Tag Archives: Counselors Audience

Counselors Audience

Suicide, substance abuse and medical trauma

By Bethany Bray September 3, 2019

Gunshot wounds, injuries from automobile accidents, a fall from a ladder, cooking burns or other incidents, either self-inflicted or unintentional: These are a few examples of the medical trauma that brings patients to the Wake Forest Baptist Health (WFBH) Medical Center in Winston-Salem, North Carolina.

Elizabeth Hodges Shilling and Olivia Smith are part of a team of counselors who talk with trauma patients at WFBH and assess them for suicidality and alcohol or substance use. The counselors have a laundry list of questions to ask patients as part of the assessment, but patients are often reeling from the traumatic incident that brought them to the hospital. At the same time, the counselors have a limited amount of time to work with each patient because patients are usually under their care for only 24 to 48 hours.

The solution? Shilling and Smith say they use a lot of “tell me” or “tell me more” questions and prompts. It’s a gentle way of getting the information they need and connecting the patient to additional resources.

For instance, instead of directly asking patients whether they drink or use drugs, Smith might say, “Tell me about when you’ve used alcohol or drugs to help you calm down or when hanging out with friends.” These types of inquiries make patients more likely to respond and open up, according to Smith, a coordinator and counselor on the adult and pediatric trauma screening and brief intervention team at WFBH.

This can be especially true with teenagers and young adults, who can be quick to put defenses up. “Sometimes we preface our questions with, ‘I’m not here to try and stop you. I just want to understand and try and support you,’” Smith notes.

Shilling and Smith are both licensed professional counselors and licensed clinical addictions specialists. They say that framing their assessments as “conversations” can help to form a connection with patients who might be overwhelmed by all the questions they’ve been getting from doctors and other medical personnel.

“Tell me about” questions are a gentle way of building rapport and opening the door to get more information from patients, says Shilling, an assistant professor in the department of surgery at Wake Forest School of Medicine. It also lets patients know that the issues with which they might be struggling aren’t unusual; other individuals are struggling with them as well.

The counselors may use prompts such as, “Tell me about the last time you thought about hurting yourself” or “Tell me about the times you’ve tried to cut down on your drinking,” says Shilling, a member of the American Counseling Association.

“Just throwing it into the conversation and bringing it out in the open gets them thinking about it,” Smith says. “[Also,] it eases up on the stigma about these thoughts and normalizes that it happens. We often hear embarrassment, and [patients who say,] ‘I’m having these thoughts, and I don’t know what to do with them.’”

Roughly 50% of the trauma patients they see at WFBH are admitted because of an accident or incident related to alcohol, Shilling says. This includes suicide attempts while under the influence of alcohol, intoxicated driving or being a passenger in a car with an intoxicated driver, or a variety of injuries that occur after a person has been drinking. Hospitalwide, one-third of patients are admitted for a medical condition related to substance use, she says. This includes conditions exacerbated by long-term alcohol use, such as pancreatitis.

“We often see people who have never thought about making a change, or others who have been injured several times and it’s a wake-up call and they want to change. Alcohol use can be a big part of their situation but also a small thing, as they’re dealing with so many things at once,” Smith says. “Being in the hospital posttrauma really facilitates the opportunity to think about making changes in your life. … It’s a teachable moment and opportune time to reassess [your choices].”

 

Alcohol and suicide

Smith and Shilling urge mental health practitioners to include questions about alcohol and substance use when screening clients for suicidality. This is a vitally important area of risk that often gets overlooked in suicide assessment, Shilling says.

Substance use problems are one of many suicide risk factors included on a list on the American Foundation for Suicide Prevention website, afsp.org.

Substance use can increase a person’s impulsivity, and it numbs the parts of the brain that trigger thoughts and behaviors that keep a person safe, Shilling says. “We see patients who, when sober, say they would not have taken those pills or used their gun, etc. But when they drink, that rational piece [of brain function] gets overridden. Using substances puts you at particular risk.”

Additionally, substance use can have negative effects on the overall mental health and wellness of patients, even if they do not exhibit signs of a substance use disorder. Asking questions about substance use can help patients understand how their drinking or substance use affects the whole picture, including mental health and mood, Shilling says.

“Substances impact their mental health in a lot of ways. They may be using substances in a way that’s not risky per se, but it may be affecting their mental health,” she adds.

Shilling urges practitioners who want to learn more about substance abuse — especially those who work with vulnerable populations such as teens — to seek continuing education or even additional licensure (such as becoming an addictions specialist).

 

Asking the right questions

Smith and Shilling’s cohort at WFBH uses several screening tools to assess for substance use in the patients in the hospital’s trauma, burn and medicine units.

The first is the Alcohol Use Disorders Identification Test (USAUDIT) developed by the U.S. Substance Abuse and Mental Health Services Administration. Available to the public at ct.gov/dmhas/lib/dmhas/publications/USAUDIT-2017.pdf, the assessment places users into one of six categories, ranging from “low-risk alcohol use” (no more than 14 drinks per week for men and seven per week for women) to “alcohol dependence” (which includes a cluster of symptoms indicating dependence on alcohol).

The Wake Forest team also uses the CAGE Substance Abuse Screening Tool developed by the Johns Hopkins School of Medicine. Smith says this mnemonic screening tool helps prompt patients with open-ended questions:

Cut down: Have you ever felt you should cut down on your drinking?

Annoyed: Have people annoyed you by criticizing your drinking?

Guilty: Have you ever felt bad or guilty about your drinking?

Eye-opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?

Read more about the CAGE screening tool at hopkinsmedicine.org/johns_hopkins_healthcare/downloads/all_plans/CAGE%20Substance%20Screening%20Tool.pdf

 

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Call for help

The National Suicide Prevention Lifeline offers free and confidential support around the clock, seven days a week, at 800-273-8255 or via chat at suicidepreventionlifeline.org.

 

Read more about addressing the topic of suicide with clients in Counseling Today‘s September cover story, “Making it safe to talk about suicidal ideation.”

 

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Contact the counselors interviewed for this article:

 

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Bethany Bray is a senior 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.

 

Maintaining motivation as a counselor

Compiled by Jonathan Rollins

As a whole, professional counselors are known to be driven by their desire (many might even deem it a calling) to help others. But as is the case in any job or profession, that internal sense of motivation to show up day after day and perform to the best of one’s abilities can sometimes wax and wane.

And let’s face it. Counseling is not just any profession. Yes, the intrinsic rewards can be great, but there are some inherent challenges to being a “helper” for a living.

Counseling Today recently contacted a handful of American Counseling Association members to ask them how they maintain their motivation levels in a profession that can be demanding, draining and exceedingly rewarding — all at the same time.

Note: Some responses have been edited slightly for purposes of space or clarity.

 

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Meet the counselors

The following members of the American Counseling Association agreed to share their personal insights regarding maintaining motivation as a counselor:

  • Mary Barros-Bailey is a bilingual certified rehabilitation counselor, a national certified counselor, a diplomate of the American Board of Vocational Experts, and a certified life care planner in Boise, Idaho.
  • Aaron Norton is a licensed mental health counselor, licensed marriage and family therapist, certified clinical mental health counselor and certified rehabilitation counselor working at Integrity Counseling Inc. in Largo, Florida.
  • Kathryn L. Bright is a licensed professional counselor, parental responsibilities evaluator (known in other states as a child custody evaluator), and parenting coordinator/decision-maker in Boulder, Colorado.
  • Anita B. Wright is a licensed professional counselor and national certified counselor. A retired principal, she opened her counseling private practice, Anita B. Wright, Counseling, Tea and Therapy PLLC, in Winterville, North Carolina, on a part-time basis in 2018. She is also the dean of middle school and special education/English language learners at Winterville Charter Academy.
  • Aaron J. Preece is a licensed professional counselor who works at High Country Behavioral Health in Pinedale, Wyoming.
  • Summer R. Collins is a licensed professional counselor intern currently practicing under Cristina Sevadjian (LPC-S) at Sparrow House Counseling, a group private practice in Dallas.

 

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What originally motivated you to enter the counseling profession?

Aaron Norton: To echo the most common answer I get on this question from graduate students in clinical mental health counseling, I was very driven to a profession that enabled me to help people. On deeper reflection over the years though, I do not think I could consider this answer thorough and honest if I didn’t add that I wanted to continue learning more about mental health to better understand my own mental health and wellness.

I first saw a counselor at 19 years of age, and I’ve seen a few others over the years. They were instrumental in helping me to heal from experiences in my personal life, and those experiences were so invaluable to me that I very much wanted the opportunity to pay it forward.

Anita B. Wright: My transition from teacher to school counselor was a natural progression. It was clear that the needs of the students I served required more from me. My instructional role toward academic proficiency could not be achieved without having first attended to the social/emotional realities [of the students].

Summer R. Collins: What originally motivated me was to help alleviate the intensity of people’s emotional pain. I experienced emotional distress in a capacity I never had before during my first year postgrad when my mother and then my grandfather were both diagnosed with cancer. I was also grieving the loss of my career as a competitive collegiate swimmer while facing these family members’ cancer diagnoses, and it all felt like too much. The relief and peace I felt in seeking help through my own counseling motivated me to become that same safe place for others experiencing pain.

Mary Barros-Bailey: Serving people with disabilities, particularly Portuguese and Spanish speakers.

Kathryn L. Bright: As an angsty yet dauntless teen, I longed to help those less fortunate than me, in particular my first boyfriend. He had left home, quit school, and ended up in a juvenile facility. At 18, he was convicted of marijuana possession and given the choice to go to jail or join the Army. He chose the Army. After a year in Vietnam as a foot soldier, he returned to the U.S. with severe posttraumatic stress disorder, depression and anger issues.

My parents scorned my choice of boyfriend, but I saw so much good in him beyond his troubled façade. One day, while imploring my mother to let me see my forbidden Romeo so I could help him, she curtly retorted, “You’re not qualified to help him.” From then on, the seed was planted in me to become qualified — through education and experience — to help people deal with traumas and life’s dramas.

I’m also gifted with being a highly sensitive, empathic, intelligent woman who grew up in a dysfunctional Southern family in the ‘50s and ‘60s. Good counselors were hard to come by then. The ones who were available greatly benefited me, making a huge difference in my own struggles and motivating me to share that benefit with others.

Aaron J. Preece: I spent 12 years in a deep depression, the last 1.5 years with daily suicidal ideation and related challenges. I then began working as a staff member in a wilderness therapy program and, while helping the clients, found many tools that I too could use and benefit from.

 

We’re all aware that counseling can be a challenging profession and that counselors sometimes face the risk of burnout. What has helped you maintain your motivation level as a counselor long term?

Mary Barros-Bailey: I always understood that I could grow professionally in a variety of directions. Initially, I started as a master’s-level vocational rehabilitation counselor with a private practice in California. Within a couple of years, I landed in Idaho, started a single-person private practice that I still run today, and entered a doctoral program. My love for rehabilitation counseling led me to become professionally involved at the local, national and international levels; to serve on accreditation and credentialing boards; to chair federal government panels; to teach [as an] adjunct for four universities; to research, publish and present in areas of my interest; and to develop a forensic practice where I have had cases north to Canada and Alaska, from California to Maryland, and as far south as Brazil, thus stoking my other love — travel.

I have learned that it’s OK to say “no.” Every few years, I take a self-imposed sabbatical from attending or presenting at conferences, joining any committees or teaching a class. I keep up with technology that has made me very efficient and allowed me to practice in ways I never dreamed possible when I started as a counselor. I’m still very excited about the challenges posed by counseling and where I’m going professionally, particularly in forensic practice.

Kathryn L. Bright: Self-care is the biggest help. That includes healthy lifestyle choices such as regular exercise, sunshine and fresh air, along with meditation, social interaction, consultation with colleagues, and continuing education.

Aaron J. Preece: Balance. I do not take my work home with me if at all possible. I also involve myself in social, religious and community programs not related to counseling. Also, nurturing and maintaining relationships with family and friends on a weekly basis.

Anita B. Wright: Absolutely the work. The intrinsic stories. Having the privilege to join the journey.

Summer R. Collins: What has helped me maintain motivation as a counselor long term is to view my career as an endurance race. I know there will be parts of the race that will feel more daunting and challenging, and I can expect that. But I can also expect … the “runner’s high” of different victories that I know I’ll experience in the field when I get to witness clients making lasting changes with improved emotion-regulation skills and cognitive flexibility.

Aaron Norton: I keep a collection of artifacts — letters, cards, drawings, emails, etc. — from clients who have expressed their gratitude for my help over the years. I can look at them anytime that I want a reminder of why I do what I do.

Additionally, I try to practice healthy self-care. When I was a student in my clinical mental health counseling program, I took a class on the art and science of personal change. We were required to create and implement a personal change project using the knowledge we acquired during the class. My goal was to exercise regularly — a goal that I had not ever been able to consistently practice prior to that class. I implemented my change plan, and I have continued it without any lapses for the past 13 years. In my humble opinion, all counselors should exercise regularly, although that regimen may look very different from person to person.

I also regularly spend time with family members, friends, my partner and colleagues doing things that have nothing to do with my job, and I start every day off with my daily Stoic meditation. I try to practice healthy eating, do not hesitate to take vacations and time off, spend time in nature and with pets, participate in weekly peer consultation, stay very connected to my colleagues through professional associations, implement time-saving organizational measures, and enforce boundaries with my clients.

 

What is the biggest threat to your sense of motivation as a counselor?

Summer R. Collins: The biggest threat to my sense of motivation … is that our work as counselors cannot be measured and graded. I can question whether or not I’ve made an impact and if my work has meaning when I’ve had a particularly difficult week.

Kathryn L. Bright: Self-doubt creeps in from time to time, making me second-guess myself and lose confidence in my considerable abilities, thus slowing me w-a-a-a-y down.

Aaron J. Preece: Supervisors who expect unrealistic goals or results. Lack of variety in my job.

Aaron Norton: At the present time, I am finishing a doctoral program in counselor education and supervision. This is simultaneously a joy and a burden. Sometimes, when I am busy at work on my dissertation, or when I’m feeling particularly stressed or overwhelmed, I feel less psychologically available to my clients. I view this, however, as a very temporary problem.

Anita B. Wright: The weight of the therapeutic process as the [person’s] pain and vulnerability are being tempered via me.

Mary Barros-Bailey: Apathy. I like variety — clinical and forensic practice, teaching, research, writing and innovation.

 

What one to two things currently energize you about your work as a counselor?

Aaron J. Preece: Our community began a prevention coalition in which I am deeply involved in substance abuse and suicide prevention work. I also enjoy learning new tools or techniques for approaching clients.

Anita B. Wright: Earning the sweet spot of trust as the therapeutic relationship develops.

Aaron Norton: My colleagues energize me. I have met such wonderful friends in our field. The clinical mental health counseling specialty is, to me, a tribe of sorts, and I enjoy having a place in this tribe. I belong.

Second, those moments when clients seem to “get it” have always been a consistent source of energy for me.

Mary Barros-Bailey: Innovation in assistive and instructional technologies and with counseling techniques, such as new methods in integrated behavioral health.

Kathryn L. Bright: When clients accept, practice and benefit from what I offer. When I see that “aha!” lightbulb shining brightly behind eyes filled with insight and gratitude. When colleagues show confidence in my work through their referrals.

Summer R. Collins: One thing currently energizing me is learning new treatment skills for working with clients with posttraumatic stress disorder and witnessing firsthand the effectiveness of this treatment and the healing I’ve seen my clients experience.

 

Are there any particular techniques, tricks or strategies that you use to stay motivated?

Aaron Norton: I start every day off with a daily mediation from Stoic philosophy, the ancient philosophy that essentially informs cognitive behavioral theory. I also like to read about or listen to people in our field whom I very much look up to. I attend a great deal of workshops, retreats and training programs in our profession, and I always leave feeling energized and ready to get back to work.

Kathryn L. Bright: A daily practice of the techniques of self-knowledge helps me focus my attention within to experience peace and fulfillment. Taking time each day to enjoy that experience puts me in touch with my innate strength, clarity and wisdom. That helps me, more than anything else, to maintain my motivation as a counselor and an optimistic outlook on life. A sense of humor helps too.

Summer R. Collins: One trick I use to stay motivated is to continue staying connected with my colleagues in this field. I recognize my need to connect with others who understand the difficulties that come with being a counselor. Relating with them and being able to share hits and misses is a very helpful and important thing for me. It gives me grace for myself as I continue to seek to become an effective and helpful counselor to my clients.

Anita B. Wright: Continuous learning of clinical language and effective therapeutic approaches.

Aaron J. Preece: Exercise is my Prozac. I make a diligent effort to exercise at least three times a week — more if possible. I also work in the yard; keep involved in community music programs, Scouts, religious attendance, and youth programs on a volunteer basis; eat healthy; read; and make sure to get adequate sleep. Generally, it is about stress. I manage my low-level stress every day so big stresses don’t immediately overwhelm me.

Mary Barros-Bailey: The personal strategic plan format I cobbled together with a variety of resources over the years has become my go-to when I’m in a motivation hole and need to shovel myself out and reenvision.

 

 

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Jonathan Rollins is the editor-in-chief of Counseling Today. Contact him at jrollins@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.

Challenging the inevitability of inherited mental illness

By Lindsey Phillips August 29, 2019

With a family history that famously includes depression, addiction, eating disorders and seven suicides — including her grandfather Ernest Hemingway and her sister Margaux — actress and writer Mariel Hemingway doesn’t try to deny that mental health issues run in her family. She repeatedly shares her family history to advocate for mental health and to help others affected by mental illness feel less alone.

And, of course, they aren’t alone. Mental health issues are prevalent in many families, making it natural for some individuals to wonder or worry about the inherited risks of developing mental health problems. Take the common mental health issue of depression, for example. The Stanford University School of Medicine estimates that about 10% of people in the United States will experience major depression at some point during their lifetime. People with a family history of depression have a two to three times greater risk of developing depression than does the average person, however.

A 2014 meta-analysis of 33 studies (all published by December 2012) examined the familial health risk of severe mental illness. The results, published in the journal Schizophrenia Bulletin, found that offspring of parents with schizophrenia, bipolar disorder or major depressive disorder had a 1 in 3 chance of developing one of those illnesses by adulthood — more than twice the risk for the control offspring of parents without severe mental illness.

Jennifer Behm, a licensed professional counselor (LPC) at MindSpring Counseling and Consultation in Virginia, finds that clients who are worried about family mental health history often come to counseling already feeling defeated. These clients tend to think there is little or nothing they can do about it because it “runs in the family,” she says.

Theresa Shuck is an LPC at Baeten Counseling and Consultation Team and part of the genetics team at a community hospital in Wisconsin. She says family mental health history can be a touchy subject for many clients because of the stigma and shame associated with it. In her practice, she has noticed that individuals often do not disclose family history out of their own fear. “Then, when a younger generation person develops the illness and the family history comes out, there’s a lot of blame and anger about why the family didn’t tell them, how they would have wanted to know that, and how they could have done something about it,” she notes.

Sarra Everett, an LPC in private practice in Georgia, says she has clients whose families have kept their history of mental illness a secret to protect the family image. “So much of what feeds mental illness and takes it to an extreme is shame. Feeling like there’s something wrong with you or not knowing what is wrong with you, feeling alone and isolated,” Everett says. Talking openly and honestly about family mental health history with a counselor can serve to destigmatize mental health problems and help people stop feeling ashamed about that history, she emphasizes.

Is mental illness hereditary?

Some diseases such as cystic fibrosis and Huntington’s disease are caused by a single defective gene and are thus easily predicted by a genetic test. Mental illness, however, is not so cut and dry. A combination of genetic changes and environmental factors determines if someone will develop a disorder.

In her 2012 VISTAS article “Rogers Revisited: The Genetic Impact of the Counseling Relationship,” Behm notes that research in cellular biology has shown that about 5% of diseases are genetically determined, whereas the remaining 95% are environmentally based.

The history of the so-called “depression gene” perfectly illustrates the complexity of psychiatric genetics. In the 1990s, researchers showed that people with shorter alleles of the 5-HTTLPR (a serotonin transporter gene) had a higher chance of developing depression. However, in 2003, another study found that the effects of this gene were moderated by a gene-by-environment interaction, which means the genotype would result in depression if people were subjected to specific environmental conditions (i.e., stressful life events). More recently, two studies have disproved the statistical evidence for a relation between this genotype and depression and a gene-by-environment interaction with this genotype.

Even so, researchers keeps searching for disorders that are more likely to “run in the family.” A 2013 study by the Cross-Disorder Group of the Psychiatric Genomic Consortium found that five major mental disorders — autism, attention deficit/hyperactivity disorder (ADHD), bipolar disorder, major depressive disorder and schizophrenia — appear to share some common genetic risk factors.

In 2018, a Bustle article listed 10 mental health issues “that are more likely to run in families”: schizophrenia, anxiety disorders, depression, bipolar disorder, obsessive-compulsive disorder (OCD), ADHD, eating disorders, postpartum depression, addictions and phobias.

Adding to the complexity, Kathryn Douthit, a professor in the counseling and human development program at the University of Rochester, points out that studies on mental disorders are done on categories such as major depression and anxiety that are often based on descriptive terms, not biological markers. The cluster of symptoms produces a “disorder” that may have multiple causes — ones not caused by the same particular genes, she explains.

Thus, thinking about mental health as being purely genetic is problematic, she says. In other words, people don’t simply “inherit” mental illness. A number of biological and environmental factors are at play in gene expression.

Regardless of the genetic link, family history does serve as an indicator of possible risk for certain mental health issues, so counselors need to ask about it. As a genetic counselor, Shuck, a member of the American Counseling Association, admits that she may handle family history intake differently. Genetic counseling, as defined by the National Society of Genetic Counselors, is “the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease.” It blends education and counseling, including discussing one’s emotional reactions (e.g., guilt, shame) to the cause of an illness and strategies to improve and protect one’s mental health.

Thus, Shuck’s own interests often lead her to ask follow-up questions about family history rather than sticking to a general question about whether anyone in a client’s family struggles with a certain disorder. If, for example, she learns a client has a family history of depression, she may ask, “Who has depression, or who do you think has depression?” After the client names the family members, Shuck might say, “Tell me about your experiences with those family members. How much has their mental health gotten in the way? How aware were you of their mental health?”

These questions serve as a natural segue to discussing how some disorders have a stronger predisposition in families, so it is good to be aware and mindful of them, she explains. Discussing family history in this way helps to normalize it, she adds.   

Everett, who specializes in psychotherapy for adults who were raised by parents with mental illness, initially avoids asking too many questions. Instead, she lets the conversation unfold, and if a client mentions alcohol use, she’ll ask if any of the client’s family members drink alcohol. Inserting those questions into the discussion often opens up a productive conversation about family mental health history, she says.

Environmental factors

Mental disorders are “really not at all about genetic testing where you’re testing genes or blood samples because there are no specific genetic tests that can predict or rule out whether someone may develop mental illness,” Shuck notes. “That’s not how mental illness works.”

Shuck says that having a family history of mental illness can be thought of along the same lines as having a family history of high blood pressure or diabetes. Yes, having a family history does increase one’s risk for a particular health issue, but it is not destiny, she stresses.

For that reason, when someone with a family history of mental disorders walks into counseling, it is important to educate them that mental health is more than just biology and genetics, Shuck says. In fact, genetics, environment, lifestyle and self-care (or lack thereof) all work together to determine if someone will develop a mental disorder, she explains.

One of Shuck’s favorite visual tools to help illustrate this for clients is the mental illness jar analogy (from Holly Peay and Jehannine Austin’s How to Talk With Families About Genetics and Psychiatric Illness). Shuck tells clients to imagine a glass jar with marbles in it. The marbles represent the genes (genetic factors) they receive from both sides of their family. The marbles also represent one’s susceptibility to mental illness; some people have two marbles in their jar, while others have a few handfuls of marbles.

Next, Shuck explains how one’s lifestyle and environment also fill the jar. To illustrate this point, she has clients imagine adding leaves, grass, pebbles and twigs (representing environmental factors) until the jar is at capacity. “We only develop mental illness if the jar overflows,” she says.

Behm, an ACA member, also uses a simple analogy (from developmental biologist Bruce Lipton) to help explain this complex issue to clients. She tells clients to think of a gene as an overhead light in a room. When they walk into the room, that light (or gene) is present but inactive. They have to change their environment by walking over and flipping on a switch to activate the light.

As Everett points out, “Our experiences, drug use, traumas, these things can turn genes on, especially at a young age.” On the other hand, if someone with a pervasive family history of mental disorders had caregivers who were aware and sought help, the child could grow up to be relatively well-adjusted and healthy in terms of mental health, she says.

In utero epigenetics is another area that illustrates how environment affects our genes and mental health, Douthit notes. The Dutch Hongerwinter (hunger winter) offers an example. In 1944-1945, people living in a Nazi-occupied part of the Netherlands endured starvation and brutal cold because they were cut off from food and fuel supplies. Scientists followed a group who were in utero during this period and found that the harsh environment caused changes in gene expression that resulted in their developing physical and mental health problems across the life span. In particular, they experienced higher rates of depression, anxiety disorders, schizophrenia, schizotypal disorder and various dementias.

Why is this important to the work of counselors? If, Douthit says, counselors are aware of an environmental risk to young children, such as the altered gene expression coming from the chronic stress and trauma associated with poverty, then they can work with parents and use appropriate therapeutic techniques such as touch therapy interventions in young infants and child-parent psychotherapy to reverse the impact of the harmful
gene expression.

Behm uses the Rogerian approach of unconditional positive regard and “prizing” the client (showing clients they are worth striving for) to create a different environment for clients — one that is ripe for change.

Counseling interventions that change clients’ behaviors and thoughts long term have the potential to also change brain structure and help clients learn new ways of doing and being, Behm continues. “It’s the external factors that are making people anxious or depressed,” she says. “If you get yourself out of that situation, your experience can be different. If you can’t get yourself out of it, the way you perceive it — how you make meaning of it — makes it different in your brain.”

The hope of epigenetics

Historically, genes have been considered sovereign, but genetics don’t tell the entire story, Behm points out. For her, epigenetics is a hopeful way to approach the issue of familial mental illness.

Epigenetics contains the Greek prefix epi, which means “on top of,” “above” or “outside of.” Thus, epigenetics includes the factors outside of the genes. This term can describe a wide range of biological mechanisms that switch genes on and off (evoking the prior analogy of the overhead light). Epigenetics focuses on the expression of one’s genes — what is shaped by environmental influences and life experiences such as chronic
stress or trauma.

Douthit has written and presented on the relationship between counseling and psychiatric genetics, including her 2006 article “The Convergence of Counseling and Psychiatric Genetics: An Essential Role for Counselors” in the Journal of Counseling & Development and a 2015 article on epigenetics for the “Neurocounseling: Bridging Brain and Behavior” column in Counseling Today. In her chapter on the biology of marginality in the 2017 ACA book Neurocounseling: Brain-Based Clinical Approaches, she explains epigenetics as the way that aspects of the environment control how genes are expressed. Epigenetic changes can help people adapt to new and challenging environments, she adds.

This is where counseling comes in. Clients often come to counseling after they have struggled on their own for a while, Behm notes. The repetition of their reactions to their external environment has resulted in a certain neuropathway being created, she explains.

Clients are inundated with messages of diseases being genetic or heritable, but they rarely hear the counternarrative that they can make changes in their lives that will provide relief from their struggle, Behm notes. “Through consistent application of these changes, [clients] can change the structure and function of [their] brain,” she adds. This process is known as neuroplasticity.

Behm explains neuroplasticity to her clients by literally connecting the dots for them. She puts a bunch of dots on a blank piece of paper to represent neurons in the brain. Then, for simplicity, she connects two dots with a line to represent the neuropathway that develops when someone acts or thinks the same way repeatedly. She then asks, “What do you think will happen if I continue to connect these two dots over and over?” Clients acknowledge that this action will wear a hole in the paper. To which she responds, “When I create a hole, then I don’t have to look at the paper to connect the dots. I can do it automatically without looking because I have created a groove. That’s a neuropathway. That’s a habit.”

Even though clients often come in to counseling with unhealthy or undesirable habits (such as responding to an event in an anxious way), Behm provides them with hope. She explains how counseling can help them create new neuropathways, which she illustrates by connecting the original dot on the paper with a new dot.

Of course, the real process is not as simple as connecting one dot to another, but the illustration helps clients grasp that they can choose another path and establish a new way of being and doing, Behm says. The realization of this choice provides clients — including those with family histories of mental illness — a sense of freedom, hope and empowerment, she adds.

At the same time, Behm reminds clients of the power exerted by previously well-worn neuropathways and reassures them that continuing down an old pathway is normal. If that happens, she advises clients to journal about the experience, recording their thoughts and feelings about making the undesirable choice and what they wish they had done or thought differently.

“The very act of writing that out strengthens the [new] neuropathway,” she explains. “Not only did you pause and think about it … you wrote about it. That strengthened it as well.”

In addition, professional clinical counselors can help bring clients’ subconscious thoughts to consciousness. By doing this, clients can process harmful thoughts, make meaning out of the situation, and create a new narrative, Behm explains. The healthy thoughts from the new narrative can positively affect genes, she says.

Protective factors

When patients are confronted with a physical health risk such as diabetes or high blood pressure, they are typically encouraged by health professionals to adjust their behavior in response. Shuck, a member of the National Society of Genetic Counselors and its psychiatric disorders special interest group, approaches her clients’ increased risk of mental health problems in a similar fashion: by helping them change their behaviors.

Returning to the mental illness jar analogy, Shuck informs clients that they can increase the size of their jars by adding rings to the top so that the “contents” (the genetic and environmental factors) don’t spill over. These “rings” are protective factors that help improve one’s mental health, Shuck explains. “Sleep, exercise, social connection, psychotherapy, physical health maintenance — all of those protective factors that we have control of and we can do something about — [are] what make the jar have more capacity,” she says. “And so, it doesn’t really matter how many marbles we’re born with; it’s also important what else gets put in the jar and how many protective factors we add to it to increase the capacity.”

Techniques that involve a calming sympathetic-parasympathetic shift (as proposed by Herbert Benson, a pioneer of mind-body medicine) may also be effective, Douthit asserts. Activities such as meditation, knitting, therapeutic massage, creative arts, being in nature, and breathwork help cause this shift and calm the nervous system, she explains. Some of these techniques can involve basic behavioral changes that help clients “become aware of when [they’re] becoming agitated and to be able to recognize that and pull back from it and get engaged in things that are going to help [them] feel more baseline calm,”
she explains.

In addition, counseling can help clients relearn a better response or coping strategy for their respective environmental situations, Behm says. For example, a client might have grown up watching a parent respond to external events in an anxious way and subconsciously learned this was an appropriate response. In the safe setting of counseling, this client can learn new, healthy coping methods and, through repetition (which is one way that change happens), create new neuropathways.

At the same time, Shuck and Douthit caution counselors against implying that as long as clients do all the rights things — get appropriate sleep, maintain good hygiene, eat healthy foods, exercise, reduce stress, see a therapist, maintain a medicine regime — that they won’t struggle, won’t develop a mental disorder, or can ignore symptoms of psychosis.

“You can do all of the right things and still develop depression. It doesn’t mean that somebody’s doing something wrong. … It just means there happened to have been more marbles in the jar in the first place,” Shuck says. “It’s [about] giving people the idea that there’s some mastery over some of these factors, that they’re not just sitting helplessly waiting for their destiny to occur.”

Shuck often translates this message to other areas of health care. For example, someone with a family history of diabetes may or may not develop it eventually, but the person can engage in protective factors such as maintaining a healthy body weight and diet, going to the doctor, and getting screened to help minimize the risk. “If we normalize [mental health] and make it very much a part of what we do with our physical health, it’s really not so different,” she says.

Bridging the gap

Shuck started off her career strictly as a genetic counselor. As she made referrals for her genetics clients and those dealing with perinatal loss to see mental health therapists, however, several clients came back to her saying the psychotherapist wasn’t a good fit. Over time, this happened consistently.

This experience opened Shuck’s eyes to the existing gap between the medical and therapeutic professions for people who have chronic medical or genetic conditions. Medical training isn’t typically part of the counseling curriculum, often because there isn’t room or a need for such specialized training, she points out.

Shuck decided to become part of the solution by obtaining another master’s degree, this time in professional counseling. She now works as a genetic counselor and as a psychotherapist at separate agencies. She says some clients are drawn to her because of her science background and her knowledge of the health care setting.

Behm also notes a disconnect between genetics and counseling. “I see these two distinct pillars: One is the pillar of genetic determinism, and the other is the pillar of epigenetics. And with respect to case conceptualization and treatment, there aren’t many places where the two are communicating,” she says.

Douthit, a former biologist and immunologist, acknowledges that some genetic questions such as the life decisions related to psychiatric genetics are outside the scope of practice for professional clinical counselors. However, helping clients to change their unhealthy behaviors and though patterns, deal with family discord or their own reactions (e.g., grief, loss, anxiety) to genetically mediated diseases, and create a sympathetic-parasympathetic shift are all areas within counselors’ realm of expertise, she points out.

An interprofessional approach is also beneficial when addressing familial mental health disorders. If Behm finds herself “stuck” with a client, she will conduct motivational interviewing and then often include a referral to a medical doctor or other medical professional. For example, she points out, depression can be related to a vitamin D deficiency. She has had clients whose vitamin D levels were dangerously low, and after she referred them to a medical doctor to fix the vitamin deficiency, their therapeutic work improved as well.

Another example is the association between addiction and an amino acid deficiency. Behm notes that consulting with a physician who can test and treat this type of deficiency has been shown to reduce clients’ desires to use substances. Even though counselors are not physicians, knowing when to make physicians a part of the treatment team can help improve client outcomes,
she says. 

Another way to bridge the gap between psychotherapy and the science of genetics is to make mental health a natural part of the dialogue about one’s overall health. “Mental illness lives in the organ of the brain, but we somehow don’t equate the brain as an organ that’s of equality with our kidneys, heart or liver,” Shuck says. When there is a dysfunction in the brain, clients deserve the opportunity to make their brains work better because that is important for their overall well-being,
she asserts.

Facing one’s fears

Having a family history of mental illness may result in fear — fear of developing a disorder, fear of passing a disorder on to a child, fear of being a bad parent or spouse because of a disorder.

“Fear is paralyzing,” Shuck notes. “When people are fearful of something … they don’t talk about it and they don’t do anything about it.” The aim in counseling is to help clients move away from feeling afraid — like they’re waiting for the disorder to “happen” — to feeling more in control, she explains.

Some clients have confessed to Everett that they have doubts about whether they want or should have children for several reasons. For instance, they fear passing on a mental health disorder, had a negative childhood themselves because of a parent who suffered from an untreated disorder, or currently struggle with their own mental health. For these clients, Everett explains that having a mental health issue or a family history of mental illness doesn’t mean that they will go on to neglect or abuse their children. “With parents who have the support and are willing to be open and ask for help … [mental illness] can be a part of their life but doesn’t have to completely devastate their children or family,” she says.

Shuck reminds clients who fear that their children could inherit a mental illness that most of the factors that determine whether people develop a mental disorder are nongenetic. In addition, she tells clients their experience with their own mental health is the best tool to help their child if concerns arise because they already know what signs to look for and how to get help.

Even if a child comes from a family with a history of mental illness, the child’s environment will be different from the previous generations, so the manifestations of mental illness could be less or more severe or might not appear at all, Douthit adds.

The potential risk of mental illness may also produce anger in some clients, but as Shuck points out, this can sometimes serve as motivation. One of her clients has a family history that includes substance abuse, addiction, hoarding, anxiety, bipolar disorder, OCD, depression and suicide. The client also experienced mental health problems and had a genetic disorder, but unlike her family, she advocated for herself. When Shuck asked her why she was different from the rest of her family, the client confessed she was angry that she had grown up with family members who wouldn’t admit that they had a mental illness and instead used unhealthy behaviors such as drinking to cope. She knew she wanted a different life for herself and her future children.

Defining their own destiny

Everett doesn’t focus too heavily on client genetics because she can’t do anything about them. Instead, her goal is to encourage clients to believe that they can change and get better themselves. She wants clients to move past their defeated positions and realize that a family history of mental illness doesn’t have to define them.

Likewise, Behm thinks counselors should instill hope and optimism into sessions and carry those things for clients until they are able to carry them for themselves. To do this, counselors should be well-versed in the science of epigenetics and unafraid of clients’ family histories, she says. Practitioners must believe that counseling can truly make a difference and should attempt to grow in their understanding of how the process can alter a client’s genes, she adds.

From the first session, Behm is building hope. She has found that activities that connect the mind and body can calm clients quickly and make them optimistic about future sessions. For example, she may have clients engage in diaphragmatic breathing and ask them what they want to take into their bodies. If their answer is a calming feeling, she tells them to imagine calm traveling into every single cell of their bodies when they breath in. Alternately, clients can imagine inhaling a color that represents calm. Next, Behm asks clients what they want to let go of — stress or anxiety, for example — and has them imagine that leaving the body as they exhale.

Hope and optimism played a large role in how Mariel Hemingway approached her family’s history of mental illness. She recognized that her history made her more vulnerable. Determined not to become another tragic story, Hemingway exerted control over her environment, thoughts and behaviors. Today, she continues to eat well, exercise, meditate and practice stress reduction.

Hemingway’s story illustrates the complexity of familial history and serves as a good model for counselors and clients, Douthit says. “Whether it’s genetic or not, it’s being passed along from generation to generation,” Douthit says. “And that could be through behaviors. It could be through other environmental issues. It could be any number of modifications that occur when genes are expressed.”

Shuck says she often hears other mental health professionals place too great an emphasis on the inheritance of mental illness. A family history of mental illness alone does not determine one’s destiny, she says. Instead, counselors and clients should focus on the things they do have control over, such as environmental factors and lifestyle.

“We have to emphasize wellness [and protective factors] much more than the idea that ‘it’s in my family, so it’s going to happen to me,’” she says. “We have to look at those things we can do as an individual to enhance those aspects of our well-being to make [the capacity of the mental illness] jar bigger.”

 

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

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.

Taming impulses

By Lindsey Phillips August 5, 2019

About five years ago, a young client walked reluctantly into Jennifer Skinner’s office. In addition to impulse-control issues, the 10-year-old had been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), struggled with issues around being adopted, and had medical concerns. This long list meant the boy was often being told what to do and felt powerless.

Shortly after the boy’s parents dropped him off, he walked out of Skinner’s office and headed toward his house a few blocks away. Skinner, a licensed professional counselor (LPC) at Kettle Moraine Counseling in Wisconsin, quickly followed. She told him she wasn’t going to stop him from going home, but she was going to make sure he got there safely. Hearing this, the boy circled back to Skinner’s office and locked her out. Skinner stayed calm, and eventually he let her back in.

According to prevalence data cited by Psych Central, 10.5% of Americans have an impulse-control disorder. Even so, Skinner, a licensed professional school counselor who works with students with self-esteem, impulse-control and other social-emotional issues, says that impulsiveness is often poorly understood or is not on people’s radar. She rarely has clients present and tell her they are impulsive.

Similarly, Laura Galinis, an LPC in private practice in Georgia, affirms that when she uses the term impulsivity to describe her work with clients, she is frequently met with blank stares.

Impulsiveness comes from an internal place in which individuals either react without thought or can’t stop themselves from doing the impulsive behavior, says Skinner, a member of the American Counseling Association. Sometimes, if these individuals don’t yell or lash out, they will be left feeling unsatisfied, she adds.

Edward F. Hudspeth, an associate dean of counseling at Southern New Hampshire University, acknowledges that “some impulsivity is just a natural part of growing up [and] learning from situations.” It becomes a problem, however, when repeated consequences and societal pressures have no impact on the person’s impulsive behavior. “Basically,” adds Hudspeth, a member of ACA, “you’re saying that everyone around you and even consequences are of no value to change [your] behavior. It’s just, ‘I’m going to be impulsive,’ and nothing seems to stop this.”

According to Galinis, impulsivity is an inclusive term that describes the ways that people disconnect from themselves, their relationships and their reality. The majority of her clients come in because they are having relationship problems or because someone suggested they seek help. She finds that “the deeper root is not really feeling present when you make decisions.” To her, this means that impulsive behavior can take several forms, including sleeping with lots of people indiscriminately or drinking or spending more than one wants to.

Because impulsivity can be broadly defined, Galinis recommends asking clients what they mean when they say they struggle with impulsivity. She also suggests questions that will help counselors determine whether a client’s impulsivity has gone too far:

  • Has the client been unsuccessful in attempts to fix the impulsive behavior?
  • What consequences is the client facing because of impulse-control issues?
  • Is the client’s impulsive behavior causing problems in relationships, with finances or with work?
  • Does the client’s impulsivity stem from not setting parameters, or is the client disassociated and being prompted to engage in behaviors he or she may not want to do?
  • Is there a pattern with the client’s impulsivity? Does it show up in just one relationship or across the board?

Impulsivity across the life span

Impulse-control disorders are often first diagnosed in childhood, but as Hudspeth points out, they can occur across the life span.

Children with impulse-control issues will often act on impulsive desires because their prefrontal cortex, which regulates impulse control, has yet to fully develop, explains Hudspeth, who is both an LPC and a registered pharmacist. In adults, he finds that impulsive behavior shifts in terms of its intensity. For example, impulsive behaviors that showed as verbal outbursts and some physical aggression as a child would develop into something more disruptive and destructive as an adult, he says.

Galinis, whose specialty areas include impulsivity and trauma, agrees that some people remain impulsive into adulthood unless treated. Impulse-control issues just look different across age ranges, she says. Often, adults can hide or delay the consequences of impulsive behavior because they are more independent, typically coordinating their own schedules, funding their own lifestyles and so on, she says. Teenagers, on the other hand, may be referred to counseling because they are spending too much time on their phones in school. But with adults, the impulsivity progresses beyond simple phone addiction to behaviors that cause relationship issues, such as an impulse to watch pornography or to spend money online.

Shifting societal norms for young adults have created a different developmental stage, known as emerging adulthood, for people ages 18-26, says Hudspeth, co-author of a chapter on impulse-control disorders and interventions for college students in the book College Student Mental Health Counseling: A Developmental Approach. He explains that members of this age group aren’t at the same level of brain development that they would have been 30 years ago. That’s in part because they no longer feel pressured to instantly get a job in their early 20s and start a family, he says. Instead, they often have a period of exploration before emerging as adults.

“Add that to impulsivity, and you get a lot of chaos and a lot of strange behaviors,” Hudspeth continues. “They’re adults. They have adult rights. They can consent to things. They can do things without the approval of someone else, so it presents the opportunity for a lot more riskiness and impulsivity.” For example, it’s not uncommon for these young adults to engage in impulsive behaviors such as taking a last-minute vacation while trying to hold down a job.

Hudspeth, president-elect of the Association for Creativity in Counseling, a division of ACA, points out that impulse-control disorders have morphed over the past three versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), so diagnosing and treating impulsivity can be challenging. In 2013, the DSM-5 published a new chapter on “Disruptive, Impulse-Control and Conduct Disorders.” Intermittent explosive disorder, pyromania, kleptomania, conduct disorders and ODD were included under that heading. At the same time, disorders such as gambling, sexual addiction and trichotillomania were moved out of the impulsive category. 

The new DSM-5 chapter attempts to limit the misconception that impulsivity is only a childhood issue by bringing in the developmental perspective and detailing that these disorders can also show up in different forms in adolescence and adulthood, Hudspeth says. In fact, while doing research for a book chapter in Treating Disruptive Disorders: A Guide to Psychological, Pharmacological and Combined Therapies, Hudspeth found that intermittent explosive disorder is often underdiagnosed and misdiagnosed because it was previously included in a chapter on childhood disorders in the DSM.

Counseling professionals need to be aware that impulse-control disorders can occur across the life span and not just during a particular developmental phase, he says.

Symptom or disorder?

For counselors, the challenge is not necessarily determining whether a client is impulsive but rather figuring out if impulsivity is the main presenting issue or a symptom of other issues such as substance use, ADHD or trauma, Hudspeth says. For this reason, the initial intake and assessment are crucial with regard to impulsivity. Hudspeth advises counselors to look beyond clients’ observable impulsive behaviors to try to figure out what is initiating those behaviors. Why and in what situations are clients being impulsive?

Skinner says it is common to see dual diagnosis with impulse issues. For example, ODD, conduct disorders, eating disorders, addiction and ADHD all have impulse control as a symptom.

Galinis finds that trauma is often an underlying cause of impulsivity. In fact, she says she has yet to see a client struggling with impulsivity who doesn’t also have some trauma attached to it.

Hudspeth concurs: “Trauma and abuse will make a person very hypervigilant and impulsive, and if it’s just treated as an impulse-control disorder, you’re never getting to the core issue.” He advises counselors to ask clients whether a history of trauma, abuse or neglect is connected to their impulsive behavior, either directly or indirectly. If there is, then counselors should approach impulsivity from a different perspective than they would if it were just part of ODD, ADHD or another disorder.

In addition, Hudspeth suggests asking clients the following questions: What is their developmental history? What was their temperament as a child (e.g., easy to soothe, difficulty eating or sleeping)? Where does the impulsive behavior occur (e.g., at school, at home, in the community, everywhere)? Is the person generally well-controlled but then suddenly explode? Does the person make spur-of-the-moment decisions such as taking a weeklong vacation at the drop of a hat?

Because inadequate sleep can make it more difficult to manage impulses, counselors should also ask clients about their sleeping habits, Skinner adds.

It also can be beneficial, if given consent by the client, to speak with others who are around the client on a regular basis, Hudspeth says. All of these situational factors can help counselors determine how best to treat the impulsive behavior, he explains.

Contextual factors such as culture, gender and socioeconomic status also can play a role. Hudspeth points out that every culture perceives and deals with impulsivity differently, so counselors need to consider these factors too. For example, are clients being impulsive because they feel they may never have that experience again or because they’ve never had that experience before and thus don’t have a tool in their toolbox to deal with it? “If it’s an experience that you don’t have on a regular basis and your brain hasn’t collected enough evidence on how to deal with it, then you [may be] impulsive,” Hudspeth observes.

Some recent studies suggest that living in poverty can lead people to opt for short-term rather than long-term rewards. For example, the well-known marshmallow experiment (in which a child’s ability to delay gratification of eating a marshmallow predicted better life outcomes) has recently been challenged by Tyler Watts, Greg Duncan and Haonan Quan’s 2018 study that aligns one’s social and economic background with the ability to delay gratification.

Factors such as trauma, depression and poverty can all affect people’s abilities to regulate their impulses and can make it difficult for them to see the world outside of themselves, Skinner adds.

Thus, to get a better sense of clients’ skills for handing their impulses, counselors should ask how they respond in new or unfamiliar situations, Hudspeth says.

Hudspeth also warns counselors not to latch on to the initial report or diagnosis too quickly when it comes to impulse-control issues. “There’s a lot more behind it than just the symptoms that somebody has reported,” he explains. “It takes a thorough comprehensive intake with assessment and then the willingness to more or less change as you know more.” He advises counselors to consider the first 90 days with the client as a continual period of assessment in which the diagnosis could change as the counselor learns more.

The shame of impulsivity

With impulse-control disorders, the client’s distress can adversely affect the well-being and safety of others and even violate others’ rights (through aggression or destruction of property, for example).

Impulse control “is one of those disorders that could be considered to be both internal and external,” Hudspeth says. “Internally, you’re not stopping yourself from doing something that’s impulsive. Externally, you’re affecting others. You’re in their space. You may be disruptive. You may be yelling. The origins are internal, but how it displays and who it affects is the individual and everybody around them.”

People who struggle with impulsivity often act without thinking and frequently lament their actions almost immediately afterward, which means their lives might be filled with regret, Skinner says. That consistent presence of regret can turn into shame, she adds.

In fact, one huge warning sign that clients’ impulsivity is getting out of hand is when they try to keep their impulsive behaviors a secret, Galinis points out. Even clients with whom she is familiar will sometimes mention impulsive behaviors they have been hiding from her, especially if they involve vulnerable topics such as sexual behavior or addiction. This secrecy results from the sense of shame these clients feel over their behavior and lack of impulse control, she says.

When clients mention being anxious or having uncomfortable emotions, counselors should check in to see how they are handling those emotions, Galinis advises. Asking how clients are coping often opens a door into the unhealthy and impulsive ways they are attempting to manage those feelings, she adds.

With her younger clients who have trouble identifying and communicating their feelings, Skinner likes to read books such as Bryan Smith’s What Were You Thinking? Learning to Control Your Impulses, about a boy whose impulsivity often gets him in trouble. Eventually, the boy learns to control his impulses by thinking about the possible consequences of his actions.

“Reading stories with clients, especially with children, takes the focus off of them, helps them realize they’re not the only person who is struggling with [impulsivity], and shows them possible solutions,” she says.

Engaging emotions and the senses

Impulse control “is not often based in logic,” Galinis says. “It is an emotional experience that drives the behavior, so we need to be able to incorporate the emotions into it because logic is going to fall short every time.” Counselors can’t simply tell people to stop being impulsive. Instead, she explains, they have to help clients understand their emotions and connect them to their behaviors.

“Sometimes we will act on an emotion before we even realize that we are having that emotion,” Skinner notes. For instance, a child might instinctively yell when a teacher enforces limits on the child. Children don’t necessarily know how to handle their feelings when someone makes them mad, so they just react, Skinner explains.

Thus, a large part of her work with clients involves helping them understand their emotions. “Just being able to name your emotions takes … the reactive part of the brain offline and allows your executive functioning to come into play more, and as soon as your executive functioning is coming into play, you’re going to have a better response to the situation,” Skinner says.

She often uses the Disney-Pixar movie Inside Out to explain to younger clients how each emotion has a purpose. “Emotions don’t just happen out of the blue,” she says. “They happen because we have a need that needs to be met.”

To help clients develop a habitual awareness of their emotions, Galinis has clients pick a number on the clock in her office. Then, she tells them that every time they see that number anywhere throughout the course of their day, they should check in on how they are feeling in the moment.

Skinner also gets creative to help clients better understand and name their emotions. For instance, she asks clients to play feelings charades (in which they name and act out all of the feelings they can think of). She also has clients look through magazines and find different emotions on people’s faces. Sometimes, she has clients make up stories about why the person in the magazine feels that way. “That [exercise] helps develop empathy and perspective taking, and both of those things are really important in treating impulse-control disorders,” she says.

Skinner also advises parents and caregivers to continue these exercises at home by pausing when reading stories or watching television to discuss characters’ emotions. She recommends asking questions such as “What do you think this person is feeling right now?” and “Why is the person feeling this way?”

She explains that guiding clients to develop a broad, robust vocabulary about their emotions will help them learn over time to act, not just react, when they are feeling impulsive.

Slowing the process down

Because impulsivity is a quick response, Galinis’ goal is to help clients slow down. She wants clients to connect to their feelings without flooding their emotions, she says. To help clients achieve this balance, she often uses somatic experiencing, which aims to regulate or reset the nervous system by releasing the energy accumulated during stressful events.

For example, if a client is talking about an event that was triggering during the week, Galinis may stop the client upon noticing that he or she is getting agitated and ask what the client is feeling in the body. If the client responds, “My hands are clenched,” she will direct the client to hold that feeling and then ask what the clients wants to do. The client may say, “I want to punch something.” Then, with Galinis’ help, the client will follow through with the punch in slow motion. According to Galinis, this technique helps clients get “unstuck” so they can fully process their impulse and the emotions in their body.

Galinis also has clients create a timeline of feelings and actions surrounding an impulsive behavior. For example, she may have clients walk her through what they noticed from the moment they woke up until the moment they impulsively started watching pornography, even though they hadn’t planned to or didn’t want to. As they talk through this event, she will ask what they notice in their body. Is their heart rate elevated? Does their stomach feel swirly?

If clients notice a change in their body, Galinis tells them to hold on to the uncomfortable feeling for a minute rather than immediately trying to get rid of it or run away from it. This process helps clients build up distress tolerance so that when they’re feeling uncomfortable, they are less likely to feel the need to escape and act impulsively, she explains.

Like Galinis, Skinner uses behavioral sequencing to help clients connect their thoughts, feelings and actions. She asks clients: What is the problem? What happened before you acted out? What happened and what were you feeling during the impulsive behavior? What was the outcome? “Through that process, we try to figure out offramps from that one trajectory that they are on,” she says.

Skinner also finds mindfulness useful with impulse-control disorders because it helps clients understand what is happening in the body. She recommends the 5-4-3-2-1 grounding technique, which engages the senses to help clients get back to the present. With this technique, counselors tell clients to take a deep breath and name five things they see, four things they feel, three things they hear, two things they smell and one thing they taste.

Skinner says meditation is one of her favorite tools for addressing impulsivity because it calms the nervous system down, which allows clients to make better choices instead of just reacting.

Galinis keeps tactile sensory objects such as stress balls, stuffed animals and a cozy blanket in the counseling room to make clients feel more comfortable and to help them calm their body down. Sometimes she even lets clients take a calming stone or an essential oil home with them because it serves as a tangible reminder of what they are working toward and aids them in finding that sense of calm they experienced in her office.

Learning control through play

Impulsive behaviors can frequently impede on the rights and safety of others. This means that many clients who enter counseling for impulsivity might not be there of their own accord. In fact, Skinner says that 95% of the time, her child and adolescent clients are seeing her at someone else’s suggestion.

Understanding that these clients may be reluctant participants in counseling, she uses creative counseling techniques such as games and role-playing. Any activity “where kids have to really stop and think about what their body is doing and pay attention to their surroundings is really helpful and fun” for them, she says. Games also help take the focus off of the client and their “problem,” she adds.

Skinner particularly likes to use the therapeutic board game Stop, Relax & Think with clients who struggle with impulse control. The objective of the game is to help impulsive children think before they act. Players move through the Feelings, Stop, Relax and Think stations on the board, collecting chips along the way.

With the feeling cards, clients name how they would feel in different situations. For example, if the card says, “Your brother hits you,” the client might respond, “I would be angry and want to hit him back.” The cards support clients in better understanding not only their own feelings but also the other players’ feelings, which helps them develop perspective taking, Skinner says.

When players land on a stop sign space, they have to perform an action such as patting their head and rubbing their stomach — which, as Skinner points out, requires a lot of concentration — until another player says, “Stop.” If the player stops immediately, then he or she gets a chip.

Skinner loves that clients can judge counselors when landing on this space. Children, especially ones with ODD, often feel powerless, she points out, and this stopping activity allows them to feel empowered in a safe, healthy way. Sometimes Skinner will purposely fail to stop in time. She wants clients to know that she’s not perfect and doesn’t expect them to be either. It also allows her to model appropriate behavior when someone is frustrated or makes a mistake. 

The relax spaces on the board help clients learn how to calm their bodies. The space may instruct them to take three slow breaths, think about white clouds, or say “I am calm” three times. With the think cards, players come up with ways to handle different scenarios (such as a friend breaking their favorite toy) and earn a token if it is a good plan.

Skinner also uses games such as Uno and Parcheesi to help clients learn how to wait their turn and practice impulse control. In addition, she recommends basic childhood games such as Mother May I; Red Light, Green Light; Simon Says; and Follow the Leader. She says counselors can even stage relay races in which children have to walk carefully while balancing a marshmallow on a spoon. These types of games also work well for group counseling sessions, she adds.

Hudspeth, editor of the International Journal of Play Therapy and The Journal of Counselor Preparation and Supervision, agrees that games are a great way to help child and adolescent clients learn to focus and grasp that there is a sequence of events they must follow to get what they want. Take darts, for example. “Just throwing the dart at the wall is not going to get you points,” he says. “Taking time to aim at the place that’s going to get you the most points is more likely to get you to the place of winning the game.” 

When sessions become impulsive

Sometime clients’ impulsive behaviors spill into the counseling session. When this happens, Skinner reminds counselors to be calm, ignore the bad behavior and reward the positive behavior.

When Skinner worked as a clinical intern at an outpatient clinic with youth who experienced trauma, she had clients whose impulsive and aggressive behavior resulted in overturned chairs and tables and smashed lamps in the office. When this happened in group settings, she would get the other kids out of the room and then make sure the child having the impulsive reaction stayed safe. Other than that, she would show no reaction to the outburst and praised the child when he or she calmed down and regained control.

Control is a big part of impulsivity, Hudspeth points out. For this reason, he uses play therapy, which provides clients with a sense of control but allows counselors to set limits and model appropriate behavior in a safe, trusting environment. For example, with children with impulsive behaviors, Hudspeth would tell them they were allowed to do anything in the playroom as long as they didn’t hurt themselves. This statement might not have been one hundred percent true, he says, but it helped the children feel a sense of control. Then, if a child picked up a Nerf gun and shot darts at him, he would respond, “I am not for shooting, and if you choose to shoot me, you choose not to play with that toy.” After setting this limit, he would offer the client an alternative (and more appropriate) behavior such as shooting the wall.

Skinner and Hudspeth both point out that counselors might also have to train parents to use this method at home to help their children make progress with the impulsive behavior. Often, people assume that children understand what is happening during the impulsive moment, so they may yell or remove children from the situation without giving them a reason, Hudspeth says. “By setting the limit and giving them the alternative and then telling them what the consequence is, you’ve spelled it all out,” he explains. “There’s nothing left to wonder about as a child.”

One realization Skinner had was that clients with impulse-control issues, and especially those with ODD and conduct disorder, could trigger her own impulsive and angry reactions. She acknowledges that sometimes it is difficult as a counselor to hear what certain clients are doing to other people or how they are reacting. In fact, she admits once making a snarky comment to an adult client who was rolling his eyes and being defiant throughout a session. Skinner says she instantly felt terrible and knew that her comment wasn’t helpful to the counseling process.

The experience taught Skinner that she has to temper her own impulses and focus on giving clients what they need in session. She says she also learned that she needs to take a moment between sessions to calm down and prepare for the next one. Even if all she has available is 30 seconds, she closes her door, takes a deep breath and centers herself.

It’s quite possible that counselors will face challenging moments with clients who struggle with impulse control. Five years later, Skinner is still working with the client who stormed out of the counseling session determined to walk home, only to turn around and lock her out of her own office. Thankfully, he has come a long way since that first meeting

Challenging sessions still occur in which the client comes in and won’t say a word. Skinner simply responds, “That’s OK. I guess this is going to be a quiet one. Let me know if you want to do anything.” Sometimes, the client will say that he wants to play a game.

“But within that space, he has learned how to control himself a little bit,” she says. “He has learned that he has some control over his life. He has found his voice … and he’s been able to assert himself with adults in a calmer and more appropriate way.”

 

 

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

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.

Heading to college with social anxiety

By Bethany Bray July 31, 2019

The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety.

The key is preparation, says Holly Scott, a licensed professional counselor whose Dallas private practice is a regional clinic of the National Social Anxiety Center. Counselors who are working with college-aged clients with social anxiety should talk through and create a plan for the client to navigate the many anxiety-provoking situations that may arise as they begin (or return to) school.

Try and anticipate daily challenges with the client, such as eating in the cafeteria with peers instead of taking food to go and eating it alone in their dorm room. Talk through healthy ways to negotiate shared space with a roommate who has a different lifestyle or sleeping schedule, Scott suggests. Help the client identify places on campus where they can study quietly as well as plan for ways to meet new friends, such as joining clubs on campus or finding volunteer or extracurricular activities.

“If I’m working with a client who is getting ready for college, we focus a lot on getting rid of avoidance behavior. People with social anxiety might rush back to their dorm room [after class] because it’s scary for them, which can lead to isolation … Their strongest coping skill is often avoidance,” Scott says.

Help the client identify what might be the most fearful experiences for them, and build a plan with healthy coping mechanisms and small goals they can work toward. Perhaps they’re anxious about the thought of having to share a bathroom and walk down the hall to take a shower. Talk that through with the client and get creative, Scott suggests. For someone with social anxiety, the best plan might be to schedule a daily shower in between classes during the day, when the dorms will be quieter.

“The first step is educating the client on what to expect at college. Some have a good idea but others don’t,” Scott says. “The more they can see what it will be like – what will their dorm room look like, where they will eat, what the classrooms look like – the better. Lower their level of uncertainty as best you can. Establish a daily plan. [Unmanaged] social anxiety can lead to depression so it’s good to equip clients with a routine.”

Scott recalls a college-aged client whose social anxiety would spike on weekends, when he didn’t have scheduled classes. She worked with him to set small goals and establish a plan for weekends, such as inviting someone to lunch or going to a sporting event on campus.

More than being shy, introverted or socially awkward, social anxiety is a diagnosable form of anxiety that is accompanied by a constant feeling of apprehension regarding social or performance situations and a fear of judgement from others.

Roughly 12% of U.S. adults will experience social anxiety disorder in their lifetime, according to the National Institute of Mental Health. In adolescents (ages 13-18), the lifetime prevalence is 9.1%.

In cases of severe social anxiety, a counselor can work with a college for special accommodations for the client, such as finding a single (unshared) dorm room, Scott notes.

While planning ahead for the college transition is important, it’s equally vital to ensure that clients with social anxiety continue to check in with a counselor throughout the semester, Scott says. It’s helpful for clients to debrief – and readjust, if needed – on the ways they’re managing their anxiety, as well as the goals they’ve set with a counselor.

If a client goes to college far from home, teletherapy or phone conversations with their existing counselor may be an option. But ideally, a client who needs regular sessions should find a local counselor to see while on campus, either at a college counseling center or in the community, Scott says. If granted permission by the client, a counselor can work in tandem with the client’s college counselor, sharing treatment plans and keeping in contact.

 

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Read more on living with social anxiety in Counseling Today’s August cover story, “More than simply shy.”

 

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Transitioning to college life: Tips for success

“Should I change my major?” “What should I do this weekend?” “Should I drop this class?” It’s easy to feel paralyzed by all the potential and possibilities that come with starting college. Decisions — even minor ones — often feel as if they will have an unchangeable and lasting impact on the direction your life will take.

If you’re feeling overwhelmed, know that you’re not alone. University counseling centers across the country are seeing an increase of students looking for support as they face the academic and social challenges college can bring, says Richard Tyler-Walker, president of the American College Counseling Association. Social anxiety, social isolation, interpersonal and self-esteem issues are some of the most common issues that bring students to college counseling centers, according to the Center for Collegiate Mental Health.

Setting small goals – and reaching out to your college counseling center for extra support – can help you find balance and manage anxiety as you start college, says Tyler-Walker, a licensed professional counselor supervisor and associate director of the College Counseling Center at North Carolina State University in Raleigh. He suggests the following:

  • Set realistic goals. A student who may not have had the social life they wished for in high school may view college as a fresh start or a “do-over.” College is a time to build new friendships and deepen existing ones. A person can set themselves up for success by setting goals that reflect who they are, not who they wish they were. It is unlikely that someone who is most comfortable with quiet conversation will feel content becoming the life of the party.
  • Build a network. Many students report feeling socially isolated at college. As you walk across crowded lawns and through noisy hallways on campus, it can feel like everyone else has all the friends they need. Reach out to acquaintances who are going to the same college. Start a conversation with your roommate before you arrive on campus. Get to know your resident advisor (RA), teaching assistants, academic advisor and other helpful personnel. Join a group for people with similar interests. Identify a cultural center on campus that interests you. Most colleges have centers for groups that include women, African American, LGBTQ and multicultural students.
  • Practice being friendly. Introduce yourself to a new person each day. Join clubs that focus on things of interest. Student involvement can help with getting a sense of the college or university and starting to build connections with others. Challenge yourself to go to meetings at least three times before deciding if it’s right for you. This will allow you to see the core group of people that attend and allows the members to become more familiar with you at the same time.
  • Embrace orientation. Orientation is staffed by student affairs professionals and trained students who focus on creating a welcoming environment for all new students. It’s a time to learn about the ins and outs of the system and make connections with others. Everyone is new to the college, so orientation is a great level playing field.
  • Pick a residence hall that suits you. “Where will I live?” It’s one of the first decisions a college student makes. Residence halls may be massive dormitories where there are shared rooms and bathrooms. In other cases, they’re set up with suite-style rooms or learning villages. Some students may enjoy the anonymity of a larger space while others may benefit from a smaller environment – especially where there might be common thread that connects. Learning villages at universities put students with common interests such as the arts, international studies, women in science, technology or other subjects together.
  • Find a space to breathe. Colleges and universities range from massive to virtually pocket-sized. Whatever the size of your school, look for a quiet corner where you can get away when you need to have some quality alone time. You might have done this by your choice of residence, such as a single room. For those whose living quarters are not a solitary refuge, every library, student union, green space and building on a college campus can have a nice spot for sanctuary if you keep your eyes open.
  • Reduce avoidance. No one likes the feeling of anxiety and we tend to avoid those situations that make us anxious. The more we do that, the more we create an endless loop of anxiety and avoidance. Your anxiety is trying to tell you that it is keeping you safe by not putting you into situations that will be scary. Once you put a name on fear it has much less power over you.
  • Practice, practice, practice. No one is a virtuoso the first time they pick up an instrument. It takes practice and skill. Don’t get caught up in whether [social skills] seem easier for others than for yourself. This is a challenge that you can welcome with the right attitude. Practicing these skills isn’t a matter of standing in front of a mirror, it’s about incorporating small moments of opportunity throughout the day. Practice smiling at others, saying hello, accepting a compliment, telling a joke or even flirting.
  • Ask for help if you need it. College counseling centers have trained staff that can help through counseling, either in group or individual formats. Counselors can build on the skills you’ve identified and help create harmony between your public and private selves.

Source: Richard Tyler-Walker, LPC-S, president of the American College Counseling Association, a division of the American Counseling Association.

 

 

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Bethany Bray is a senior 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.