Tag Archives: Counselors Audience

Counselors Audience

Procrastination: An emotional struggle

By Lindsey Phillips October 24, 2019

Procrastination is a common issue — one that people often equate with simply being “lazy” or having poor time-management skills. But there is often more to the story.

William McCown, associate dean of the College of Business and Social Sciences and professor of psychology at the University of Louisiana at Monroe, cites a case example of a man in his mid-30s with a degree in chemical engineering who was procrastinating about applying to graduate school. The client reported just not being able to “get it together.” Through therapy, however, the man discovered that he had an emotional block. His parents supported his choice to get another degree, but their own lack of formal schooling often led them to make detractive comments, such as the father stating that when his children thought they were as smart as him, he would just die. The client came to realize that comments such as these sometimes incited him to self-sabotage his career.

According to Joseph Ferrari, a psychology professor at DePaul University in Chicago, “Everyone procrastinates, but not everyone is a procrastinator.” His research indicates that as many as 20% of adults worldwide are true procrastinators, meaning that they procrastinate chronically in ways that negatively affect their daily lives and produce shame or guilt.

According to McCown, a pioneer in the study of procrastination and co-author (along with Ferrari and Judith Johnson) of Procrastination and Task Avoidance: Theory, Research, and Treatment, procrastination becomes problematic when it runs counter to one’s own desires. “We all put things off,” he notes. “But when we put off things that are really in our best interest to complete and we do it habitually, then that’s more than just a bad habit or a lifestyle issue.”

McCown finds that clients with chronic procrastination often come to counseling for other presenting concerns such as marital problems, depression, work performance issues, substance use, attention-deficit/hyperactivity disorder (ADHD) and anxiety. He has noticed, however, that younger generations are starting to seek counseling explicitly to work on procrastination.

McCown says that among Gen Xers and particularly among baby boomers, tremendous stigma existed around procrastination. But that largely changed with the Great Recession, he contends, because people realized that having a procrastination problem hurt them at work — a luxury they could no longer afford.

Managing emotions, not time

A growing body of research suggests that procrastination is a problem of emotion regulation, not time management. Julia Baum, a licensed mental health counselor (LMHC) in private practice in Brooklyn, New York, agrees. “Poor time management is a symptom of the emotional problem. It’s not the problem itself,” she says.

Nathaniel Cilley, an LMHC in private practice in New York City, also finds that chronic procrastination is often a sign of an underlying, unresolved emotional problem. People’s emotional triggers influence how they feel, which in turn influences how they behave, he explains. However, clients may incorrectly assume that procrastination is their only problem and not connect it to an underlying emotional issue, he says.

People procrastinate for various reasons, including an aversion to a task, a fear of failure, frustration, self-doubt and anxiety. That is why assessment is so important, says Rachel Eddins, a licensed professional counselor and American Counseling Association member who runs a group counseling practice in Houston. “There’s not one answer to what procrastination is because [there are] so many things that lead to it,” she says.

Procrastination can also show up in conjunction with various mental health issues — ADHD, eating disorders, perfectionism, anxiety, depression — because it is an avoidance strategy, Eddins says. “Avoidance strategies create psychological pain, so then that leads to anxiety, to depression, and to all these other things that people are calling and seeking counseling for,” she explains.

Sometimes, procrastination may even mask itself initially as another mental health issue. For example, overeating in itself is a procrastination strategy, Eddins says. She points out that if certain people have a hard task they are avoiding, they may head to the refrigerator for a snack as a way of regulating the discomfort.

If a client comes to counseling because he or she is binge eating and procrastinating on tasks, then the counselor first has to determine the root cause of these actions, Eddins says. For example, perhaps the client isn’t scheduling enough breaks, and the stress and anxiety are leading to binge eating. Perhaps food acts as stimulation and provides the client with a way to focus, so counselors might need to explore possible connections to ADHD. Maybe the client is rebelling against harsh judgment, or perhaps the root cause is related to the client experiencing depression and feeling unworthy.

One approach Eddins recommends for finding the root cause is the downward arrow technique, which involves taking the questioning deeper and deeper until the counselor uncovers the client’s underlying emotion. For example, if a client is avoiding cleaning his or her house, the counselor could ask, “What does it mean to have a messy house?” The client might respond, “It means I can’t invite people over.” The counselor would follow up by asking, “What does that mean?” These questions continue until the client and counselor get to the issue’s root cause — such as the client not feeling worthy.

Eddins and Cilley both find imaginal exposure helpful for accessing clients’ actual memories and experiences and discovering the underlying cause of procrastination. For instance, if a client is procrastinating over writing an article, Cilley may have the client imagine sitting at his or her desk and staring at the blank computer screen. Cilley would ask, “What’s going on in this moment? Where are we? What is around you? How are you feeling emotionally at the thought of writing this article?” The client might respond that he or she feels anxious about it, which means the underlying cause is emotional.

“Imagination is really great with drumming up emotions,” Cilley notes. “The emotion starts to come into the session when [clients visualize what they are avoiding].”

Addressing irrational thoughts

“You can do all the time-management skills in the world with someone, but if you haven’t addressed the underlying irrational beliefs fueling the anxiety, which is why they’re procrastinating, they’re not going to do [the task they are avoiding],” notes Cilley, an ACA member who specializes in anxiety disorders.

As described by Cilley, the four core irrational beliefs of rational emotive behavior therapy (REBT) are:

  • Demands (“should” and “must” statements such as “I should go to the gym four times a week”)
  • Awfulizing (imagining a situation as bad as it can be)
  • Low frustration tolerance, which is sometimes referred to as “I-can’t-stand-it-itis” (belief that the struggle is unbearable)
  • Self-downing (defining oneself on the basis of a single aspect or outcome, such as thinking, “If I mess up one work project, then I am a failure”)

“When we’re having procrastination problems, a lot of times we awfulize about the task and have abysmally low frustration tolerance about the energy required to do it,” observes Cilley, a certified REBT therapist and supervisor and an associate fellow at the Albert Ellis Institute. “And we disproportionately access how bad it would be to do it or to be put through it and minimize our ability to withstand or cope with it.” Put simply, sometimes when people think something will be too difficult, they don’t do it.

Another common reason people procrastinate is a fear that they could fail, and they interpret failure to mean that something is inherently wrong with them, Cilley says.

For example, imagine a client who comes to counseling because he procrastinates responding to work emails out of fear that he will answer it incorrectly and his co-workers will realize he is a failure. To first identify the root cause, Cilley would ask a series of open-ended questions to the client’s statements regarding procrastination: I am avoiding responding to emails at work. What would it mean if you responded to the emails? I’m afraid I would do it incorrectly. What if you did respond incorrectly? My boss would think I’m an idiot. What would that mean to you? That I’m no good at my job. I’m a bad employee.

A self-label of “bad employee” causes the client to filter everything through that lens, including minimizing the good that he does, Cilley points out. In addition, the man will act as if he is a “bad employee,” which reinforces this label and makes him more prone to procrastination, Cilley says.

One technique that Cilley uses with clients to challenge unhealthy thinking and break the vicious cycle is the circle exercise. He draws a big circle, and at the top he writes the client’s name. At the bottom, he writes the negative thought in quotes — “I’m a bad employee.” Then, he places six plus signs and six minus signs inside the circle and asks the client to think of six things that he or she does poorly at work. The client might respond, “I procrastinate on tasks, I show up late, I make mistakes when I respond to emails” and so on. Next, Cilley has the client name six things that he or she does well. For example, the client could say, “I care about the work I do, I stay late if needed, and my co-workers can depend on me.”

If clients respond by saying that they don’t have any positive qualities at work, then Cilley will ask them to think about what positive things another co-worker would say about them (even if the clients don’t believe the statements themselves).

Next, Cilley circles one of the statements in the minus category and asks the client if this one negative statement erases the other six positive statements. To emphasize the flawed logic, he may also ask if one positive trait causes all of the negative ones to go away and makes someone a “perfect” employee.

This exercise challenges black-and-white thinking and helps clients separate their identities from their actions or the task they messed up on, such as sending an incorrect email, Cilley explains.

Even after clients identify their irrational beliefs and create rational coping statements (positive beliefs used to replace the negative and irrational ones), they still may not believe the rational ones. When this happens, Cilley uses an emotiveness exercise he refers to as “fake it till you make it.” He asks clients to read the rational beliefs out loud 10 times with conviction — as if they were Academy Award-winning actors and actresses who wholeheartedly endorse and embrace the beliefs.

If clients are going to rebut thoughts such as “I am a failure” and “I can’t do anything right,” then a monotone voice won’t help them change their thoughts or calm down, Cilley notes. “Anyone can go up on stage and read a speech,” he says. “The emotion and conviction behind your voice is what moves the audience, and that’s what we have to do to ourselves when we’re trying to convince ourselves of the rational beliefs.”

Even though clients may not initially believe what they are saying, by the eighth or ninth time they repeat it, they are finally internalizing the beliefs, Cilley says. On the 10th time — when clients are starting to actually believe what they are saying — he records them repeating the rational beliefs. Clients are then instructed to listen to this recording three times per day throughout the week as a way of talking themselves into doing whatever they have been procrastinating over, he says.

Cilley has also used role-play to help clients put stock in more rational thoughts. He does this by adopting the client’s irrational belief (e.g., “I am a failure” or “I am unworthy”) and then asks the client to try to convince him of more rational thoughts. By doing this, the clients start to convince themselves. Even though clients often laugh at this exercise, Cilley has found it to be one of the quickest ways to change clients’ irrational thoughts.

REBT and other short-term therapy techniques are not just effective but also efficient for clients who procrastinate, notes Baum, a rational emotive and cognitive behavior therapist and supervisor, as well as an associate fellow at the Albert Ellis Institute. With procrastination, clients often want to see results quickly, she says. They want to finish the work project, clean their house or get to the gym next week, not next year. REBT helps clients quickly “take responsibility for their behavior and recognize that they have agency to change it,” Baum emphasizes.

Learning to tolerate discomfort

Often, people procrastinate to avoid discomfort, Eddins notes. This discomfort comes in many forms. Maybe it’s procrastinating on beginning a complex task at work out of fear of failure, or avoiding having a difficult conversation with a friend.

The first step is helping clients become aware of the discomfort they are avoiding, Eddins says. “When we suppress our feelings, that’s when the procrastination and avoidance habits emerge,” she adds.

Eddins often uses the “name it to tame it” technique. She will first ask clients what they are feeling when thinking about the task they are avoiding. Clients may not have a word for this discomfort, so she will ask them to identify what they are feeling physically, such as a tightness in their chests.

Baum, a member of the New York Mental Health Counselors Association who specializes in helping creative professionals and entrepreneurs overcome procrastination, helps clients learn to cope with feelings of discomfort through imaginal exposure. First, Baum teaches clients coping skills such as breathing exercises to use when they experience discomfort. She also helps them identify, challenge and replace irrational thoughts that contribute to emotional distress and self-defeating behaviors. Then, she asks them to imagine walking through the scenario they have been avoiding.

For example, a man procrastinates about going to the gym because he feels ashamed of being out of shape. The client thinks to himself, “I’m out of shape. I won’t fit in at the gym. I’m no good because I let myself go.” These thoughts and his fear of others judging him prevent him from going to the gym despite the health benefits.

To address this emotional problem, Baum would have the client imagine walking into the gym and getting on the treadmill as others stare at him. During this exercise, she would guide the client to breathe slowly to keep his body calm and have him practice rational thinking, such as accepting himself unconditionally regardless of the shape he is in or what others may think. This will help him overcome his shame and productively work toward a healthy fitness routine.

Eddins also uses a mindfulness-based technique called “surfing the urge” to help clients. She instructs clients to stop when they feel the urge to procrastinate and ask themselves what the urge feels like in their bodies and what thoughts are going through their heads. For instance, clients may notice having an urge to get up and grab a snack rather than work on their task. This technique helps them learn to sit with their discomfort and face the urge rather than distracting themselves from it or trying to change it, she explains.

The power of rewards and consequences

Cilley finds rewards and consequences a useful motivational tool for those clients who are good at identifying irrational beliefs and who already possess coping and emotion-regulation skills yet are still procrastinating when faced with certain tasks (or even their therapy homework). For example, clients could reward themselves by watching their favorite show on Netflix after they complete the task. The ability to watch the show could also become a consequence — they would withhold watching the show until they complete the task.

Counselors may need to help clients determine appropriate rewards. McCown, a clinical psychologist at the Family Solutions Counseling Center in Monroe, Louisiana, finds that clients sometimes want to use grandiose rewards that really aren’t helpful motivators. For example, a client may decide that he or she will take a trip to Europe after finishing writing a novel. McCown notes that the likelihood of this motivating the client to make progress on the novel isn’t as strong as if the client used smaller rewards, such as going out with a friend or taking a walk to celebrate completing 300 words of their novel.

If clients are having trouble enforcing rewards or consequences themselves, counselors can become the enforcers — but only as a last resort, Cilley says. For example, Cilley had a client who was procrastinating when it came to taking steps toward starting a side business because he feared he would do it imperfectly, and that would make him a “failure.” After learning how to identify his irrational thoughts and how to regulate his emotions, the client still needed one final push to start his business. The client was a gamer, so both he and Cilley agreed that if he didn’t start his business that week, Cilley would change the client’s PlayStation 4 password so that he couldn’t play video games until after the business was launched.

“You want to make sure you have a good working alliance with the client and that they feel safe to be vulnerable and that [you] can laugh about this [with them] because it’s kind of unorthodox. But sometimes that’s what works for some people. They need that accountability,” Cilley says. “Just laughing about how silly the consequence is in therapy can make it more of a fun challenge.”

Giving yourself permission

Eddins finds that shame is a big factor with people who procrastinate. “Somehow we learned that shame [is] a way of motivating — ‘If I’m just hard on myself, then maybe I’ll get it done’ — and that for sure backfires and leads to procrastination,” she says.

For some people, their inner critic is shaming them constantly with “should” statements (e.g., “I should work out four times a week”). Procrastination is their way of rebelling against this harsh judgment, Eddins explains.

Self-compassion is one way to address critical thoughts and shaming, Eddins says. For example, the critical inner voice that declares a client lazy if he or she doesn’t go to the gym could be changed to use more motivating statements such as “It feels good when I go outside and move my body.”

In addition, if critical thoughts start to surface when clients are trying to complete a task, they can use a self-compassionate voice to remind themselves that they will feel better after they take a break, Eddins advises. In fact, the act of giving oneself permission to take a break, practice some self-care, and rest and relax can sometimes break the cycle of procrastination, Eddins says.

A 2010 study found that students who forgave themselves for procrastinating when studying for a first exam were less likely to procrastinate when studying for the next one. The researchers concluded that self-forgiveness allows people to move past the maladaptive behavior and not be burdened by the guilt of their past actions.

At the same time, Eddins advises counselors to be careful with the technique of giving permission. Clients with black-and-white thinking may interpret that as the counselor telling them it is OK to be “lazy.” Instead, she recommends that counselors use this strategy within a context that the client will accept.

Eddins had a client who put off meal planning each week because it was stressful. When Eddins asked why it was stressful, she discovered the client was preparing up to three different meals each night to accommodate each family member’s personal preferences. Eddins knew that if she told this client to give herself permission to cook only one meal each night, the client would engage in black-and-white thinking: “Well, that would make me a bad mom.”

So, instead, Eddins said, “No wonder you are exhausted. You are trying to do everything for everyone else but not for yourself. This doesn’t work for you. You have permission to take care of yourself and do what works for you. And that does not make you a bad mother.”

Strategies for success

Procrastination does offer momentary relief and reward, which only reinforces the behavior and continues the cycle of avoidance, Eddins notes. So, the more times that an individual avoids a task, the more difficult it becomes to stop the cycle of procrastination.

In counseling, clients can learn strategies that are more effective than avoidance. One therapeutic technique that Eddins likes involves breaking tasks into smaller ones that are realistic and obtainable. For instance, an individual who hasn’t formally engaged in exercise in the past year might be tempted to set a goal of working out four times a week. This person has created an ideal “should,” but because the goal is overwhelming, he or she is likely to continue avoiding exercising, Eddins points out.

Should this happen, Eddins might explore why the client is procrastinating on the goal: “Tell me about the last time you worked out. When was that?”

When the client responds that it was a year ago, Eddins would suggest establishing a smaller goal to ensure success and build motivation. For example, the client could start by exercising one day a week for 10 minutes and build from there.

“I want [clients] to take the smallest possible step because I want to [help them] build success,” Eddins says. “That is actually reinforcing in the brain because … it gives you that sort of reward and that success, and then that allows people to achieve the goal.”

McCown points out that “the rehabilitation of a severe procrastinator is almost like working with a severely depressed person: Once they are able to … do anything, they will feel better about themselves, and they’ll have more self-efficacy.” That’s why it is important to get these clients to succeed at some task, even if it is a small and relatively meaningless one such as going to the grocery store or getting the car washed, he says.

Counselors can also help clients who procrastinate to create specific — rather than generic — goals, Eddins says. For example, a goal of “meal planning” would become “planning four meals for dinner on Sunday afternoon.” The counselor can then collaborate with these clients to identify the specific actions they will need to take to meet that goal: What typically happens on Sunday afternoons? What could get in the way of this task? How can you make time on Sunday afternoons? What do you need to prepare in advance? What steps will you take to complete this task?

Some clients, especially those with perfectionist tendencies, may resist setting a small goal or task because they don’t see it as “good enough” or as an effective way of achieving their larger goal, Eddins says. In these cases, counselors may need to address the client’s black-and-white thinking and the role it can play in procrastination, she adds.

Counselors can also help clients identify optimal times to complete tasks that they have been procrastinating on, Eddins says. For instance, clients might tell themselves they will complete an unpleasant task right after getting home from work. But if the counselor knows the client doesn’t like his or her job and will likely need some time to decompress after getting home, the counselor can point that fact out and note that it increases the likelihood of the client avoiding the task, she says.

Shifting clients’ focus to what they will do — rather than what they won’t do — is another way to motivate clients, Eddins says. For example, counselors can encourage clients to think along the lines of “I’m going to come home, get a glass of water, put on my tennis shoes, go out for a 10-minute walk, and then come home and fix dinner” rather than “I’m not going to sit on the couch this evening and watch television.” Trying to avoid procrastination or its underlying emotional root makes procrastination more active and powerful in one’s mind, Eddins points out.

All of these strategies can aid clients in addressing the deeper emotional problems connected to their procrastination. McCown stresses that procrastination won’t go away by itself. “Joe Ferrari phrases it quite beautifully: ‘It’s not about time.’ It’s often something deeper,” McCown says, “and I think counselors are in a great role to figure out whether it’s just simply a bad habit or whether it’s something a little more serious.”

 

****

 

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

Letters to the editor: ct@counseling.org

 

****

 

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.

Finding strength in sensitivity

By Lindsey Phillips September 24, 2019

When Louisa Lombard, a licensed professional clinical counselor in private practice in California, worked as a school counselor, parents would sometimes come to her saying, “My child is so sensitive. I don’t know why he’s like this. Everything is such a big deal. I parent my children the same way. Why is he like this? His brother’s doing great in school and not throwing tantrums and crying. What’s wrong with this kid?”

In actuality, nothing was “wrong” with the child. What the parents didn’t know was that their child had an innate temperament trait referred to as sensory processing sensitivity. Approximately 20% of the population has this sensitivity trait and is categorized as a “highly sensitive person.” Narrow that focus to the therapeutic world, and closer to 50% of psychotherapy clients possess this trait, according to Elaine Aron, a pioneer in the field of sensitivity, in Psychotherapy and the Highly Sensitive Person.

People with this trait often look carefully before entering new situations or retreat from overwhelming ones. For this reason, they are sometimes mislabeled as being shy, when in fact, an estimated 30% of highly sensitive people are extraverted.

Because no one person’s experience is the same, Aron identified four basic characteristics of the highly sensitive person (also known as the DOES model):

  • Depth of processing
  • Overstimulation
  • Emotional responsiveness and empathy
  • Sensitivity to subtleties

Aron points out that the sensory processing sensitivity trait is a survival advantage in some situations because it allows individuals to process information more thoroughly and increases their responsiveness to the environment and social stimuli.

So, why do highly sensitive people — who have this survival advantage — make up roughly 50% of therapy clients? Julie Bjelland, a licensed psychotherapist in private practice in California, thinks the number is so high because highly sensitive people are a) more responsive to therapeutic work and self-help and b) more likely to have higher levels of stress, anxiety and depression.

Heather Smith, an assistant professor of human development counseling at Vanderbilt University, posits that because these individuals process deeply, they are more inclined to seek out answers and are drawn to counseling for its penetrating conversations. In addition, she says, these clients may have developed low self-esteem because of negative stereotypes about sensitivity, or they might want tools to help them navigate times when they feel more emotional intensity.   

Misdiagnosing a trait for a disorder

According to Erica Sawyer, an American Counseling Association member in private practice in Vancouver, Washington, misdiagnosis of the highly sensitive person often occurs because people aren’t aware that the trait exists or of the trait’s specific characteristics. The scientific name for the trait — sensory processing sensitivity — doesn’t help. The similarity in name between sensory processing sensitivity and sensory processing disorder often leads to confusion. But sensory processing sensitivity is a temperament trait, not a disorder. (Aron notes on The Highly Sensitive Person website, hsperson.com, that sensory processing disorder, on the other hand, is a neurological disorder involving the senses.)

As Lombard points out, most therapists receive limited training on temperaments. She first learned about sensory processing sensitivity after graduate school when her oldest daughter started showing signs of the trait, including being sensitive to noise, facial expressions and food. As Lombard learned more, she realized that she is also highly sensitive. She had long suspected that she had attention-deficit disorder because she had a hard time paying attention in her college classes if another student was kicking a desk in a rhythmic pattern behind her or if there was a bright light overhead in the room.

In fact, because highly sensitive people can get overwhelmed and overstimulated more easily when a lot is going on around them, they can commonly be misdiagnosed with attention-deficit/hyperactivity disorder (ADHD), Bjelland says. However, whereas a highly sensitive person is typically able to concentrate in the right environment — when at home in a quiet room, for example — someone with ADHD might not be, she explains.

One confusing aspect to the highly sensitive temperament is that it doesn’t necessarily produce problems in daily life other than overstimulation, says Smith, a licensed professional counselor and an ACA member. Thus, when clinicians hear about a client’s distress due to overstimulation, they can erroneously attribute it to symptoms of a disorder, she explains. To help prevent this, Smith recommends that counselors investigate whether a client’s issue (such as anxiety, stress or an inability to concentrate) decreases if he or she is no longer in an overstimulating environment. If the client’s issue is still present, then it might be a symptom of a disorder.

Smith also points out that counselors often rely on observable behaviors to indicate a possible symptom or disorder. However, depth of processing is not easily observable, she notes. To help counselors learn to identify this characteristic, Smith describes some cues: Highly sensitive people think more about the meaning of life. If in an environment where they are not overstimulated and their ideas are valued, they have the ability to describe all facets of a problem and generate potential prevention steps or solutions — often before others realize there is a problem. They are observers, not the ones to jump into action. They often don’t make decisions quickly. When they speak, it seems as though they have grasped the insight or concept quickly, in large part because they have been thinking about all of these connections for most of their lives.

One tool that can help counselors assess for sensory processing sensitivity is Aron’s 27-item self-test (see hsperson.com/test/highly-sensitive-test). Smith, Julie Sriken and Bradley Erford analyzed the strength of this scale and found it to be a valid screening instrument that counselors can use in their practices (see “Clinical and Research Utility of the Highly Sensitive Person Scale” published in the Journal of Mental Health Counseling.) Smith presented on this topic at the ACA 2019 Conference.

However, to avoid labeling, Smith cautions counselors against placing too great an emphasis on the cutoff score of this self-test. Instead, she recommends having a conversation about how the client marked each item on the scale. This approach focuses less on the total score and more on the person’s experience overall and with each item.

Smith also advises counselors to be careful about interpreting the results from these test items or problem-solving a client’s distress too early on the basis of these initial conversations. In addition to risking misdiagnosis, counselors run the risk of not being seen as credible by clients who have been deeply thinking about issues related to this trait for a while, she says.

Wired differently

Misunderstandings about the sensory processing sensitivity trait also occur when it is assumed that this population is just sensitive to lights and sounds. It is more than that. The brains of highly sensitive people are wired differently than the brains of other people. A 2018 post on the website Highly Sensitive Refuge notes four differences in the brains of highly sensitive people:

  • Their brains respond to dopamine differently.
  • Their mirror neurons (which allow people to “mirror” the behaviors of others and be more empathetic) are more active.
  • They experience emotions more vividly than others (as enhanced by their ventromedial prefrontal cortex).
  • Their brains are more finely tuned to noticing and interpreting other people.

A recent fMRI study published in Brain and Behavior found that highly sensitive people have increased brain activation in regions related to awareness, action planning, empathy, and self-other processing. Lombard, who specializes in working with teenagers and adults who are highly sensitive, shows clients brain scan images from studies such as this one to illustrate how the highly sensitive brain differs in emotional situations such as watching a scary movie or seeing a picture of a loved one. She finds that these images help normalize the trait for clients.

On a podcast for Unapologetically Sensitive, Esther Bergsma, a counselor in the Netherlands and an expert on high sensitivity, reported that highly sensitive people have more brain activation, especially in the areas surrounding social context (e.g., wondering what others think about them, how others view them, or if others accept them). Bergsma pointed out that always being tuned into social contexts is a strength; it is only when people can’t regulate their emotions well that it leads to increased anxiety and stress.

Because people who are highly sensitive have to process more information and can experience nervous system overload as a result, they can be prone to chronic health conditions if they do not have adequate self-care and downtime, says Bjelland, author of The Empowered Highly Sensitive Person: How to Harness Your Sensitivity Into Strength in a Chaotic World.

She likens the way that highly sensitive people deeply process information to cups of water being dumped into the nervous system (“the container”). Highly sensitive people might have 100 cups that they dump into the container, whereas other people have only a few cups to dump. In other words, these individuals notice and process more detail. For example, a highly sensitive child in a classroom might simultaneously notice that a teacher is upset and the happy expression on a classmate’s face across the room and a tree branch tapping against the classroom window.

One way to simplify these brain differences is to think of the brain as two parts: the emotional brain and the cognitive brain. The emotional part of the brain in highly sensitive people is more activated, and if it becomes too activated, the cognitive part of the brain goes to sleep in a sense, Bjelland says. “That’s why [highly sensitive people] might have a hard time with emotional regulation and can get stuck in worry, rumination, anxiety and overwhelm,” she explains. “During times of high stress, the brain cannot tell the difference between a real threat and a perceived threat, so it sends out alarm bells in the system to prepare for fighting or fleeing. In those moments, [highly sensitive people] can’t even access facts, memory and rational thought because that all comes from [the] cognitive brain.”

However, counselors can teach clients ways to reactivate the cognitive brain to support their system and to let the brain know that it isn’t time to send out those alarms, Bjelland continues. For example, she uses a simple breathing technique to calm the body and let the brain know that the person isn’t in danger. Clients breathe in for four counts, hold for two counts, and exhale for seven; they repeat this for about five to seven breath cycles. “The exhale is very long and slow because that sends a signal to your brain that you are not in danger and that it can stop sending out adrenaline and stress hormones. When you exhale slowly, your brain realizes you are OK because that is not how you breathe when you’re in danger,” she explains.

The counting part (whether done out loud or silently) is important because it helps “wake up” the cognitive part of the brain, she adds.

Reframing the perception of sensitivity

As a highly sensitive person herself, Bjelland grew up hearing the negative messages often directed toward people with the sensory processing sensitivity trait: “Why are you so sensitive? What’s wrong with you? Why are you reacting that way?” When people hear those messages as children, she says, they do begin wondering what is wrong with them.

That internalized message is why psychoeducation about the trait is so important, along with validating clients’ experiences. Most highly sensitive people spend their entire lives feeling misunderstood and that something is different about or wrong with them, Bjelland says. Therapy is the place where these clients can begin changing this narrative and turning it into something empowering, she notes.

In her experience working with this population, Bjelland finds that clients often have a transformative experience once they realize that their temperament is normal, that they are not alone, and that they can take steps to improve their experience.

On the other hand, Smith has noticed that some highly sensitive clients experience a grief response after first learning about the trait. They may need time to grieve that they are unlike the other 80% of the population and yet live in a world designed by those without the sensitivity trait, she observes.

Sawyer, a licensed mental health counselor and art therapist, also helps clients reframe their negative experiences, such as being labeled crybabies as children. Counselors can help clients understand that they feel both negative and positive emotions more intensely than other people do. So, when they cried, they were just naturally expressing what they were sensing, which is normal for someone with this trait, she explains.

“They don’t have the problem,” Sawyer says. “It’s the perception that they have a problem that can turn it into one.” So, rather than thinking that they can’t control their emotions, clients can come to understand that with the right support, they can regulate their emotions. They can also take pride in the fact that they feel not only sadness on a deeper level than most people do but also experience incredible happiness, Sawyer says.

Lombard carefully selected the name of her private practice, Strong and Sensitive, to counter the tendency to equate sensitivity with weakness. Many of her clients come in with low self-esteem because of negative stereotypes about being sensitive. She reassures them that it is a normal temperament variation and not a problem. By normalizing the trait, counselors can help clients to embrace it and see it as a strength rather than a weakness, Lombard adds.

Smith teaches clients to more effectively communicate with those who seem to point out sensitivity as a problem. For instance, rather than taking on the onus to defend their sensitivity, clients could ask the other person, “What part of my sensitivity are you having a problem with?” This question reverses the normal assumption that something is wrong with the client’s sensitivity and shifts the conversation to how the other person may need to adjust his or her language or thinking to help problem-solve the relationship dynamic.

Susceptibility to the environment

Research has shown that in a positive developmental environment, highly sensitive children are more likely to thrive than are their peers who are not highly sensitive. However, in a stressful environment, highly sensitive people tend to do worse than do their peers who are not highly sensitive. In other words, this population is highly susceptible to both the good and bad aspects of their environment — a concept known as differential susceptibility.

A highly sensitive person once told Bjelland that when she was younger, her parents made her wear a wool sweater. After repeatedly asking her parents if she could stop wearing it because the material bothered her, they simply replied, “Wear it anyway.” Bjelland notes that this is an example of a highly sensitive person not being supported, and that circumstance can lead to problems.

Bjelland has also noticed that if a highly sensitive child has anxiety, then almost always one or both parents do too. Therapists can’t easily help anxious children if they have an anxious parent, she says, because the child mirrors the parent and will feel unstable if the parent also feels that way.

Parents who are highly sensitive should also be on counselors’ radar because they can suffer from overstimulation and neglect of self-care, Lombard says. The highly sensitive population is also more negatively affected by sleep deprivation, which is common for parents of young children, Lombard notes. She has noticed that highly sensitive parents are sometimes so focused on being the best parents they can be that they don’t take good care of themselves, pumping breast milk constantly or not making time for meaningful adult conversation, for example.

Lombard and Sawyer both recommend that highly sensitive parents get extra support in the form of family members, friends, daycare or a nanny. If finances are an issue, these parents could consider setting up a rotation with another trusted parent to watch each other’s children on occasion, Lombard says. She also encourages highly sensitive parents to wear earplugs or noise-reducing headphones when appropriate because they turn the noise down a bit and can lessen overstimulation.

Other life changes such as a death in the family, menopause, illness or other stressful events can make highly sensitive people feel unbalanced and overwhelmed, especially if they aren’t taking care of themselves, Bjelland says. If they experience too much emotional activation, they may temporarily lose access to the tools and strategies they normally use to cope with overstimulation, she adds.

To counter this, Bjelland tells clients to keep a “positive journal” to record positive events, such as someone saying something nice to them, or techniques that make them feel good, such as going on a hike in nature. Then, when they are having a bad week, they will have a visual record of self-care tips and positive reminders.

The acceptance of sensitivity within a culture also affects one’s environment. Some clients, but especially men, deny having this temperament because society reinforces the idea that sensitivity is not a positive characteristic, Smith says. (Research suggests that the sensory processing sensitivity trait is equal among men and women.) Thus, counselors should be careful about labeling clients as highly sensitive.

Lombard agrees. In fact, if a client grew up in a machismo culture that considers sensitivity to be negative for men, then she might not directly use the term “highly sensitive person” because it may distract from their treatment or therapeutic progress. “Depending on the culture and family of origin, men can carry more shame around [their heightened] sensitivity,” Lombard says. Instead, she mentions that all people have different temperaments and explains that some situations, such as witnessing a car accident, for example, might affect them differently. She also teaches these clients many of the same coping skills without labeling them as being for highly sensitive people.

Bjelland, who is a global educator on this trait and teaches courses for highly sensitive people, doesn’t see as many self-esteem issues in cultures where sensitivity is more accepted. “In the United States where it’s not so accepted, we see a lot of self-esteem issues. And that’s connected to shame too. Most of us walk around with the narrative that something is wrong with us because that’s what we’ve been told,” she says. “Helping to change the client’s narrative to a positive one, where they recognize why this trait is important to the world, is incredibly important.”

Recently, a male client who identified as highly sensitive came to see Sawyer because he needed a safe space to talk. He was struggling to find and maintain a romantic relationship because he found that women often wanted a stereotypical man — someone bold, assertive and athletic. As they talked, Sawyer discovered that he had internalized the belief that being sensitive was negative, which caused his own social anxieties and made relationships even harder for him. After Sawyer reassured the client that he possessed a normal temperament trait and explained its four main characteristics, he felt less self-judgment.

Although simply providing psychoeducation around the trait can be liberating for some clients, counseling often requires a longer process to help clients begin shifting their negative self-perception of being “weak” or “weird,” she adds.

Mindful changes in an overstimulating world

The good news is that highly sensitive people can makes changes so that their lives are more compatible with this trait and they can more readily cope with the challenges posed by living in an often insensitive and overstimulating world.

Bjelland recommends that highly sensitive people carve out two hours of alone time per day and dedicate one complete day each week to downtime. Not surprisingly, many clients balk at this suggestion, saying they don’t have the available time to do that. Bjelland will ask them to try it for one week and, according to her, they will universally report that they had more energy and were more productive because they were more focused, calm and balanced.

Bjelland also advises clients to follow a slower routine in the morning to help set the tone for the day. Why? Think of the nervous system like a motor, she says. If a highly sensitive person jumps out of bed to get the kids ready for school and then races into work, their nervous system revs up, she explains.

The process of slowing down applies to the bedtime routine as well because, as Bjelland points out, this population often struggles with sleep issues. “If a highly sensitive person wakes up from having a good night’s sleep, they get to have their full 100 points of energy for the day, but if they’re having sleep issues, maybe they’re only going to get 50 points for the day, and they’re already starting out depleted,” she says.

She often tells clients to adopt a ritual of doing the same five things before bed, such as taking a warm bath, reading a nonstimulating book, listening to soft music, meditating, and shutting off all electronics. By the time they reach the third action, the brain realizes sleep is coming, she explains.

“You’re teaching them a new type of self-care because [they’ve] been trying to do what the 80% [of the population that is not highly sensitive] are doing, and it’s not working,” Bjelland adds.

Smith agrees that counselors may need to have conversations centered on how self-care for these clients may differ from what rejuvenates other people. For example, if a highly sensitive person tries to relax by going to a concert with lots of lighting and sound effects after work with friends, he or she may instead feel drained and overstimulated by the end of the night.

Overstimulation is a difficult challenge for people with the sensory processing sensitivity trait because they need so much downtime, Lombard points out. She finds mindfulness techniques helpful for teaching these clients how to stay in the moment and self-regulate. For example, a highly sensitive person may find a coffee shop with loud music and people talking overstimulating. However, counseling can provide the client with strategies to successfully navigate such a space. For instance, perhaps the client limits his or her amount of time in the coffee shop or brings noise-canceling headphones, Lombard suggests.

Because these clients feel so deeply, they often need help learning to calm their nervous systems, Lombard continues. Highly sensitive people “are taking in so much more sensory information, and it’s really overwhelming,” she says. “And sometimes [they’re] not even aware, if [they’re] not mindful, of what it was that made [them] feel down or anxious.” She asks her clients to meditate daily using an app such as Calm or Ten Percent Happier and practice breathing techniques to help them become more mindful, present and calm.

Sawyer also suggests that clients use meditation apps such as Headspace or Insight Timer and practice yoga. Sometimes, even the simple act of closing one’s eyes, listening to nature sounds, or going to a quiet spot such as a bathroom or car can be helpful, she adds. The key is finding activities that “help retrain the brain to slow down [and] pay more attention to what’s happening in [the] body,” she says.

Retraining the brain in this way also helps highly sensitive people realize that they have some control and do not have to feel overwhelmed all the time, Bjelland says. For example, every time clients catch their mind wandering during meditation and bring it back to what they’re focusing on, such as their breath, it is like strengthening a muscle. Then, if clients become overwhelmed at work or a large event, they have trained their brains to notice, and they recognize that they need to take a break, she explains.

To help clients exercise this “muscle,” Bjelland instructs them to ask themselves two questions every time they go to the bathroom: 1) How am I doing? and 2) What do I need? This process makes them aware of preventing depletion or overwhelm, she explains. “Highly sensitive people tend to be very externally focused because they’re always scanning the environment for other people’s needs,” Bjelland says. “Most highly sensitive people need to be taught how to explore internally to learn what they need without always filtering it through other people’s needs.”

Of course, the heightened sensitivity to one’s environment also has benefits. Smith has often heard highly sensitive people talk about spending time in nature because there isn’t as much stimulation there. It is a place where they can escape and delight in the beauty of the natural world.

For some highly sensitive people, listening to a bird chirp or watching a sunset can elicit intense feelings of joy or elation, Sawyer says. Spending time in nature — simply walking barefoot in the grass, for example — can also help calm the nervous system, she adds.

Lombard recommends that counselors take these clients outside if they can or, alternatively, bring the natural world into their offices with nature sounds or a water fountain to help create a sense of calm. Lombard has noticed that clients often feel calmer when they see, touch or hear water, so she frequently has clients listen to the sounds of a rainstorm or flowing brook.

Learning to communicate one’s needs

Although highly sensitive people’s empathetic nature often makes them great partners in life and work, relationship issues are one of the primary reasons that they seek counseling. “Highly sensitive people in relationship are going to be so attuned to what the other person is feeling that sometimes they allow that to dominate over their own needs,” Smith says. For example, they may take on more work to please their boss even when they are already overwhelmed.

Smith finds role-play beneficial for helping these clients learn how to assert themselves in relationships. In counseling, they can safely practice communicating their own needs even if it initially seems strange or dramatic to them, she says.

Because highly sensitive people often hold themselves up to the standards of the 80% of the population that is not highly sensitive, they may not be aware that they need more downtime or need to do less so they can maintain their health and wellness, Sawyer says. To help these clients identify their needs and build new habits and coping strategies, she sometimes has them create a values collage of images that speak to them or make them feel good. Through this visual exercise, clients often will discover a common theme, such as nature. The values collage also serves as a reminder of ways that clients can calm an overstimulated nervous system the next time they find themselves in a stressful or overwhelming situation, Sawyer says.

For example, if a client’s collage contains mainly pictures of the ocean, Sawyer will ask how much time the client is spending near the beach or water. If the client says only once or twice a month, Sawyer will recommend increasing the time that the client engages in activities that will replenish them. For example, the client could go for regular walks on the beach or, if that isn’t feasible, pull up YouTube videos of ocean waves and sounds or simply take a bath to connect with water.

Working with these clients also involves helping them learn to set boundaries and communicate their needs, Sawyer says. She finds that nonviolent communication, an approach developed by psychologist Marshall Rosenberg, is a useful tool for highly sensitive people because it provides them with structure for setting boundaries. This type of communication involves:

  • Observing what does or does not contribute to their well-being
  • Identifying how they feel in relation to what they observed
  • Identifying the needs or values that cause their feelings
  • Making a request to fill that need or have that need met (the concrete actions they would like to see)

Sawyer provides a hypothetical case example. A highly sensitive person is worried about going on vacation with her friends because they are extraverted. The client also fears she will be expected to participate in every activity they have planned and that she won’t get enough downtime. First, Sawyer would help this client identify her needs and preferences for this trip. The client says she would like to have the room farthest away from the common areas because it will provide less stimulation if others stay up late talking. She would also like to tell her friends that she will opt out of an activity to stay in and read.

Next, Sawyer and the client discuss her fear of appearing antisocial if she communicates these needs to her friends. Sawyer uses emotional freedom techniques to help the client ease that fear and calm her nervous system. She asks the client to identify her fear. The client responds, “I feel nervous about talking to my friends.” Sawyer then asks where she feels that fear. The client says, “My stomach feels like it has butterflies.”

After ranking the intensity of the feeling (on a scale from 1 to 10), the client taps different pressure points while repeating the phrase, “Even though I feel nervous about speaking to my friends, I deeply and completely accept myself.” The goal is to have the intensity of her fear drop to a 2 or below.

Next, Sawyer and the client role-play scenarios of the client having this conversation with her friends. For example, she could say, “I’m someone who needs downtime. Would it be OK if I stay in from an outing so I don’t feel so anxious?” or “I’m excited about this trip and love hanging out with you, but I wanted to let you know that I will probably need a couple hours of alone time each day.”

Being a more sensitive counselor

Highly sensitive people “have higher responsivity to counseling interventions,” according to Smith. “Where they have positive fit with the counselor, they do better or they have more of a treatment response, and they seem to get more out of the counseling relationship.”

But how can counselors ensure that they are a good fit for a highly sensitive client? Smith recommends that counselors first think about their own temperament because it will inform any strategy they use. Are they highly sensitive, or are they among the other 80% of the population? At the same time, highly sensitive therapists shouldn’t assume that clients’ experiences are the same as their own, she adds.

“The 80% are very capable of working with highly sensitive people, but they need to be very careful of their own biases because they represent the majority,” Smith continues. “They may jump to a conclusion, or they may have some internalized negative biases of people who are highly sensitive.” If counselors aren’t aware of their internal biases, they risk unintentionally perpetuating some of those negative messages in the therapeutic process, she says. “And the highly sensitive person is coming to counseling because they’re looking for something different than what they’re getting in society.”

The good news is that “many counseling approaches would work well if the counselor is able to adapt it in light of what they know of the client’s high sensitivity,” Smith says. For example, if the counselor stares intently while the client is doing a sand tray intervention, then the client could become overstimulated and have a negative experience, making the intervention less effective, she explains. Instead, the counselor could step back and say, “I’m going to let you do this activity for 10 minutes. I’ll be over here doing my notes.”

Counselors should also think about the way they use language and how the highly sensitive person might perceive it. “The highly sensitive person is probably going to pick up more on nuanced language because, in general,” Smith says, “they’re wired to pick up more subtleties in their environment.” This also includes tone of voice, surroundings in an office, and nonverbal language, she adds.

Bjelland advises counselors to consider the environment in their offices. Is the lighting too bright? Is the client looking into a window? What is the texture of the couch? Does the office have a lot of strong smells such as cleaning products, perfumes or incense?

Smith also cautions counselors to be careful with cognitive behavior therapy. Because highly sensitive people process their environment and emotions deeply, asking them to think about cognitive distortions — the simple ways that the mind convinces a person that something isn’t true — can seem simplistic to them. It can even come across as patronizing to ask a highly sensitive client to reframe a cognition when he or she is having thousands of cognitions on a very deep level, Smith adds. Instead, she suggests saying, “Are these cognitions or depths of processing working well for you, or are these cognitions moving more into rumination?”

Counselors should also be careful when using interventions that might not value the depths of processing because they may unintentionally indicate that there is something wrong with the way the client is processing information, she notes.

Counselors also have the opportunity to reinforce clients’ gift of high sensitivity by validating the strengths and positives of the trait, Smith says. For example, a teacher might feel frustrated because he or she can’t soothe a crying boy. But a highly sensitive child in that same class probably would have noticed that the boy is upset because his crayon rolled under his desk, or the highly sensitive child might even notice the crayon rolling under the desk before the other child does and could grab it and prevent the boy from getting upset in the first place.

Thus, working with highly sensitive people can have far-reaching effects. As Bjelland points out, “You’re really creating a domino impact across the globe when you help a highly sensitive person lift off that layer of overwhelm and help them access those gifts and teach them how to care for their sensitive system because when they are thriving, they go out and help people and make a difference in the world. It’s just who they are.”

 

****

 

The highly sensitive therapist

Many professional counselors don’t just treat highly sensitive clients — they have the sensory processing sensitivity trait themselves. Find out how they manage the benefits and challenges of this trait in the article “Advice for the highly sensitive therapist,” available exclusively at CT Online.

 

****

 

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

 

****

 

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.

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

 

****

 

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.”

 

****

 

Contact the counselors interviewed for this article:

 

****

 

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.

 

****

 

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.

 

****

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.

 

****

 

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.

 

 

****

 

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

 

****

 

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.”

 

****

 

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

 

****

 

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.