific nature and content of their thoughts and examine the ways in which these thoughts influence emotional distress.

Through CBT-oriented trial and error, thought records and behavioral experiments, clients can develop a comprehensive tool belt for responding to stressful events in a self-structured and practical manner. The active identification and disputation of negative thinking leads to improved emotional states and healthier behavioral reactions. I often introduce this concept as an enhanced version of the common treatment goal of learning how to “think prior to reacting.”

 

Framework

Before an individual forms an emotion, that individual needs to observe an event. This event can be a person, place, thing or activity. The important criteria here is not what the individual observes but simply the fact that an event has been noticed.

Once an event is observed by the individual, the brain produces a thought. A thought is very different from an emotion. A thought is a statement that is verbalized or experienced silently. A thought has sentence structure. Every thought has punctuation. Some thoughts end in a period. Some thoughts end in a question mark. Some thoughts end in an exclamation mark. It is important for the counselor to offer this education to the client. To experience success with CBT coping tools, it is essential for the client to be able to differentiate between thoughts and emotions.

Once a thought is produced and experienced by the individual, an emotion is formed. I tell my clients that in some cases, it feels as if the emotion occurs before the thought, but CBT tells us this is not exactly true.

Individuals experience emotions as an internal continuum of distress. This means that emotions can fluctuate from low distress to moderate distress to high distress. Most of the time, individuals will experience emotions consistent with mad, sad, glad or fearful. The continuum of emotional distress is often experienced parallel to physical symptoms. In other words, certain emotional states will produce certain physical symptoms. Counselors can assist clients in recognizing which physical symptoms are most typically associated with each emotional state.

For example, the emotional state of mad often occurs parallel to a headache or clenched fists. The emotional state of sad often occurs with tearfulness and internal weight between the stomach and lungs. The emotional state of glad most often occurs with smiling or laughter. The emotional state of fear most often occurs with a rush of adrenaline, quickening heart rate and sweaty palms. Of course, individuals can experience many other emotional labels and physical symptoms, but acquiring this basic education about emotion-body response can enhance our clients’ abilities to more clearly identify what they are feeling at any given time. This also provides clients with another important layer in understanding the difference between thoughts and emotions.

Once an emotional state is experienced, a behavioral reaction will be provoked. A behavioral reaction is simply something that the individual says or does that leads to a desirable or undesirable environmental/social outcome. Behavioral reactions that lead to undesirable outcomes typically create more barriers and perpetuate the cycle of life problems. Positive behavioral reactions lead to desirable outcomes and ignite a cycle of positive change.

The key to all of this is for individuals to identify where they can initiate intervention in their cognitive behavioral processes. Intervention can occur immediately after thoughts or immediately after the formation of the emotion. As long as intervention is implemented prior to the behavioral reaction, then positive change can take place.

Counselors can assist clients in building cognitive behavioral skills through the examination of self-talk. Self-talk is another term used for thought. Because thoughts have sentence structure to them, the sentence content in our thoughts is directly responsible for the formation of emotion.

Certain “words” increase emotional distress when they are experienced within our self-talk. One of the biggest culprits is the word “should.” When individuals experience “should” in their thoughts, it produces an emotional state associated with a demand to achieve extreme standards or ideals. The emotional consequence is likely to be guilt, frustration or depression. When directing their “should” thoughts toward others, individuals are likely to feel anger and resentment.

 

Protocol/intervention

I have developed the following intervention as a tool that counselors can use with clients consumed with persistent “should” thoughts and who identify unpleasant emotional responses that have led to patterns of undesirable behavioral reactions and environmental/social consequences. The intervention’s goal is to offer a protocol for effective identification, practice, application and implementation of cognitive restructuring, specifically in the context of problematic “should” thoughts.

 

S-H-O-U-L-D

Say: It is important to encourage the client to verbalize the “should” thought out loud. This brings life to the negative thought process and makes the negative self-talk a concrete, tangible item to work on in the counseling process. It also creates a safe opportunity for the counselor and client to work at restructuring negative internal dialogue within the realm of trust and rapport that they have developed.

Counselor: “Help me understand these should thoughts. I would like to invite you to verbalize them out loud to me.”

Client: “I should not feel depressed. I have no reason to be depressed.”

 

Hold: It is important for the client to learn to tolerate the distress created from the negative self-talk. The counselor encourages the client to practice tolerating the emotional discomfort through a pause and delay. This creates an opportunity to enhance distress tolerance ability, while engaging in safe examination of the negative self-talk.

Counselor: “There is pressure to react to these emotions. Try not to react. Let’s slow things down so we can address this rationally. I would like you to try and sit with these emotions, in the presence of my support, for as long as you can tolerate. Let’s try to pause and delay a reaction for one to two minutes.”

Client: “I will try my best.”

 

Offer: The counselor and client engage in a discussion of possible alternative ways of thinking that could potentially lead to more desirable emotional states and healthier behavioral reactions. This is a brief trial-and-error component within the intervention. The counselor will engage with the client in a balanced, rotational practice of coping thoughts.

Counselor: “If we were to remove the word should from your negative self-talk, what can we replace it with that might reduce the emotional pressure that you feel? Let’s discuss all the possibilities together.”

Undo: It is important to identify one coping thought that the client can continue to practice within his or her routine internal dialogue. For example, the counselor might ask the client to write one coping thought on an index card that can be kept in a safe, visual space. This encourages proactive, routine practice of healthier self-talk. It also makes the coping thought a concrete, tangible tool that can be used both in the present and in the future, as needed, in the context of counseling goals.

Counselor: “Which one of the coping thoughts that we discussed today do you feel you could continue to utilize as positive self-talk during future episodes of distress?”

Client: “I have experienced depression for a reason. I have permission to feel how I feel. I am always working on finding ways to cope with my life stressors, and I am doing the best that I can.”

 

Learn: The counselor and the client identify a homework assignment or task for the client to complete that encourages ongoing utilization of this tool. For example, the counselor might invite the client to begin a thought log, in which the client actively records dates and times when the tool is utilized and how effective it was in reducing emotional distress or contributing to healthier behavioral reactions. This provides opportunities for the client to begin constructing a cognitive behavioral blueprint for effective thought substitution.

Counselor: “I would like to introduce you to an exercise called a thought log. This will provide you with a platform to practice replacing ‘should’ thoughts with more positive self-talk this coming week. Remember, the most effective change takes place when you can take the skills learned in counseling and apply them to situations outside of these office walls.”

 

Do: Follow-up is essential to the counseling process. If the counselor and client agree on homework assignments or behavioral experiments, it is important for the counselor to follow up with the client to examine the client’s beliefs about what is effective versus ineffective. This holds both the counselor and the client accountable for maintaining diligence and dedication in their roles within the counseling relationship.

Counselor: “In the prior session, we discussed problematic ‘should’ thoughts, and I offered you the assignment of a thought log. How did you do with that?”

 

Conclusion

As a professional counselor, I am always looking for ways to enhance my practice and also share my interpretation of theories and treatment approaches. I hope that this piece will help you reflect on ways in which you may be able to use a tool such as the one I described with the clients you serve. Through continued consultation, collaboration and publication, mental health professionals can become unified in our mission to initiate genuine counseling processes that contribute to the enhanced well-being of our clients. I would love to hear your feedback on how this CBT tool is working for you and the individuals you serve.

 

 

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Brandon S. Ballantyne is a licensed professional counselor and national certified counselor who has been practicing clinically since 2007. He currently practices at Reading Health System in Reading, Pennsylvania, and Advanced Counseling and Research Services in Lancaster. He has a specialized interest in using cognitive theory to help his clients recognize problematic thought patterns and achieve more desirable emotions and healthier behavioral responses. Contact him at Brandon.Ballantyne@readinghealth.org.

 

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Other articles by Brandon S. Ballantyne, from the Counseling Today archives:

 

 

 

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

 

 

A light in the darkness

By Bethany Bray October 30, 2017

Erin Wiley, a licensed professional clinical counselor in northwestern Ohio, once had a client tell her that seasonal depression was like diving into a deep, dark pond each fall. Wiley understands the comparison. With seasonal depression, “you have to prepare to hold your breath for a long time until you get across the pond, reach the other side and can breathe again,” she says.

Wiley routinely sees the effects of seasonal depression in her clients — and in herself — as summer wanes, with the days getting shorter and the weather getting colder. Ohio can be a hard place to live when daylight saving time takes effect and the sun starts setting just after 4 p.m., she says.

Seasonal depression “feels like a darkness that’s chasing you. You know it’s coming, but you don’t know when it’s going to pin you down,” says Wiley, a member of the American Counseling Association. “[It’s like] getting pinned down by a wet blanket that you just can’t shake, emotionally and physically. … For those who get it every year, you can have anxiety because you know it’s coming. There is a fear, an apprehension that it’s coming. [You need] coping skills to have the belief that you have the power to control it.”

For Wiley, the owner of a group practice with several practitioners in Maumee, Ohio, this means being vigilant about getting enough sleep and being intentional about planning get-togethers with friends throughout the winter months. Keeping her body in motion also helps, she says, so she does pushups and lunges or walks a flight of stairs in between clients and leaves the building for lunch. If a client happens to cancel, “I will sit at a sunny window for an hour, feel the sun on my face, meditate and be mindful,” she adds.

Seasonal depression, or its official diagnosis, seasonal affective disorder (SAD), can affect people for a large portion of the calendar year, Wiley notes. Although there is growing awareness that some people routinely struggle through the coldest, darkest months of the year, it’s less well-known that it can take time for these individuals to start feeling better, even once warmer weather returns in the spring. According to Wiley, seasonal depression can linger through June for her hardest-hit clients.

“It takes that long to bounce back,” she says. “They’re either sinking into the darkness or coming out of it for half the year.”

Symptoms and identifiers

SAD is classified as a type of depression, major depressive disorder with seasonal pattern, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. According to the American Psychiatric Association, roughly 5 percent of adults in the U.S. experience SAD, and it is more common in women than in men. The disorder is linked to chemical imbalances in the brain caused by the shorter hours of daylight through the winter, which disrupt a person’s circadian rhythm.

People can also experience SAD in the reverse and struggle through the summer, although this condition is much rarer. Wiley says she has had clients who find summers tough — especially individuals who spend long hours inside climate-controlled, air-conditioned office environments with artificial lighting.

Regardless, a diagnostic label of SAD isn’t necessary for clients to be affected by seasonal depression, say Wiley and Marcy Adams Sznewajs, a licensed professional counselor (LPC) in Michigan. Sznewajs says that SAD isn’t a primary diagnosis that she sees often in her clients, but seasonal depression is quite common where she lives, which is less than 100 miles from the 45th parallel.

“I live in a climate where it is prevalent. I encounter it quite a bit and, surprisingly, people are like ‘Really? This makes a difference [with mental health]?’” says Sznewajs, an ACA member who owns a private practice in Beverly Hills, Michigan, and specializes in working with teenagers and emerging adults. “We change the clocks in November, and it’s drastic. It gets dark here at 4:30 in the evening, so kids and adults literally go to school and go to work in the dark and come home in the dark.”

Likewise, Wiley says that she frequently sees seasonal depression in clients who don’t have a diagnosis of SAD. “I notice it with my depressive clients,” she says. “I have been seeing them once a month [at other times of the year], and they ask to come in more often during February, March and April, or they need to do more intensive work in those months. It’s rare for someone to be healthy the rest of the year and struggle only in the winter. It’s [prevalent in] people who struggle already, and winter is the final straw. They need extra help in the winter and reach out [to a mental health professional] in the winter.”

In other instances, new clients begin to seek therapy because life events such as the loss of a job or the death of a loved one push them to a breaking point during a time of the year — typically winter — when they already feel at their lowest, Wiley notes.

Cindy Gullo, a licensed clinical professional counselor in O’Fallon, Illinois, says that she doesn’t encounter clients who have the SAD diagnosis very often. However, she says that roughly 2 out of every 10 of her clients who have preexisting depression experience worsening mood and exacerbated depression throughout the fall and winter months.

The symptoms of SAD mimic those of depression, including loss of interest in activities previously enjoyed, oversleeping and difficulty getting out of bed, physical aches and pains, and feeling tired all of the time. What sets seasonal depression apart is the cyclical pattern of symptoms in clients, which can sometimes be difficult to see, Sznewajs says. If a client presents with worsening depressive symptoms in the fall, counselors shouldn’t automatically assume that seasonal depression is the culprit, she cautions. Instead, she suggests supporting the client through the winter, spring and summer and then monitoring to see if the person’s symptoms worsen again in the fall.

“If they show improvement [in the spring/summer], and then I see them in October and they start to slide again, that’s when I have to say it could be the season. And certainly if they point it out themselves — [if] they say, ‘I’m OK in the summer, but I really struggle in the winter.’ It’s really when you start to notice a pattern of worsening mood changes in November and December [that alleviate] in the summer.”

Sznewajs recalls a female client she first worked with when the client was 13. She saw the client from October through the end of the school year, and the young woman showed significant improvement. The client checked in with Sznewajs a few times during the summer, but Sznewajs didn’t hear from her much after that. Then, when the client was 16, she suddenly returned to Sznewajs for counseling — in the wintertime. In recounting the prior few years, the young woman noted that her struggles usually seemed to dissipate around April each year, even though the pressures of the school year were still present at that point.

“‘I don’t know what’s going on with me,’” Sznewajs remembers the client remarking. “‘I’m a mess right now.’ It was very evident that there was a pattern [of seasonal depression] with her.”

Wiley notes that clients with seasonal depression often describe a “heaviness” or feelings of being weighed down. Or they’ll make statements such as, “It’s just so dark,” referring both to the lack of sunlight during the season and the emotional darkness they are enduring, Wiley says.

Gullo, an ACA member and private practitioner who specializes in working with teenagers, keeps an eye out for clients who become “very flat” and engage less in therapy sessions in the fall and winter. Other typical warning signs of seasonal depression include slipping grades (especially among clients who normally complete assignments and are high achievers at school), changes in appetite, sluggishness, weepy or irritable mood, and withdrawal from friends and family. For teens, the irritability that comes with seasonal depression can manifest in anger or frustration, Gullo says. For example, young clients may have an outburst or become agitated over small things that wouldn’t bother them as much during other times of the year, such as a parent telling them to clean their room, Gullo says.

John Ballew, an LPC with a solo private practice in Atlanta, estimates that up to one-third of his clients express feeling “more grim,” irritable or unhappy as winter approaches. He contends that the winter holidays “are a setup to make things worse” for clients who are affected by the seasons.

Overeating and overconsumption of alcohol are often the norm during the holidays, and this is typically coupled with the magnification of family issues through get-togethers, gift giving and other pressures, notes Ballew, a member of ACA. In addition, many coping mechanisms that clients typically use, such as getting outside for exercise, may be more difficult to follow in the winter. And although many people travel around the holidays, that travel is often high stress — the exact opposite of the getaways that individuals and families try to book for themselves at other times of the year.

“It’s a perfect storm for taking the ordinary things that get in the way of being happy and exacerbating them,” Ballew says. “People feel heavily obligated during the holidays, more so than in other seasons. It means that we’re not treating ourselves as well, and that can be a problem.”

[For more on helping clients through the pressures and stresses of the holiday season, see Counseling Today‘s online exclusive, “The most wonderful time of the year?https://wp.me/p2BxKN-4TI]

In the bleak midwinter

The first step in combating seasonal depression might be normalizing it for clients by educating them on how common it is and explaining that they can take measures to prepare for the condition and manage their feelings.

“Educating [the client] can give them control,” Sznewajs says. “People often feel shame about depression. Explain that you can take steps to treat yourself, just like you would for strep throat. You can’t will yourself to get better, but you can do things to help yourself get better. When you know what’s causing your depression, it gives you power to take those steps.”

Ballew notes that many of his clients express feeling like a weight has been lifted after he talks to them about SAD. “Many of them won’t think they have [SAD], but they will say, ‘Winter is a hard time for me’ or ‘I get blue around the holidays.’ They’re caught off guard by this unhappiness that seems to come from nowhere. People seem to feel a certain amount of relief to find that it’s something they will deal with regularly but that they can plan for and be cognizant of. It doesn’t mean that they’re defective or broken. It’s just that this is a stressful time. That helps us take a more strategic and problem-solving approach.”

Many counselors find cognitive behavior therapy (CBT) helpful in addressing seasonal depression because it combats the constant negative self-talk, catastrophizing and rumination that can plague these clients. CBT can assist clients in turning around self-defeating statements, finding ways to get through tough days and taking things one step at a time, Sznewajs says.

Gullo gives her teenage clients journaling homework (she recommends several journaling smartphone apps that teenagers typically respond well to). She also encourages them to maintain self-care routines and social connections. For instance, she might request that they make one phone call to a friend between counseling sessions.

Wiley guides her clients with seasonal depression in writing a plan of management and coping mechanisms (or reviewing and updating their prior year’s plan) before the weather turns cold and dark. She types out the plan in session while she and the client talk it over. Then she emails it so that the client will have it on his or her smartphone for easy access. The plans often include straightforward interventions — such as being intentional about going outside and getting exposure to natural light every day — that clients may not think about when dealing with the worst of their symptoms midwinter.

“It sounds simple, but those [individuals] who are down may not realize that the sun is shining and they better get outside to feel it on their face,” Wiley says. “We list exercises that are feasible. You might not join the gym, but what can you do? Can you walk the staircase at your house five times a day? Or, what’s one [healthy] thing you can add to your diet and one thing you can take away, such as cutting down to having dessert once per week, cutting out your afternoon caffeine or drinking more water. And what’s one thing you can do for your sleep routine? [Perhaps] take a hot shower before bed [to relax] and go to bed at the same time every night.”

Wiley also reminds clients to simply “be around people who make you feel happy.” She suggests that clients identify those friends and family members whom they enjoy being with and include those names on their therapeutic action plans for the winter.

All of the practitioners interviewed for this article emphasized the importance of healthy sleep habits, nutrition and physical activity for clients with seasonal depression. “All of these things are really hard to do when you feel lousy, so that’s why the education [and planning] piece is so important,” Sznewajs says. “Let them know that this [the change in seasons] is why you feel lousy, and it’s not your fault. But there are ways to feel better.”

Sznewajs typically begins talking with clients about their seasonal action plans in early fall and always before the change to daylight saving time. One aspect of the discussions is brainstorming how clients can modify the physical activities they have enjoyed throughout spring and summer for the winter months.

One of the cues Wiley uses to tell if clients might be struggling with seasonal depression is if they mention cravings for simple carbohydrates (crackers, pasta, etc.), sugars or alcohol when the days are dark and cold. They don’t necessarily realize that they are self-medicating in
an attempt to boost their dopamine, Wiley says.

Of course, exercise is a much healthier way of boosting dopamine levels. “Exercise is important, but it’s really hard to get depressed people to exercise,” Wiley acknowledges. “Telling them to join the gym won’t work when they just want to cry and lay in bed. So, turn the conversation: What is something you can do? If you already walk your dogs out to the corner, can you walk one more block? Take the stairs at work instead of the elevator, or park farther away from the grocery store.”

Effectively combating seasonal depression might also include counselor-client discussions about proper management of antidepressants and other psychiatric medications. Gullo recommends that her clients who are on medications and are affected by seasonal depression set up appointments with their prescribers as winter approaches. Sznewajs and Wiley also work with their clients’ prescribers, when appropriate, to make sure that these clients are getting the dosages they need through the winter.

Wiley will also diagnose clients with SAD if the diagnosis fits. “For someone who is really struggling and could benefit from [psychiatric] medication, the prescriber is often thankful for a second opinion. It adds weight and clarity to what the client is saying and what the doctor is hearing,” Wiley says. “It also helps the client to have a diagnosis so they don’t just wonder, ‘What’s wrong with me?’ It removes the blame and shame for people who are really struggling.”

Seeking the light

Many factors contribute to seasonal depression, but a main trigger is the reduced amount of daylight in the winter. It is vitally important for clients with seasonal depression to be disciplined about getting outdoors to feel natural light on their faces and in their eyes, Wiley says. She coaches clients to be disciplined about making themselves bundle up and get outside on sunny days or, at the very least, sit in their car or near a window for extra light exposure.

Wiley cautions clients against using tanning beds as a source of warmth and bright light to fend off seasonal depression. However, she acknowledges that she has seen positive results with tanning beds in severe cases of seasonal depression in which individuals were verging on becoming suicidal. In those extreme cases, counselors must weigh the long-term risks of using a tanning bed versus the more immediate risks to the client’s safety, Wiley says.

In addition to encouraging those with seasonal depression to get outdoors, Gullo and Sznewajs have introduced their clients to phototherapy, or the use of light boxes. Roughly the size of an iPad, these boxes have a very bright light (more than 10,000 lumens is recommended for people with seasonal depression) that clients can use at home.

Sznewajs recommends that clients use a light box first thing in the morning for at least 30 minutes to “reset their body,” increase serotonin and boost mood. If a client responds positively to phototherapy, it also serves as an indicator that he or she has SAD (instead of, or in addition to, nonseasonal depression), she notes.

Neither Gullo nor Sznewajs require clients to purchase light boxes. Instead, they simply introduce the idea in session and suggest it as something that clients might want to try. Insurance doesn’t typically cover light boxes, but they can be purchased online or at medical supply stores.

Gullo does keep a light box in her office so she can show clients how it works. She also recommends “sunrise” alarm clocks, which feature a light that illuminates 30 minutes before the alarm sounds. The light gradually becomes brighter and brighter, mimicking the sunrise. Gullo uses this type of alarm clock at home and finds it helpful.

The light box and sunrise alarm clock “are game changers,” Gullo says, “and a lot of people don’t know they exist.”

Powering through

In The Lion, the Witch and the Wardrobe, the second book in C.S. Lewis’ The Chronicles of Narnia series, characters struggle through never-ending cold that is “always winter but never Christmas.” Grappling with seasonal depression can feel much the same way: an uphill battle in a prolonged darkness in which occasions of joy have been snuffed out.

The key to making it through is crafting and sticking to a plan. Sznewajs says she talks with clients in the early fall to help them prepare: Yes, winter is coming, and you’re probably going to feel lousy, but it won’t last forever, and there are ways of getting through it.

“People need to understand that this is a totally predictable kind of concern,” Ballew concurs. “It’s not weak or self-indulgent [to feel depressed]. This is a hard time of year for many people, and you need to plan for it. … We [counselors] are in a great place to validate clients’ concerns, but also help them to strategize beyond them.”

 

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To contact the counselors interviewed for this article, email:

 

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

Letters to the editor: ct@counseling.org

 

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

The most wonderful time of the year?

By Bethany Bray October 23, 2017

Counselors can help clients prepare for the pressures that come during the holiday season, from a barrage of parties and social events to the temptation to compare themselves with the happy, near-perfect holiday scenes in movies, advertisements or friends’ social media posts.

For clients with seasonal depression, it can all be overwhelming — just at a time when people are expected to be happy and joyful, says John Ballew, a licensed professional counselor (LPC) with a private practice in Atlanta. Financial stresses, relationship concerns, grief over the loss of a loved one and other life challenges can feel more intense.

“This can be exactly the time that’s going to press on an old wound,” says Ballew, a member of the American Counseling Association.

Cindy Gullo, an ACA member and licensed clinical professional counselor in O’Fallon, Illinois, says she also notices an uptick in depression symptoms in her teen clients during the unstructured weeks of school break for the holidays, as well as anxiety over the return to school in the new year. She coaches clients to create and maintain structure over holiday breaks, including getting up at the same time in the morning and keeping up with the tasks they normally do while in school, such as completing reading assignments or practicing a musical instrument.

For Ballew’s adult clients, setting boundaries — from limiting their party RSVPs and holiday overeating to avoiding toxicity on social media — is often key to navigating the holidays. He also talks about the difference between self-care and self-indulgence with clients when preparing for the season.

“The adage that ‘No is a complete sentence’ is very applicable here,” Ballew says. “Especially if they have social anxiety, three hours at a party can feel totally overwhelming. Plan to go for 20 minutes, say hello to at least three people, then leave and admit you’ve done something difficult.”

On the flipside, clients who don’t receive any holiday invitations can sink into isolation or self-pity. Ballew says he works with clients to challenge themselves. Are they sitting at home waiting for the phone to ring? If so, they can be the one to call friends and initiate get-togethers. They can volunteer. They can choose to attend concerts and other local events on their own.

The holidays — from Thanksgiving to Valentine’s Day — can also be a struggle for clients who are single and unhappy about it. Again, Ballew says he challenges these thought patterns with clients. “For people who are alone, it’s learning to love being alone and make peace with it,” he says. “Reassess old patterns and beliefs and let go of things that aren’t working. What activities can you do alone? What beliefs do you have that keep you from enjoying things alone?”

Conversations with clients about setting boundaries can also be helpful in preparing for the family pressures and get-togethers that crop up during the holidays. For clients with particularly toxic or unhealthy family situations, this may mean limiting their involvement or staying away altogether, Ballew says. It may even be helpful to create their own new traditions during the holidays.

Sometimes, Ballew coaches clients to think of family visits as a trip to the zoo: What behavior might you see? What can you expect? What responses can you have ready for when family members make inappropriate or triggering comments?

When appropriate, he will create a “family bingo” board with clients, listing predictable patterns and negative behaviors that they can track in their minds. Although they wouldn’t bring the board to family gatherings, its creation is a way to prep for managing potentially challenging situations, Ballew explains.

“Approaching things with a sense that it doesn’t need to be that serious can be helpful,” he says. “With other folks, if the family is seriously dysfunctional, they just need to set boundaries. For example, if dad gets drunk, they don’t need to wait around to be berated. Have a [plan and] a place to go so you aren’t as vulnerable as when you were younger.”

Marcy Adams Sznewajs, an ACA member and LPC with a private practice in Beverly Hills, Michigan, specializes in working with teenagers and emerging adults. Like Ballew, she works with clients to prepare for family interactions over the holidays, with focus placed on empathy and listening skills.

“We do a lot of role-play in anticipation of family events,” she says. “What would happen if your uncle goes down this path and you respond in this way? How might that end? How would you like it to end? What are some different ways you can approach the situation? Teens don’t always have the ability to step back and say, ‘Just because someone doesn’t understand me doesn’t mean that I need to spout off my opinion at all times or respond.’”

“We also talk about understanding other people’s perspectives and life experiences,” she continues. “If they can look at a [family member’s] actions and behaviors from a place of empathy, sometimes it’s easier to sit through a conversation. Or, sometimes, it’s so horrible that all they can do is take a deep breath and get through it. Then we talk about management, mindfulness and ‘this too shall pass.’

“I tell them, ‘I can’t always help fix this, but I can help you cope, and you are strong enough to deal with this.’”

 

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READ MORE about supporting clients through seasonal depression in the article, “A light in the darkness” in Counseling Today‘s November magazine: https://wp.me/p2BxKN-4V1

 

From the Counseling Today archives: “Unhappy holidays: Helping clients through the ‘holiday blues’

 

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

 

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

 

 

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