Tag Archives: Counselors Audience

Counselors Audience

It’s not about ‘clean’: Dismantling the language of HIV stigma

By J. Richelle Joe and Sarah B. Parkin June 5, 2018

Words matter. The language we use when discussing sensitive, controversial or stigmatized topics reflects and shapes our attitudes and beliefs about those topics. Such is the case with HIV and AIDS. Since being widely identified in the 1980s, HIV and AIDS have been perceived negatively by the general public, resulting in the pervasive use of language that characterizes those living with the virus or the disease as undesirable and even dangerous.

The counseling context is not immune to such damaging language, and it is reasonable to infer that words have a powerful influence on mental health and counseling outcomes for people living with HIV. Counselors must beware of the power of language; outdated information about HIV and AIDS can intersect with the inadvertent use of stigmatizing language and undermine the ethical principles of nonmaleficence and beneficence that form the foundation of our profession. We also have a responsibility to actively oppose HIV- and AIDS-related bias and stigma by educating ourselves about HIV and AIDS and changing the language we use when discussing them.

Let’s start by offering a quick guide to HIV and AIDS terminology:

  • HIV: Human immunodeficiency virus; people can be diagnosed with HIV and not have an AIDS diagnosis
  • AIDS: Acquired immunodeficiency syndrome; caused by HIV
  • CD4 cells: Cells that are a part of the body’s immune system; also known as T cells
  • Viral load: The amount of HIV particles in the body
  • Opportunistic infections: Illnesses, including certain types of cancer, that occur more often when someone has a weakened immune system
  • ART: Antiretroviral therapy, a common treatment for HIV
  • PrEP: Pre-exposure prophylaxis, daily medication that can reduce one’s risk of contracting HIV
  • PEP: Post-exposure prophylaxis; prescribed use of ART within 72 hours of a possible exposure to HIV
  • Viral suppression: When the amount of HIV particles in an individual’s system decreases to the point that the virus is not detectable by current tests; occurs when an individual is adherent to treatment; also known as having an undetectable viral load

The changing face of HIV and AIDS

In the United States, AIDS was originally called GRID (gay-related immune deficiency), and the illness was most commonly associated with gay white males. Although the name of the illness changed as it became apparent that minority sexual orientation was not a determinant of HIV transmission, AIDS continued to be viewed as a “gay disease,” with multiple layers of associated stigma.

Although the stigma remains, the demographics of individuals living with HIV have shifted and increasingly include women and individuals of color. According to the Centers for Disease Control and Prevention (CDC), women account for approximately 20 percent of new HIV diagnoses, and among African American women, the estimated lifetime risk of an HIV diagnosis is 1 in 54 (compared with 1 in 941 for white women). African American and Latinx communities are disproportionately affected by HIV and AIDS. This is largely as a result of social determinants of health such as access to accurate information, preventive methods and health care, which are influenced by geographic location, cultural and social beliefs, socioeconomics, and stigma about sex and sexuality.

As the demographics related to HIV and AIDS have changed since the 1980s, so has the scientific knowledge, leading to key advancements in HIV prevention, diagnosis and treatment. Today, people with HIV can live long, healthy lives, provided that they adhere to treatment and monitor other aspects of their health.

Unfortunately, much of what is commonly known about HIV and AIDS is outdated and inaccurate. For instance, recent surveys conducted by the Kaiser Family Foundation indicated that some Americans still believe that HIV can be transmitted via mosquito bites, shared eating utensils and toilet seats. Many Americans also instinctively associate HIV with death, despite critical advancements in HIV care.

HIV is not a death sentence. For individuals living with HIV, the key to their health is the strength of their immune systems as measured by their CD4 cell count and viral load. Ideally, the goal for people living with HIV is to have a high CD4 cell count and a low viral load. Fortunately, as a result of significant medical advances over the past few decades, individuals with HIV who are consistent in their adherence to ART can have a viral load that is undetectable. Studies have shown, and the CDC has affirmed, that individual with undetectable viral loads have almost zero chance of transmitting HIV to another person even if other protective measures are not present. Never before in the history of HIV and AIDS has there been such hope for HIV prevention generally and people living with HIV specifically.

Unfortunately, not all individuals living with HIV access care and have an undetectable viral load. According to the CDC, approximately 1.1 million Americans are currently living with HIV, with 85 percent of these individuals aware of their HIV status. However, only 62 percent of Americans living with HIV are engaged in care, and only 49 percent of individuals living with HIV have an undetectable viral load. Multiple factors, including public health policies and social determinants of health, contribute to these statistics.

Unaddressed mental health needs might also be at work. People living with HIV may experience adjustment difficulties, depression, anxiety and trauma — all of which can affect an individual’s willingness and ability to seek medical care and remain adherent to treatment. In the past, HIV care focused primarily on the medical needs of people living with HIV. Today, there is growing awareness of the need to address the psychological and emotional aspects of HIV and AIDS because those factors may affect overall wellness.

The power of language

Despite the hope that science has given us with respect to HIV prevention and treatment and the increased awareness of the need for mental health support for people living with HIV, the language frequently used to describe HIV and AIDS continues to bolster the stigma associated with the illness.

Whereas phrases such as “clean bill of health” are benign with respect to other illnesses, when used in connection with HIV and AIDS, they can have a much different connotation. For instance, use of the word “clean” to describe someone who does not have an HIV diagnosis can send the message that those who are HIV positive are somehow unclean and dirty, or even impure and sinful. But HIV is not about clean. Not having an HIV diagnosis is not a determinant of cleanliness or good moral character. Equally, having an HIV diagnosis has nothing to do with being dirty or having loose morals.

Similarly, referring to HIV “infections” rather than HIV diagnoses or transmissions conjures thoughts of contamination, impurity and even death. Simply put, the dichotomy of “clean” versus “infected” breeds stigma, negativity and hopelessness. These negative connotations make getting tested, disclosing one’s HIV status, discussing methods of protection, and accessing and staying in care more difficult.

When counselors inadvertently use stigmatizing language in reference to HIV and AIDS, they risk harming clients by perpetuating stigma and reinforcing barriers to both physical and mental health care. By reducing stigma through intentional language choices, counselors can better help individuals explore their options for entering care or identify potential barriers that may prevent them from staying in care in the future. Additionally, helping clients identify protective factors such as support systems, positive coping strategies and individual strengths can be beneficial to their growth and development.

Regardless of HIV status, and in the name of balance, it is also important for counselors to inquire about aspects of their clients’ sexual wellness when the topic arises. As previously mentioned, with clients who are living with HIV, counselors can discuss getting and staying in care. With clients who are not living with HIV, counselors can use psychoeducation to identify appropriate prevention methods, including PrEP, PEP and proper condom use.

 

 

Say this, not that

Recognizing the negative impact that stigmatizing language has on individuals is only the first step toward defusing the taboo of HIV and AIDS. The next step is to identify specific stigmatizing phrases and replace them with appropriate alternatives.

On a foundational level, counselors can make an easy change in their communication about HIV and AIDS simply by using person-first language. Saying “person living with HIV” rather than “AIDS patient” does several things. First, it builds the therapeutic relationship and helps to externalize the diagnosis rather than fusing it with the client’s identity. Second, person-first language decreases stigma by emphasizing the possibility of living, and living well, with HIV.

The use of “person living with HIV” rather than “AIDS patient” also reflects a more accurate understanding of the illness and its progression. Often, HIV and AIDS are used interchangeably, despite an important medical distinction between the two. For counselors, it is essential to accurately differentiate between an HIV diagnosis and an AIDS diagnosis.

An HIV diagnosis follows a reactive test for the HIV virus; however, a diagnosis of AIDS is given by a physician only if an individual’s CD4 cell count is below 200 or if the individual develops certain opportunistic infections. Given that effective treatment is available for individuals who have been diagnosed with HIV, it is likely that someone who is adherent to treatment will never receive an AIDS diagnosis. By ignoring the difference between these two diagnoses, a counselor might appear to be invalidating, deterministic and incompetent to a client who is living with HIV.

Additionally, the phrase “full-blown AIDS” needs to be retired from our collective vocabulary. This phrase — which bolsters fear, reinforces HIV stigma and conjures thoughts of death — is wholly inaccurate and is no longer used among medical professionals. Along the same lines, stating that someone “died from AIDS” is also unproductive and inaccurate. If HIV progresses to the point that an AIDS diagnosis is given, an individual is vulnerable to opportunistic infections, which could be fatal. Hence, an individual might die from an opportunistic infection or an AIDS-related illness but not from AIDS itself.

Accuracy in our language when discussing this particular illness is critical. Errors in our word choices can communicate misinformation and harm clients, adding to the barriers that often prevent clients with HIV from seeking medical and mental health care services.

Conclusion

Understandably, discussing HIV and AIDS can be awkward or uncomfortable for some individuals, including counselors. However, equipped with the right language, counselors can engage their clients in vital conversations about their sexual and mental health. By discussing HIV transmission rather than infection, we can destigmatize the illness and the conversation. We can disrupt the pervasive narrative that equates HIV and AIDS with death, uncleanliness and immorality. And most important, we can be bridges rather than barriers so that people living with HIV will feel encouraged and empowered to access care and live well.

 

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J. Richelle Joe is an assistant professor of counselor education at the University of Central Florida. Her work focuses on HIV prevention and culturally and ethically sound services for people affected by HIV or AIDS. Contact her at jacqueline.joe@ucf.edu.

Sarah B. Parkin is a master’s student in clinical mental health counseling at the University of Central Florida. Her research interests focus on intersectionality and marginalized communities.

Letters to the editor: ct@counseling.org

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

 

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

 

Past trauma in counselors-in-training: Help or hindrance?

By Bethany Bray May 20, 2018

Counselors are not immune to trauma — in fact, far from it. Many practitioners say that personal or familial experience with trauma or mental illness actually spurred them to become professional counselors.

The connection between personal experience and the pull to become a counselor is something that is hard to quantify, but “in my personal experience, I encounter it pretty frequently,” says Allison Pow, a licensed professional counselor in North Carolina and adjunct professor at both Wake Forest University and the University of North Carolina at Greensboro. “For a lot of people, past experience draws them into the counseling field, and trauma can play such a pivotal part in someone’s life. It’s a common thing that we see as supervisors and counselor educators.”

Past trauma can be either an impairment or a kind of “benefit” for counselors-in-training, depending on how much the person has worked through and processed the effects of trauma, say Pow and Amber Pope, a licensed mental health counselor and program chair of the clinical mental health counseling program at Hodges University in Fort Myers, Florida.

Counselor educators and other professionals in the field who have close contact with counselors-in-training should keep an eye out for red flags that may indicate that a person’s past trauma is interfering with their growth as a counselor or, in a worst-case scenario, has the potential to cause harm to clients.

“Just because you’ve been through trauma doesn’t mean you can’t become a counselor. You can become a great counselor if [your trauma] is processed correctly,” Pope says.

Pow and Pope co-presented a session, “Wounded healers: How to support counselors-in-training who have experienced trauma,” at the 2017 ACA Conference & Expo in San Francisco. The term “trauma” can encompass a wide variety of experiences, from an acute event to yearslong, developmental trauma, Pow explains.

People who have processed the effects of past trauma — often with the help of a therapist of their own — can become excellent counselors, Pow says. Posttraumatic growth and healing from the experience can foster empathy and strengthen coping skills.

“Going through trauma is a very unique experience [through which] you understand the way your brain works and your body reacts. That is hard for someone to understand who hasn’t gone through that,” Pow explains. “I have had some students who were very resilient because they have been forced to cope [in traumatic situations] in the past.”

“The reason a lot of people become very, very good counselors is their life experience,” Pow adds.

However, people who haven’t fully processed the trauma in their backgrounds can run into trouble as professional counselors. For example, in client sessions, they risk becoming triggered by topics that clients bring up and may be unable to regulate their own emotions or other behaviors in response. These reactions can harm the delicate balance of trust between practitioner and client.

“They may unwittingly be using their role as a counselor to work through their own unprocessed material or to recapitulate an unhealthy power dynamic to feel that they’re in control,” Pow says. “Control is often something that people seek after going through trauma. It may come from a lack of self-awareness.”

 

Red flags

Interactions with classmates and colleagues might be one of the best indicators of whether counselors-in-training have a trauma history that still needs to be worked through. During moments of vulnerability, do they become aggressive or reactive or express other strong emotions? In general, a lack of self-awareness, such as oversharing in class or being unaware of how the people around them are feeling, can be an indicator of unprocessed trauma, says Pow, who has a private practice in Greensboro, North Carolina.

Also watch for attachment issues or signs of avoidance, such as skipping classes or evading one-on-one contact with a professor or authority figures, Pow says. It can also be indicative of a trauma background if students do not generally have themselves together, including missing assignments or being late to class repeatedly, Pope says.

Other indicators can include:

  • Poor boundary keeping: This may manifest as oversharing, attention-seeking or disruptive behavior in the classroom, or an unhealthy preoccupation with relationships with classmates or colleagues.
  • Low self-confidence: Students with unresolved trauma may demonstrate low belief in themselves regardless of past successes. They may feel like they can “never do enough,” Pope explains. These students may lack motivation or even self-sabotage, such as missing a deadline even though they are capable of meeting it.
  • Rigidity in thinking: If students aren’t open to receiving feedback and unwilling to take constructive criticism, it can be a major indicator of past trauma that hasn’t been resolved. This attitude can stem from a black-and-white way of thinking in which the student categorizes things as “all good” or “all bad” with no in between, Pope says.

Everyone has bad days now and then that can set them off. However, if a student is repeatedly unable to regulate their emotions, such as becoming reactive or upset in class, it is a red flag, Pope says.

“When a student is so set in their values or way of thinking that they try and impose it on others, that can stem from trauma. If they can’t become more flexible in their thinking process or relationships with others, then they’re going to have a difficult time with clients,” she explains.

 

When it’s time to intervene

It is beneficial, for any number of reasons, for counselor educators to get to know and connect with the students in their program, Pope says. If a particular student seems to be struggling with challenges that could keep them from becoming a proficient counselor — such as issues related to unresolved trauma — it is better to intervene sooner rather than later.

Be prevention-focused instead of reactionary, Pope suggests. The longer a student continues in a graduate counseling program, the harder it will be to check their behavior or make decisions about their future.

“Don’t let students waste time and money if they’re not going to be a good fit,” she says.

Counselor educators who identify students raising red flags should pull them aside after class or ask them to stop by the counselor educator’s office, Pope advises. The first interaction with the student should be kept informal and light. Let them know that you have noticed some patterns and indicators in their behavior that require some attention, and ask them what supports they need to help them make improvements, she says. If appropriate, other professors or colleagues who know the student can sit in on this initial informal meeting to offer support, Pope says.

Check in with the student frequently during class breaks, supervision meetings and other opportunities. Ask how the student is doing and how they are practicing self-care. This conveys to the student that the professor wants them to succeed and grow, Pope says.

Pope emphasizes that this method should be applied only to counseling students who haven’t committed an egregious offense or intentionally gone against the ACA Code of Ethics. In those cases, a swifter and more formal response is necessary.

If a student does not begin to change their behavior after a first informal meeting, consider meeting with the counselor-in-training again to create a formal written behavior agreement. Spell out which behaviors aren’t acceptable, why those behaviors aren’t acceptable and what they need to do to continue in the counseling program. Be specific and include a timeline of when the expectations must be met, Pope advises.

If the student meets the requirements in the behavior agreement, they should be allowed to continue on with graduate school. If not, suggest that they take a semester or other time off to get the help they need, or leave the program entirely.

“When a student is given feedback and continues in their behavior patterns and doesn’t make any changes, that’s showing me that the student isn’t ready to change or do what they need to do to grow professionally,” Pope says.

Throughout the process, Pope says, she would recommend that the student attend counseling. There is some debate within counselor education as to whether it is ethical to require students to attend personal counseling . In the case of recommending a student to personal counseling, a counselor educator can request the student to provide proof, in the form of written letters from a provider, that they are attending therapy sessions and making progress to demonstrate their willingness to comply with their professors’ recommendation.

“We’re very open, telling students that we [their professors] have all attended or are attending counseling, and that it’s important to be as healthy as you can be, [to] take care of yourself mentally and emotionally,” Pope says.

Although sometimes uncomfortable, this process is also an opportunity for counselor educators to model what a healthy professional relationship should look like, Pope notes. It shows students that you can give critical feedback while caring and maintaining empathy.

“You can give suggestions and guidance while keeping professional boundaries. They may not have had that [example] in their life before,” Pope says.

“In my classes, I make a point of being very transparent with my expectations and predictable. I have a standard of which behaviors I respond to and which I don’t,” Pow agrees. “For a student who has gone through trauma, it’s not our job to be their counselor. But a lot of times their lives haven’t been predictable, and they haven’t had a safe base. We can be that predictable, safe base. We can talk openly about their struggles, getting help and that it’s not a bad thing that you’ve had some challenges in your life.”

 

Gatekeepers and guides

Counselor educators must strike a fine balance between acting as gatekeepers for the profession and serving as mentors and guides for those who need extra support, Pope says.

“When it comes to student trauma and challenges, for me, an ideal situation is when I can have enough conversations with a student so they can come to their own conclusions on whether the field is right for them or not,” Pow says. “Part of effective trauma treatment is creating choice and putting decision-making back into the person’s hands. That may be the choice to take some time off and return to the program. Emphasize where they have agency in things.”

It’s OK for a student to come into a graduate counseling program with unresolved trauma issues. They just have to be willing to work on it, self-process and accept help, Pow says. Students who are open to self-reflection and constructive feedback can experience a tremendous amount of growth, she says. “It’s unreasonable for us to expect, as educators, that people are going to come into these [graduate] programs having processed everything that has happened to them and be completely self-aware,” she affirms.

Processing and rising above trauma builds skills that are the hallmarks of a good counselor, including a strong sense of self-awareness, empathy and sensitivity. Counselors who have successfully processed their past trauma can become models for clients struggling with similar issues, Pope says.

“If you heal from a trauma, you really have to engage with the most vulnerable parts of yourself. It’s a depth that people who haven’t been through trauma may not fully understand,” Pope says. “That’s what creates really great counselors — [to be able to] engage with others at that level of vulnerability and intimacy. Knowing that going through something so challenging, you can become more whole, and in turn become a safe place for others. As a counselor, you’re better able to serve your clients.”

 

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Related reading

  • For more on supporting counselors-in-training through the supervision process, see the feature “Guiding lights” in the June issue of Counseling Today.

 

 

Suggested resources

Want to learn more on this topic? Pow and Pope suggest these titles:

 

 

 

 

 

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

 

 

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

 

 

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

 

 

The opioid crisis and a wounded counselor’s heart

By Antoinette D’Angelo (pseudonym) May 14, 2018

[Editor’s note: Because of the personal nature of the narrative, the author is using a pseudonym.]

 

“Welcome to the club!” This greeting, typically extended to new members, often implies certain advantages, discounts and perks. However, the club my husband and I unwittingly have joined is based on an experience I would not wish on my worst enemy.

We received “the phone call” — the one every parent dreads in their wildest nightmares — at 2:30 in the morning in mid-February. It was the police station calling to tell us that our son had overdosed. He was alive, barely, but they had found him just in time.

A tumult of thoughts raced through my mind. Our son lives 2,600 miles away. Could it be a mistake? Were they sure it was our son? He wasn’t supposed to be in that city. What is happening?

As I write this, I know similar words must have been said or written a million times over by so many other heartbroken parents. In truth, there is nothing new to read here. Yet, it is my son I am writing about, my “kid” (now in his 30s). It is my same son whom I desperately worried may not live when I went into labor at six months gestation. It is my child whom the OB-GYN gave only a 10 percent chance to make it. It is my child who did make it, who went on to do great in school, who had tons of friends, who graduated from college, who got married and had a wonderful job. It is my kid who loved cutting down Christmas trees when he was little, swam like a fish and played soccer until his feet ached. It is my child who loved our annual summer trips all across the country to see major attractions and visit dozens of national parks. And it is my son whom the police were now telling us had almost died of an opioid overdose.

I write this story partly for the cathartic release it provides. Our family has cried more tears over the past few months than we could have previously imagined possible. Perhaps more important though is this: The ultimate irony of this situation is that I am a licensed mental health counselor, a licensed addiction counselor and a master addiction counselor. I am an assistant professor of counselor education and teach courses in addiction and treatment. I “know” so very much — maybe even too much on paper — about this disease of addiction, while simultaneously finding that I know so very little.

 

A quest for treatment

A few hours later, we raced to the airport, my husband catching the first available flight to the East Coast. We decided that once my husband got more information, I would fly out. Unfortunately, his plane was delayed, he missed his connecting flight and he ended up arriving after midnight. With no “new” news about our son, the hours ticked by excruciatingly slow.

The next morning, my husband went to see our son in jail — the words still seem incredulously stark written here. They brought our son out in a wheelchair. He was retching violently, trembling uncontrollably and could barely speak. My dear, sweet, gentle husband wept because he thought our son, who was in full-blown detox, was going to die. My husband and son could talk with each other only through a television screen. After 10 minutes, they took our son away.

I called the jail shortly thereafter and pleaded to find out what was happening. The response was that they weren’t allowed to tell me. Many hours later, I was routed to an “angel” sergeant who explained the jail’s “detox protocol” — they give the inmates Tylenol and a pill for nausea, but the inmates throw that up immediately.

Our son was in sheer agony, and we had never felt so utterly helpless in our entire lives. We could not even get a message to him. The whole experience shook us to our cores, and we felt nearly incapacitated by immobilizing grief.

My husband had his “one allotted visit” for the week, which was on Saturday, meaning that the next visit couldn’t be until Monday. We were distraught with worry about our son’s condition but weren’t allowed any additional information. We contacted an attorney in the area whom we had worked with previously years prior. Blessedly, he took on our son’s case but was likewise unable to find out anything over the weekend — and Monday was a holiday. Our agony continued, piercing our souls.

Tuesday was the bond hearing. Our son had been charged with two felonies and two misdemeanors. Our attorney spoke on our behalf. Amazingly, our son was released from jail in our recognizance, as long as he agreed to go directly into treatment.

The next several days were a blur-filled nightmare that involved navigating the quagmire of insurance situations. We found that because our son was “five days sober,” no detox unit would take him, reasoning that he was not in quite desperate enough straits at that point. No residential treatment center would take him; he didn’t qualify for Affordable Care Act insurance because he had lost his job. He couldn’t get on Medicaid because his physical address was listed a state away. We couldn’t get the best insurance money can purchase because he had a pre-existing condition. Our son was still in a very fragile state, with double vision, horrible stomach pains, crawling skin sensations, major sleep deprivation and continuous hot/cold sweats. He needed help — fast.

With no other viable options, our attorney managed to get an emergency stipulation granting my husband permission to drive our son the 2,600 miles across country to where we live. Meanwhile, I had stayed at our home, spending countless hours investigating insurance options and trying to find a residential treatment center for our son. My husband drove as he never had in his life, making the trip in three and a half days. They arrived in the middle of the night, our son a mere shell of the vibrant, funny, creative, loving soul that he once was.

We signed our son up for Medicaid in our state, which featured a 45-day backlog. We could request emergency consideration, with the possibility of them meeting us within 48 hours, but there was no guarantee. Our son would have to be assessed, and then there was the issue of actually finding him a bed at a residential treatment facility.

I must have contacted at least 25 treatment centers; none would take Medicaid. So there our son languished. We watched him slipping away from us as he struggled with his new sobriety and no treatment. If our son had been suffering from any other “acceptable disease,” waiting to obtain treatment would have been deemed unconscionable and cruel. From my view, it is beyond words that we ask those who suffer to simply bear their pain and deal with it.

I emboldened myself to share the situation with some trusted co-workers. The disease of addiction is still fraught with stigma, but I was so beyond that now, knowing that if we didn’t find something soon, the agony our son was experiencing would lead him to the streets. Human beings can withstand only so much pain. He was attending 12-step meetings as best he could but was so weak, it was hard for him to focus. He was more than ready for treatment and begged us to help him find something. He was simply too ill to do this on his own.

Through the grace of a co-worker, I was able to contact a treatment center that a relative of hers had attended with great success. I called, and we made an appointment the next day. The center took only private insurance, but we had already explored every other possibility. There were no other viable alternatives. It caused us to ponder, what does a person do who has no access to health care? (And, thus, all the overdose headlines!) We brought our son in for an intake assessment, and three hours later, he was in detox treatment; the timetable was for 35 days.

 

 

An equal-opportunity disease

Our story is merely a reflection of the countless individuals now suffering from our nation’s opioid crisis. Tragically, a huge percentage of those addicted are not so lucky as our son has been to have survived. Our son has an unfathomable journey ahead of him to maintain his sobriety. The shattering statistics confirm that only about 10 percent of individuals who are addicted find treatment — perhaps half of them will remain sober.

Our son’s addiction to opioids started as many others have. He had a back injury at work a few years ago, and his doctor prescribed OxyContin. Our son found some relief from the back pain but, more insidiously, found that it also helped with his longtime struggle with depression. Alas, he was a sitting duck. When the pills were gone, he tried to get more from the doctor, to no avail. He finally asked a friend, who led him to someone who had a few, and the rest is history.

On the streets today, one pill of OxyContin can cost as much as $60; a bag of heroin costs $5. There is no mystery why so many turn to heroin — not to get high but rather to relieve the impossible, all-consuming withdrawal. My son told us he tried countless times to overcome “the beast” on his own. The longest he made it was two and a half days — two and a half days of wretched, skin-crawling, vomiting, horrible agony. And we wonder why so many people are addicted. We treat people like criminals just for self-medicating their pain. We seldom think of them as even being human anymore, deserving of immense care.

As I tell my counseling students all the time, addiction is an equal-opportunity disease. I’m not a person in recovery, but I have attended dozens of 12-step, self-help meetings through the years. I worked as the program director of an outpatient substance abuse clinic for 10 years, often accompanying colleagues to open meetings so that I could honestly recommend them to my clients, know what they were all about and for the knowledge of “keeping it real” (that last one is crucial to me as a counselor and an educator.)

When I teach addiction courses, I ask my students to attend at least two open 12-step meetings if they are not seeking their own recovery but are there to learn, or two closed meetings if they are there to help themselves. They come back to class and share their experiences, which are often incredibly humbling to hear. They include tales of feeling embarrassed, finding it hard to enter the buildings, driving around several times looking for the courage to go in and acquiring sincere admiration and respect for those in recovery who have survived and share their journeys with others. The textbooks we have are tremendous, but nothing replaces the personal epiphany one can attain by witnessing these 12-step meetings. Many students have shared the sentiment, “There but for the grace of God …”

 

Holding on to hope

My irrational side tells me to beat myself up. I have been blessed with all this incredible knowledge and insight as a counselor and still did not know what my son was going through? I have refused to do so, however, not only because I realize that now is not the time for recriminations, but because I fully comprehend that addiction is a baffling and cunning disease.

It all makes sense now, of course — the endless need for money to pay for mysterious car breakdowns and vet bills for the dog, the many trips to see doctors for a once very healthy and fit young man, the horrible pain he was experiencing when his marriage fell apart. We wondered, of course, but were too far away to verify. We spoke frequently with our son but saw him briefly only three times over the past three years. Meanwhile, his addiction truly began to escalate.

It does no good to wallow in self-pity. It is just as futile to assign blame and fault. Pain, hurt, anger, frustration, desperation, sorrow, fear — all of these, and so much more, are ongoing and understandable. However, the one thing this disease cannot take from us is hope. The rational side of my being knows about evidence-based treatments, what has the best outcomes for success and what needs to happen.

In that sense, it has made things much easier for our family to endure because all of what is unraveling is in the range of “normal,” and that brings great solace. Our family is attending family counseling, going to Al-Anon meetings, reaching out to trusted friends and relatives, and realizing that we are so incredibly not alone. Still, it amazes me that if we were to tell a friend that our son has cancer, heart disease or even HIV, the response would be more understanding, more forgiving, more helpful. We have come light years in the field of addictions during the past two decades (I know — I teach this stuff!), yet we remain in the Stone Age as far as acceptance, understanding, scorn, victimization, blame and judgment go.

My hope is that readers will find some comfort in this writing (counselors are human beings first, with real-life crises of their own). I have found that addiction is an immensely alienating and isolating disease. So many people believe it will not happen to them or their loved ones because, after all, the person does decide on their own to pick up that first drink or drug, right? However, no one ever sets out in life to become an addict of any kind.

As human beings, our physiological needs are the most basic and supersede all others (refer to Abraham Maslow’s hierarchy of needs). We want relief from our physical/psychological/spiritual pain now and resort to self-medicating on a regular basis. I often ask my students, “What is your drug of choice? Is it caffeine, tobacco products, shopping, gambling, exercise, relationships, etc., etc., etc.?”

The point is, we are all slaves to our prefrontal cortexes, and once we find something that works for us, we make those lovely endorphins, the “intermittent positive reward” phenomenon takes hold, and we get positively rewarded for repeating that behavior. We are masters at conning ourselves into believing that the consequences of whatever we rely on continue to be far less than the rewards. And slowly, insidiously, the disease of addiction takes on a life of its own for far too many.

 

A time to take action

We know the physiology behind addiction. Those of us in the field screamed our warnings regarding OxyContin when it was first introduced in the late nineties. It didn’t require a huge knowledge of biochemistry to recognize the effects; its victims were immediately seen and affected so devastatingly.

Addiction professionals continue to scream from the highest pinnacles about the high potentiation for addiction from these drugs; we portended this epidemic well over a decade ago. And yet, here we are, still screaming of the dangers even as countless individuals are prescribed these drugs daily.

In 2017, the Centers for Disease Control and Prevention estimated that more than 115 people die every day due to opioid overdoses. I am not blaming the pharmaceutical companies (though perhaps I should?) or the physicians. Their ultimate goal (one hopes) is to adhere to the Hippocratic oath, to do no harm and to relieve human suffering. However, I believe that we have reached a tipping point, as Malcom Gladwell described in his book of the same name. Our nation is realizing that this crisis affects our mothers, our fathers, our sisters, our brothers, our daughters, our sons, our relatives, our friends, our co-workers, our ministers, our doctors … and ourselves.

The #MeToo movement has shown us the time for action is now. The #TimesUp movement is doing the same. The #NeverAgain movement is gaining immense momentum. It is time for our passions, our sensibilities and our combined courage to demand more research and increased access to treatment. It is time to get over our fear, ignorance and blame regarding addiction. And we need, once and for all, to acknowledge that the disease of addiction is happening at lightning speed all around us, with no letup in sight.

There is no time to waste on blame or recriminations; we need to act. Addiction can take hold of any of us, regardless of our training, our background, our socioeconomic status or our rationale. It happened to my son, despite all of the knowledge I possess as a counselor.

My fervent belief is that with understanding and proper intervention and treatment, we can more readily help those who are afflicted. More importantly, I believe we need to get at the real root of why people need to self-medicate in such powerful ways. We knew our son had problems with depression. He attended a few counseling sessions over the years, but there was no incentive to stay, and even taking the step of seeing a counselor came with perceived stigma. We all have the power to change the paradigms around this.

As of this writing, our son is more than 60 days clean and counting. He has completed his residential treatment and is living with us, taking it one day at a time and trying to deal with life on life’s terms. The neglect of his overall health has taken a huge toll, but together, we are trying to slowly repair its ill effects. This will definitely take time, but the joy is that now we do have that precious commodity.

My message to all my dear counselor colleagues is this: This disease affects all of us. The palpable pain of our nation is excruciating, and we are all awash in its collective anguish. As a nation, we must reach out, not suffer alone. We need to find hope, discover solace and all begin to heal. We also must find the profound courage to act and change our national discourse and paradigms on how we view and treat people who are self-medicating in hopes of finding relief from traumatic pain.

As counselor change agents, we can do this! There can be no higher calling. #EndOpiods.

 

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Antoinette D’Angelo is the pseudonym for an assistant professor of counselor education teaching in a university in the western U.S. She is a licensed mental health counselor, national certified counselor, master addiction counselor and licensed addiction counselor. She has worked in the human services/counseling profession for over 44 years. Her research interests include substance abuse and trauma treatment; crisis and disaster counseling; counselor wellness and alternative holistic treatment methods; and immigration, DACA, and refugee assimilation and reform.

 

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

Finding balance with bipolar disorder

By Laurie Meyers April 24, 2018

Licensed professional counselor (LPC) John Duggan didn’t plan on bipolar disorder becoming one of his specialties, but providing emergency room support gave him a close-up view of the consequences when the disease was left uncontrolled. Duggan, who is also a licensed clinical professional counselor (LCPC), noticed the escalation in manic and hypomanic crises that accompanied the increased light and time change in spring. He also saw people who had been diagnosed with depression but whose manic or hypomanic symptoms had gone undetected until they ended up in the emergency room with full-blown mania, psychosis or dysphoria.

Some of these individuals had no one to help them remain stabilized after leaving the hospital. Seeing the need for, as Duggan puts it, “boots on the ground,” he began seeing more and more clients with bipolar disorder in his private practice in Silver Spring, Maryland. Duggan, who is now the manager of professional development at the American Counseling Association, says some of those clients came as referrals from counselors who didn’t feel qualified to work with individuals struggling with bipolar disorder.

It is not uncommon for counselors to be hesitant to take on clients with a bipolar diagnosis, according to practitioners who specialize in the disorder. At the same time, there are many individuals with bipolar disorder who truly need the support of counselors and other mental health professionals to help them manage their condition. Although the public — and perhaps even some mental health professionals — may think that the disease is rare, the National Institute of Mental Health (NIMH) estimates that approximately 2.8 percent of U.S. adults currently have bipolar disorder and that 4.4 percent will experience it in their lifetime. NIMH also estimates that approximately 2.9 percent of adolescents currently have bipolar disorder.

Some mental health practitioners may buy in to the stereotype that clients with bipolar disorder are volatile and resistant to treatment, whereas others may be daunted by the disorder’s elevated risk of suicide. The Substance Abuse and Mental Health Services Administration estimates that for those with bipolar disorder, the lifetime risk of suicide is at least 15 times higher than it is for the average person. However, Duggan and others who treat bipolar disorder say that counselors have a crucial role to play in helping clients manage the disease.

Bipolar basics

Counselors are already trained to obtain a detailed client history that includes, among other things, emotional symptoms, family history and sleep and lifestyle habits, all of which can be crucial to spotting bipolar disorder.

“Bipolar clients often seek help only when depressed. Because of this, their manic or hypomanic symptoms are often not reported or observed,” explains Valerie Acosta, an LPC who counsels a number of clients with bipolar disorder in her Richmond, Virginia, practice.

A first step is for counselors to educate clients. Although they may be familiar with the symptoms of depression, they are much less likely to know how mania or hypomania present, adds Acosta, a member of ACA. Many clients think mania involves feeling very “up” and happy, but symptoms actually include intense irritability, anxiety and distraction, she explains.

Sleep patterns are also instructive when looking for evidence of mania or hypomania, says Regina Bordieri, a licensed marriage and family therapist in New York who specializes in bipolar disorder. “If they’re not sleeping, are they feeling energetic or tired?” she asks. Most people feel tired after a short night’s rest, but in hypomanic or manic phases, those with bipolar disorder feel energized despite very little sleep, Bordieri explains.Bordieri also asks clients about times when they weren’t depressed. Did they have high levels of energy and feel like they could get a lot done? Depressed moods that alternate with periods of intense activity and feelings of almost limitless energy may be signs of bipolar disorder.

Because it can be difficult for individuals to recognize their mood and behavioral shifts, family members and partners can also play a significant role when it comes to identifying and gauging symptoms, Bordieri says. Then, of course, there is the other role that family plays in diagnosis — namely, family history. Bipolar disorder is strongly tied to genetics, so clients with a family history of bipolar disorder are more likely to develop the disease.

Duggan urges counselors who are treating clients with bipolar disorder to work closely with medical professionals. Consulting a client’s primary care physician (with the client’s permission) is particularly crucial during diagnosis so that physical causes such as sleep disorders, thyroid disorders or a reaction to medication won’t be mistaken as symptoms for bipolar disorder.

Counselors — and clients — should also be aware of their ideas concerning which symptoms and forms of bipolar disorder are most debilitating, say Acosta and Bordieri.

“Bipolar II is not a milder form of bipolar I, but a separate and different diagnosis,” Acosta explains. “Bipolar I is also not necessarily more difficult to treat. … While the manic episodes in bipolar I can be severe and dangerous, the depressive episodes associated with bipolar II can be longer lasting, causing severe impairment to the individual. While clients with bipolar II have hypomania and not full manic episodes, their depressive episodes can be more debilitating than the depressive episodes of bipolar I.”

Although the depression of bipolar II may take a greater overall toll and be harder to treat, the mania inherent in bipolar I comes with its own set of “baggage.” In the popular imagination, mania — especially more extreme episodes — is the phase most associated with bipolar disorder and contributes to the perception that those who have the disorder are “crazy.” Mania is also extremely disturbing for clients and is highly stigmatized, especially when it leads to hospital stays, Bordieri says.

Ultimately, however, each client’s experience of bipolar disorder is different, Acosta says. “A therapist might be working with two people with bipolar II, and these individuals may present with very different symptoms,” she says. “Helping clients and their families to understand the individual’s unique symptoms, and have a variety of tools and strategies for managing their moods and specific symptoms, is essential for recovery.”

Managing medication

The counselors interviewed for this article stress that because of the neurobiological nature of bipolar disorder, medication is an integral part of treatment. Cheryl Fisher, an LCPC practicing in Annapolis, Maryland, whose specialties include bipolar disorder, says that counselors should work closely with a psychiatrist when treating these clients. In fact, when Fisher sees new clients with bipolar disorder who are working with a primary care physician, she strongly urges them to begin seeing a psychiatrist. Fisher, a member of ACA, believes that psychiatrists possess the specialized psychopharmaceutical knowledge necessary for prescribing the medication “cocktail” that works best for each individual with bipolar disorder. And because counselors see clients more often (and for longer chunks of time) than their physicians do, Fisher thinks that counselors are in a better position to track the effectiveness and side effects of clients’ prescriptions.

Counselors can also help clients become better self-advocates, says ACA member Dixie Meyer. Sometimes clients aren’t comfortable speaking up at the doctor’s office or are unaware that they are even experiencing side effects, she says. Counselors are in a position to spot such problems.

Meyer gives the example of a client who was showing signs of lithium toxicity. “I asked him when was the last time he had his blood levels checked [lithium requires regular blood testing to guard against toxicity]. He asked me what I was talking about. Somehow, he never knew he needed to have levels checked regularly.”

Meyer, an associate professor in the medical family therapy program at the St. Louis University School of Medicine’s Relationships and Brain Science Research Laboratory, says counselors should also be aware that clients with bipolar disorder might be given antidepressants for depression that can cause the onset of mania or hypomania.

“Clients might feel like, ‘Wow, I’m really starting to have a good mood,’” she notes. “They don’t really think to bring that up to the doctor, but the counselor can easily recognize the difference between remission of depression symptoms versus the development of manic symptoms. [Clients] might become more impulsive, snippier, their motor behavior more agitated … Counselors and family members are often the best [resources] to spot mood shifts.”

Sometimes clients don’t want to take medication for bipolar disorder because they have experienced unpleasant side effects, says Meyer, who frequently gives presentations to counselors on the importance of understanding their clients’ medications. She urges counselors to talk through this decision with clients. Meyer informs her clients with bipolar disorder that all medications have side effects, some of which may be temporary. She then asks these clients to give the medications some time and encourages them to talk to their physicians about which side effects might be permanent.

If the side effects of the medication aren’t going to go away, Meyer talks with clients about whether the side effects are something they can live with. In some cases — especially with medications that cause significant weight gain — the client’s answer is no. In those situations, Meyer says that she, the client and the physician go back to the drawing board and look for other medications or explore whether lifestyle changes might help reduce the side effects.

Meyer says all counselors should have a copy of the Physicians’ Desk Reference on hand so that they can quickly look up any medication. She also recommends Drugs.com as an excellent online resource.

Sometimes clients with bipolar disorder get stabilized and decide that they don’t need to take their medications anymore. When that happens, Acosta says that she “reflects back” what happened the last time the client stopped taking his or her medication. (Spoiler alert: It wasn’t good.)

Fisher tries to educate clients about bipolar disorder, emphasizing that a biochemical reaction underlies their mood shifts and that the medication helps buffer that process.

Medication, however, is not the only tool in the box to help individuals with bipolar disorder. Counselors can provide the emotional and lifestyle keys that help clients manage and, hopefully, decrease their mood and behavior shifts.

Prevention and stabilization

Multiple research studies continue to demonstrate the link between the circadian rhythm and bipolar disorder. Researchers are still teasing out the specifics, but what is clear is that maintaining a schedule — particularly a sleep schedule — that hews to the circadian rhythm plays a key role in controlling the disease.

Research has shown that insomnia is not just a symptom of depression but can also cause it. Likewise, Bordieri says, disturbed sleep can be either a symptom of hypomania/mania or the trigger for an episode.

Sleep is one of the first things that Fisher investigates with all clients, but it is particularly important in those with bipolar disorder. “I ask them what their sleep routine is,” she says. “How do you end your day? How do you prepare your body to rest? What is your sleeping environment like?” Fisher talks about how the blue light from devices such as smartphones and tablets disrupts sleep and advises clients to establish total darkness in their bedrooms.

Some clients reveal that a racing brain regularly prevents them from going to sleep. For these clients, Fisher recommends tools such as guided meditation or performing what she calls a “brain dump” — emptying the mind by writing down all of the thoughts that are keeping clients awake.

Acosta encourages clients with bipolar disorder to go to bed at the same time every night, wake up at the same time every day and take their medications at the same time daily. She has found this routine has a stabilizing effect.

Fisher and Duggan both believe sleep is so essential to mental and physical health that if good sleep hygiene isn’t working, they advise clients to get a sleep aid from their physician.

Duggan has found that the changing of the seasons can also have a profound effect on bipolar disorder. It’s a component of the bipolar resiliency program he came up with called SMART.

S — (Control) stress, sleep, maintain a schedule, seasons: Duggan asks clients with bipolar disorder to track their moods and sleep. He also teaches sleep hygiene and makes note of clients’ responses to the different seasons. Summer, when there is a lot of activity going on and plenty of sun, is usually a good time for many clients with bipolar disorder. But as the season draws to a close, Duggan reminds them that once fall arrives and there is less light, they are likely to start feeling less upbeat and may feel overwhelmed. He urges these clients not to overschedule themselves in summer and to step up their self-care efforts when the calendar turns to September.

M — Medication as prescribed

A — Adjunctive treatment such as yoga, acupuncture, massage or other complementary or alternative practices: Duggan says these are all areas that are outside of his expertise but that clients have found helpful. He also works with clients on self-soothing techniques and meditation. If a client is going through a severe manic or depressive phase, however, he strongly recommends against mindfulness. “I don’t want them to ‘be’ with the bad depression or the bad mania,” he explains.

R — Recreation and relationships: Duggan urges clients with bipolar disorder to stay engaged socially and to “do things that bring you joy, that you love, that give you a sense of flow.”

T — Therapy and counseling as needed

Fisher is a proponent of what she calls “nature therapy.” Research has shown that nature has a beneficial effect on mental health, so she urges clients to find a way to get outside — even if only for a short time — every day.

“Encouraging clients to track their moods can be a very valuable tool,” Acosta adds. “There are a wide variety of apps that clients can download to help with tracking their moods. Daylio is one that a lot of my clients like to use. By recording this information over time, clients learn about how their moods cycle, and this helps them to better understand the nuances of their moods, their triggers, and what helps and does not help with stabilizing their moods. I routinely review data from these apps — or paper mood charts — with my clients. I also routinely review symptom charts with my clients to help them monitor their symptoms.”

Some of Acosta’s clients have also had their own highly personal methods of tracking problematic mood changes. One client monitored her mood elevations by the number of packages that appeared for her in her apartment lobby (overspending). Another client could connect his manic symptoms to times when he would spend several days engrossed in building things (an increased focus on goal-directed activities).

Developing this degree of self-awareness can be beneficial for clients with bipolar disorder. “Linking symptoms to behaviors, thoughts and triggers can help to foster recovery,” Acosta says.

Meyer also teaches clients to spot patterns. She has premenopausal women chart their menstrual cycles so they will be aware, for example, that three days before their periods begin, they will feel more depressed. Meyer instructs clients to note their moods throughout the day and record what was going on. She believes that when clients can identify these patterns and recognize that there was a specific reason they were particularly manic or depressed, it provides them a greater sense of control.

Meyer teaches clients to self-soothe on hard days by going for a walk, going to the park and sitting on a bench or doing whatever else makes them feel good in a healthy way. 

“It’s really important … that our clients be empowered with a strategy for their symptoms,” Fisher says. For instance, if clients with bipolar disorder are having a down day and feel as though they are shifting toward a depressive episode, they could start to manage the switch by making a plan to get together with a friend or even just calling someone close to them.

Acosta tries to equip clients with bipolar disorder against life stressors. “They need to find healthy ways to cope with stress,” she says.

Acosta teaches clients mindfulness meditation and gives assignments outside of session, such as trying yoga or a new form of exercise. She believes that physical activity helps rein in racing thoughts. Acosta also recommends music for relaxation.

Seeking support

In addition to individual therapy, Acosta has found that group therapy is very effective for clients with bipolar disorder. She runs a monthly support group for adults over 18. “Some participants have been living with bipolar disorder for decades, and some have just been diagnosed,” Acosta says. “This is an open group, so members are constantly joining and leaving the group. On average, we have three to 10 participants per group. Because this is a therapy group, participants bring in and discuss any issue that they’re currently dealing with in their lives. Some of the topics of discussion include challenges such as the struggle to be on time for work or losing a job because of their bipolar symptoms, relationship conflicts, the side effects of medication, healthy strategies for managing symptoms, grieving the losses in their lives caused by their illness and building healthy living strategies.”

Acosta also provides education as needed in the group on topics such as understanding symptoms, exploring apps to track mood and locating resources for further education and support. She believes the peer support is what is most helpful to group participants.

“Many people have never met someone else with bipolar disorder, and learning that they are not alone or the only person dealing with the challenges of bipolar disorder can be extremely comforting and helpful,” she says. “Seeing peers recover, build healthy relationships and obtain their goals and dreams is most powerful.”

Support for these clients is essential, agrees Meyer, who recommends that counselors help recruit family members and romantic partners as a kind of support team whenever possible. Loved ones can be there when counselors can’t and are often the first to spot mood changes, she explains. “We also know when clients are in good, healthy relationships, it helps stress levels, and that helps keep them in good health,” Meyer adds.

Sometimes support can come from the strangest of sources, notes Fisher, relating the story of a woman who was in particular need of connection. “I had a client who had a trauma history in addition to bipolar disorder, and she was engaging in really unhealthy behaviors and self-loathing. She was just not in good shape,” Fisher says. “She came in one day, I did a checkup, and she showed really high levels of depression.”

Fisher didn’t think the client was in immediate danger, but she felt bad leaving her without another source of support, particularly because it was a Friday and Fisher was going away for the weekend.

“I asked, ‘Who can you be with? Who can you talk to?’’ Fisher says. “The client said, ‘No one. There is no one.’”

The woman was estranged from her family, and her only “network” involved her sexual hookups.

Suddenly, Fisher had an idea. She had just bought a betta fish for her office, so she asked the client to watch it for her over the weekend.   

Fisher saw the client the following Monday — sans fish — and asked how she was doing. The client replied that she was feeling better and more upbeat.

“Then she started talking about her weekend and spending time with ‘Olive’ and watching TV with ‘Olive,’” Fisher continues.

She asked the client who Olive was. Olive was the name the client had bestowed on the betta fish. The client had neglected to bring Olive back because she didn’t want to leave the fish in the car but promised to return her later in the week.

Fisher told the woman to keep the fish but was curious as to why she had named her Olive. The client said that Olive made her think of hope — like the olive leaf the dove brought back to Noah’s Ark to show the waters were finally receding after the Great Flood described in the Bible.

What lesson did Fisher take away from this experience? “We have to get our clients to connect — even if it’s just with a betta fish,” she says.

Fisher urges counselors to overcome any reservations they might harbor about treating clients with bipolar disorder. “Get more training if you’re uncomfortable,” says Fisher, who encourages counselors to ask themselves why they might be uncomfortable and then to address those reasons.

Counselors already possess the skills needed to empower these clients, Fisher adds. “We have clients who are walking in the door with this diagnosis and identifying it with who they are,” she says. “Bipolar disorder is not who they are — their diagnosis is not their identity. People think, ‘My body is betraying me. I feel like crap. I’ve alienated all my friends — I am the monster.’ Counselors can exorcise the demon of the [bipolar] diagnosis.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

Podcasts (counseling.org/knowledge-center/podcasts)

  • “Bipolar Resiliency Program” with John Duggan (HT056)

Webinars (aca.digitellinc.com/aca)

  • “Depression/Bipolar” with Carman S. Gill

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Counseling Adults Who Have Bipolar Disorders” by Victoria Kress, Stephanie Sedall and Matthew Paylo

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor:ct@counseling.org

 

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

 

Counseling people who stutter

By Chad M. Yates, Karissa Colbrunn and Dan Hudock April 11, 2018

Kyle hears the drone of the elevator music playing behind the bland voice that states, “All calls are important to us. Thank you for your patience. A customer service representative will be with you in just a moment.” Kyle knows the message well because he has been on hold for nearly 15 minutes. While waiting, Kyle practices in his head the message he needs to state: “Hello, my name is Kyle, and I need to schedule a shuttle ride to and from the airport.”

Suddenly, a crackling voice replaces the music. “Hello, thank you for calling OK Shuttle. How can I assist you?”

Kyle feels his throat tighten and his chest begin to seize. “Hello, my name is Kyyyyyy, my name is Kyyyyyyy, Kyyyy.”

“Sir, are you there? Sir, are you there?” insists the customer service rep.

Kyle continues: “Hello, my name is Kyyyyle. I need to schedddddd … I need to schedddddd, scheddddd.”

“Sorry, sir,” the voice on the other line says. “We have a poor connection. Please call back again when your service is more reliable.”

The sound of the click thunders in Kyle’s ear as a tight-pitched squeal replaces the silence. Kyle looks down at his feet, too afraid to pick them up and move. He feels frozen in anger, disgust and helplessness. Fear precludes the idea of calling back again.

This experience is all too common for people who stutter (PWS). For these individuals, the experience of communication, which many of us take for granted, becomes a blockade that stands between connection, understanding and the navigation of one’s world.

Experts in the field of speech-language pathology define stuttering as a communication disorder involving disruptions, or disfluencies, in an individual’s speech. The cause of stuttering is typically thought to be a neurological condition that interferes with the production of speech. Although many children spontaneously recover from stuttering, for approximately 3 million U.S. adults (about 1 percent of the population), stuttering is chronic and has no cure. Despite this, there are ways to manage stuttering in both the behavioral sense (how much the person stutters) and the psychological sense (how much stuttering impacts the person’s life).

Situations such as the one that Kyle experienced can happen almost daily for PWS. The pain of these experiences often leads these individuals to isolate themselves from the things they love to do because the risk of communicating can feel as if it outweighs the benefits of living the life they want to live. Peer reactions to unusual speaking patterns can begin as early as age 4. These reactions persist and increase throughout adolescence, which can negatively affect many facets of life, including social relationships, emotional well-being and academic performance, for PWS. Adults who stutter have scored significantly lower in questionnaires regarding quality of life, specifically in regard to vitality, social functioning, emotional role functioning and mental health. Although various studies show that counseling is indicated with this population, many speech-language pathologists are not trained in counseling or do not feel comfortable with their counseling skills and abilities.

Interprofessional collaborations between speech-language pathologists and counselors can be considered best practice for helping PWS and other individuals with common communication disorders. Idaho State University’s counseling and speech-language pathology departments are involved in a unique relationship in which they are training both speech-pathology interns and counseling interns to work side by side to treat PWS. This treatment is provided through the university’s Northwest Center for Fluency Disorders Interprofessional Intensive Stuttering Clinic (NWCFD-IISC), which offers a two-week clinic for adolescents and adults who stutter.

The clinic is the first of its kind in which speech-language pathologists and counseling interns work together to treat the holistic needs of clients who stutter through acceptance and commitment therapy (ACT), a mindfulness-based mental health approach. We (the authors of this article) have conducted the clinic over four consecutive years. Through this experience, we feel that we can share recommendations for counselors working with PWS and with other clients who present with communication disorders. Additionally, we have observed key ingredients for interprofessional collaboration and can speak to strategies to build effective interprofessional teams.

Recommendations for counselors

To be effective working with PWS, counselors need to address the misconceptions they have about stuttering. Consulting resources, such as the National Stuttering Association and the Stuttering Foundation, that are supported by PWS can help counselors to debunk common myths associated with this population.

One common myth is that stress causes a person to stutter. Another myth is that taking deep breaths before one speaks can eliminate stuttering. We have heard countless “cures” for stuttering from the general public. These include placing spices under one’s tongue, receiving acupuncture and sitting or standing with the correct posture. These erroneous cures can be insulting and demeaning to PWS. At best, it is frustrating for PWS to hear these ideas repeated over and over again. Counselors should be knowledgeable about the lack of support for these types of cures while being able to point out to clients resources on effective treatments.

For PWS, reactions from listeners often can be painful. As PWS become more aware of their stuttering and encounter negative listener reactions to their disfluencies, they may develop negative emotions toward communication situations and begin to avoid speaking. The shame and guilt that PWS often feel for stuttering can lead to fear, anxiety and tension in relation to communication, as well as decreased self-confidence. PWS may develop secondary behaviors that they employ in hopes of alleviating their stuttering. These secondary behaviors might include avoiding eye contact, avoiding speaking to people in positions of authority and avoiding certain words that they anticipate stuttering. Being aware of this, it is important for counselors to understand the role that positive regard, expressed behaviorally through continuous eye contact or not averting their glance when PWS speak, can have on these individuals.

Working effectively with PWS also involves using positive and respectful communication practices. During conversations, time pressure can be present when PWS take longer to communicate. This can sometimes lead to one party attempting to finish the other’s sentences. To PWS, this behavior can suggest that their communication of ideas may not be as important as the other speaker’s time.

Finishing a person’s sentences is often done in reaction to uncomfortable feelings associated with the time pressure of communication. Counselors should be aware of when they are experiencing these feelings. They should continue to allow their clients who stutter to finish what they wish to say regardless of time pressure and regardless of whether these clients are having blocks (when sound or air is stopped in the lungs, throat or mouth/lips/tongue), breaking off speech or having repetitions (repeating a sound, syllable or word more than once or twice).

The final recommendation involves the use of person-first language. Often, PWS call themselves “stutterers.” Reframing the language to say a “person who stutters” can reduce the stigma that surrounds the word “stutterer.” This action also treats the person as an individual. During the NWCFD-IISC, we empower PWS and work to mitigate stigma by reinforcing the idea that what a person says is more valuable and important than the way he or she says it. We also affirm that all individuals deserve to communicate their thoughts and ideas.

Recommendations for interprofessional teams

Interprofessional teams can be difficult to start and maintain in practice. Professional training often maintains solo practice as its modality, adding topics related to interprofessional collaboration as elective practice. We have used the stuttering clinic as a way to train counseling and speech-language interns in interprofessional practice and application.

We have observed that to effectively build these teams, it is essential to train our interns on the respective scopes of clinical practice, professional roles and clinical responsibilities of each other’s professions. We also train our students on how to work in teams, how to build relationships based on open communication and respect, and how to understand and use team dynamics that occur during practice. Finally, we reinforce the shared values of both professions — that the well-being of the client is paramount to the purpose of the team.

We have observed that interns typically begin collaborations with thicker boundaries of professional practice and rigid time sharing when interacting with clients. However, after the pair begin to find comfort and understanding of each other’s professional roles, these boundaries begin to wane. Time sharing becomes much more dynamic and less rigid. When intern pairings are working effectively, we see the pair begin to assist each other in their roles and to plan out how they can work together to assist the client during the next session.

To facilitate the interns working together, we teach them specific strategies that are unique to each profession. For example, the speech-language interns learn how to use basic listening skills and practice these skills with the help of their counseling partners. Speech-language interns also learn the foundations of counseling interventions. Specific to the NWCFD-IISC, the interns learn the foundations of ACT. All interns are also taught the practice of meditation and mindful practice, and the principles of acceptance, thought defusion and emotional expansion. Counseling interns learn the foundations of speech-language pathology interventions. Specific to the NWCFD-IISC, they learn about how stuttering occurs, how to assess for stuttering and the social and emotional impacts of stuttering.

All interns in the clinic engage in pseudo-stuttering (fake stuttering) in public and use speech-modification techniques with all clinic participants and the public. Pseudo-stuttering can be used as a therapeutic strategy for PWS to increase acceptance and openness with their stuttering and to increase self-confidence. When the clinic interns pseudo-stuttered and used speech-modification techniques with NWCFD-IISC clients in public, the clients reported that these experiences strengthened the client-clinician relationship.

Our recommendation to counselors and speech-language pathologists who desire to develop collaborative teams is to be intentional about building a professional relationship on the grounds of respect and open communication. The team members should take time to learn about one another’s professions, roles and clinical responsibilities. We have observed during the training of our interns that speech-language pathologists are often focused on outcomes and data collection, whereas counselors are often more focused on process elements and the clinical relationship. It is essential to see both sides of the team as contributing to the overall impact in a unique way. The team members will work to support one another’s strengths and weaknesses.

Counseling interventions

The NWCFD-IISC uses an ACT framework. ACT was chosen because it provides a strengths- and skills-based approach grounded in mindfulness and psychological flexibility. ACT explores human suffering as it relates to psychological inflexibility. Using this framework, PWS learn to more fully focus on the present moment, become more accepting of their thoughts and feelings, and take steps toward acting in alliance with their personal values.

Several studies have supported positive results regarding the efficacy of ACT when applied to stuttering. In addition to this supported efficacy, we think that ACT closely aligns with the philosophy of the NWCFD-IISC. Our philosophy of treatment involves clients and students taking a team approach to understand, accept and effectively manage thoughts, emotions and behaviors related to stuttering. This is accomplished through generalized experiential activities, group education and discussion, and individual and group counseling.

ACT can be understood through the six guiding principles on the ACT hexaflex. These six principles are acceptance, thought defusion, mindfulness, self as context, values and committed action. Investigating how each principle applies, we can begin to understand the process of counseling PWS through an ACT lens.

1) Mindfulness: Clients who stutter often avoid the present moment by judgmentally reviewing the past or worrying about the future. Clinicians can help PWS to connect with the present moment through the use of meditation and mindfulness activities. Encouraging mindful practices can be a goal to incorporate in counseling.

2) Acceptance: PWS often feel like they have no control over their stuttering. Regardless of what they do, a stuttering moment may or may not arise. In these moments, PWS can choose to talk, choose to stutter openly and choose to acknowledge all the thoughts and emotions related to stuttering. Clinicians can help PWS explore acceptance of their thoughts and feelings. PWS do not need to like the thoughts or emotions they experience or enjoy stuttering. However, they can experience their thoughts or emotions as they surface without judgment.

3) Thought defusion: PWS have a tendency to overidentify with their thoughts or feelings, enabling these thoughts and feelings to become mental truths that cause inflexibility within the thought process. PWS may attempt to mentally avoid stuttering or become overwhelmed trying to control their speech. Additionally, PWS may feel certain that other people will reject or harshly criticize them, thus causing them to avoid social contact.

Clinicians can help PWS to explore and express all thoughts — helpful and unhelpful — about their stuttering. By unhooking from the thought or emotion, PWS can experience more psychological flexibility in relation to the context that the thought or emotion is occurring within.

4) Self as context: Individuals often associate with expressions in the form of labels, such as “I am smart” or “I am dumb.” These labels relate to content, not context. Individuals may define themselves in terms of content instead of context to fuse with thoughts and emotions that may be either known or unknown. PWS use self-as-content behaviors to avoid facing the reality of stuttering. PWS may think, “I stutter. That’s all I do. Because of my stuttering, I do poorly in school and never meet new people.”

Clinicians should explore with PWS how these thoughts about self are related either to content or context. Reinforcing flexibility in self-identity is key because it allows PWS to adapt more flexibly to novel situations.

5) Defining values: As described by Jason Luoma, Steven Hayes and Robyn Walser, in ACT, values are defined as “constructed, global, desired and chosen life directions” that can be expressed as adverbs or verbs. When exploring values with PWS, the notion of choice is important to discuss. Choice connotes the flexibility and autonomy they possess in defining what guides their behaviors or life direction.

A common values activity involves the “eulogy exercise.” During this activity, PWS visualize what a close friend would say at their funeral. Clinicians might even direct PWS to write down the values that were expressed during the eulogy: “He was a kind person” or “She was a caring friend” or “He was a compassionate individual.” Clinicians can then discuss these values with PWS and explore how these values are currently manifested and how they can become lost. Building awareness of what values are important in a person’s life can encourage these clients to persist through the difficult times they face.

6) Committed actions: ACT explores the concept of choice in alignment with values-based goals. When clients feel ready to initiate steps either within or outside of counseling, exploration of these committed actions in the counseling session is warranted. For PWS, committed actions could be used by encouraging challenging stuttering situations. For example, PWS may choose to take action directed at speaking situations during dating, during novel social interactions or within work settings. Committed action is the stage of counseling that encourages the synthesis of the tools within the complete hexaflex. PWS learn to engage in a way that is adaptive and flexible to their external and internal worlds.

Summary

Counseling PWS can be a rich and rewarding experience. Through our work in the NWCFD-IISC, we have built lasting connections with individuals in the stuttering community and learned how to form strong interprofessional teams that enhanced our understanding of two professions. In working with PWS, understanding the specific population concerns is key to effective treatment. Additionally, collaboration with professionals in the speech-pathology discipline can further enhance treatment experiences for PWS and for all professionals engaged in the collaboration.

 

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Chad M. Yates is a licensed professional counselor and an assistant professor in the Idaho State University (ISU) Department of Counseling. He has served as the mental health coordinator for the Northwest Center for Fluency Disorders at ISU for several years. He helped to develop the acceptance and commitment therapy (ACT) manuals and procedures for clients and clinicians at the clinic and supervises the counselors providing ACT. Contact him at yatechad@isu.edu.

Karissa Colbrunn is a school-based speech-language pathologist in Pocatello, Idaho. She is passionate about merging the values of the stuttering community with the field of speech-language pathology.

Dan Hudock is an associate professor at ISU. As a person who stutters, he is passionate about helping those with fluency disorders. One aspect of his research involves exploring effective collaborations between speech-language pathologists and mental health professionals for the treatment of people who stutter. He is the director of the Northwest Center for Fluency Disorders. For information about research, clinical or support opportunities, visit northwestfluency.org.

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