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Counselors Audience

DXM: A drug in plain sight

By Emily Weaver, Sharon J. Davis and David Saarnio November 10, 2020

We are writing this article to raise awareness among parents and counselors about a legal and easily accessible drug that is widely used by adolescents to get high: dextromethorphan (DXM). DXM is an ingredient found in certain medications meant to help us get better, so teens frequently abuse this drug without being aware of the potential consequences and dangers. Given the personal insights and experiences we have with the damaging effects of DXM, we are sharing this story in hopes of reaching a larger population and creating more efficient prevention strategies related to teen drug use.

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When co-author Sharon Davis’ son was 17, he began abusing over-the-counter (OTC) cough medicine. He had been using marijuana and K2 (synthetic marijuana) for a few years, but it was Coricidin — a cold medicine marketed as being for people with high blood pressure — that really damaged him.

Sharon’s son became a different person. He had always been a moody kid, but his moodiness turned to anger, mania and psychosis. Over a four-month period, his father and mother took him to the emergency room four times. It wasn’t until he attempted suicide that they really got him the help he needed and found out the full extent of his addiction.

He had been introduced to Coricidin through some friends. Soon he was using 30 pills at a time. Coricidin use led to cocaine use. Cocaine use led to methamphetamine use. Two years later, he is working on recovery, but his mind and mental health will never be the same.

According to the Partnership for Drug-Free Kids, 50% of American teenagers have misused a drug, and drug overdose is the fourth-leading cause of death among teens. Parents, counselors and other adults are well aware of the problem of teen drug use, and the nation’s opioid epidemic has brought the topic of medication misuse to the forefront of public attention. That attention is long overdue. However, that focus also misleads us because other critical concerns are being overlooked.

For example, our society is largely neglecting to talk about the large-scale problem of adolescent misuse of OTC medicine and its potential as a gateway to other drugs. In fact, OTC cough and cold medicine is one of the most popular drugs that youth use to get high. According to the Monitoring the Future survey funded by the National Institute on Drug Abuse, more teens got high from OTC medicine in 2019 than from prescription opioids.

Why OTC?

OTC cough medication is easy for teens to get. In some places, teens can purchase these medications from their local convenience stores. Furthermore, most stores have these medications out on the shelf where they are easy to steal. Teens can also get them from peers and even from parents. Because they don’t necessarily perceive these types of medications as “dangerous,” many parents will store them in an unlocked medicine cabinet, unknowingly allowing their teens easy access to them.

The psychoactive drug in OTC cough and cold medicine is DXM, which falls into a class of drugs known as dissociative hallucinogens. Other drugs in this category include PCP, ketamine and nitrous oxide. The Food and Drug Administration (FDA) approved DXM as a cough suppressant in 1958. It remains legal to buy and use in the U.S. DXM is a safe drug when used as directed, but when used in 10 times or more the recommended dose, it acts as a powerful dissociative, distorting reality. Currently, 85%-90% of OTC cough medications contain this effective antitussive (cough inhibitor). DXM is a synthetic opioid drug, but it activates different opioid receptors in the brain than prescription opioids do.

Teens typically misuse DXM to feel the euphoric, dreamlike experiences and hallucinations it causes. When individuals use DXM to get high, they experience various levels of inebriation, known as plateaus.

There are four plateaus associated with DXM. The first plateau involves mild intoxication and stimulant-like effects. The second plateau features increased intoxication and mild hallucinations. At the third plateau, the user enters a state of altered consciousness with impaired senses and psychosis. The fourth plateau involves a sense of derealization (in which the world appears unreal) and depersonalization (e.g., detachment from the self).

Users describe the higher plateaus as akin to being in other realms or alternate universes. Commonly, users feel an out-of-body sensation, like being transported to another dimension. They lose their sense of self and time. It is common for users to post videos or blogs about their experiences, including what they felt like and what they saw while high. The slang term robo-tripping is how many teens refer to being high on DXM. Slang terms for the drug itself include triple-C’s, robo, skittles, red hots and dex.

Why is DXM problematic?

DXM is a dangerous drug when used outside of therapeutic doses, yet little has been done to curb its misuse among teens. For decades, we have known about the consequences of misusing this drug, including seizures, hyperthermia, tachycardia, psychosis, mania and even death.

The opioid epidemic in this country is a national crisis. It is worthy of public attention and government funding to address. At the same time, DXM misuse among teens is also startling, and yet it is rarely highlighted. This drug is more popular than opioids among young people, and it is legal, inexpensive and easy to get.

It is imperative that prevention efforts and policies address this problem. For example, laws similar to those passed in 2005 that required pharmacies to move the popular methamphetamine-making drug pseudoephedrine behind the counter could make DXM less readily available. Some states already require purchasers of OTC cough and cold medications containing DXM to present an ID proving they are 18 or older. We believe this should become mandatory nationwide and that sellers of these drugs should be held accountable.

Furthermore, mass awareness campaigns targeting parents, teachers, law enforcement and counselors need to remind adults of the dangers of these drugs, whereas prevention programs for children and teens should increase their focus on the dangers of OTC medications. National campaigns and policy changes are called for, but these alone will not likely be enough to cause real change. True prevention efforts require work on multiple levels — from the policymakers in Washington to counselors and parents in local communities. Each of us has a part to play, and each can make a difference.

Where do teens hear about DXM?

In today’s era of prolific internet and social media use, teens have more access to the world than ever before. In past decades, peer pressure to use drugs was a huge concern. It was thought that susceptible teens would be influenced by their peers in the neighborhood and at school. This peer pressure occurred face to face.

Today’s teens still confront in-person peer pressure, but they now also face this pressure virtually. Peer influence can come not just from the local teens at school but from millions of teens across the world online. Many teens access the internet and find out about drugs of abuse, including how to get high on OTC cough and cold medications.

A quick search of popular sites such as YouTube can lead teens to videos that either warn of the dangers of DXM or encourage users to experience the high from it. Unfortunately, many websites include dosing recommendations and “tripping” suggestions for having a better experience of getting high.

For example, Reddit, one of the most popular social media sites around the world, has an estimated 430 million active users. Reddit consists of threads that allow its users to post about certain subjects and topics. These threads are like cybercommunities made up of members who hold similar interests. One of these threads, called “r/DXM,” has more than 31,500 users. This thread allows people a place to describe their DXM highs and the side effects. It also provides advice on how to minimize certain side effects such as nausea.

Other websites and cybercommunities such as Dextroverse.org and the Vaults of Erowid provide teens outlets to post about their DXM highs and get advice from other users on how to use the drug. The site DexCalc.com allows users to enter their weights and get a recommended dose for the “plateau” of high they want to achieve. Although many of these websites claim that their purpose is “harm reduction,” teens typically use these sites for suggestions and advice on the “safest” using pleasures. All of these websites are accessible to teens, and all of them are free to use.

Prevention efforts

Fifteen years ago, the FDA issued warning labels on OTC cough and cold medications aimed at making parents aware of the dangers of medicine abuse by teens. The Stop Medicine Abuse campaign launched nationwide in 2004, but clearly that campaign was not successful. More needs to be done to dissuade youth from abusing OTC drugs.

As counselors, we need to step to the front lines of true preventive efforts. This means that we need to know more about DXM (and other OTC medications), the reasons teens are using it, the ways teens are getting it and the most effective methods to prevent its misuse.

Getting parents involved is a good first step. Parents must know what to look for and how to talk to their teens about OTC drugs. Counselors need to get the message out to parents to be realistic and truthful when educating teens about DXM. Scare tactics do not work for many teens; in fact, they may make teens more curious about experiencing the outcomes for themselves. A better approach for prevention may be for parents, family members and other adults to increase the quality of their connection to and communication with youth.

Research shows that establishing consistent messages against drug misuse and having clear boundaries early on can be among the best prevention efforts for teen drug use. Simple steps, such as hiding medications and taking inventory, can also be effective. Most parents want to trust their teens, but having medications that contain DXM where teens can access them is not wise, and many parents are not aware of the dangers of DXM medications. OTC cough and cold medicine should be as securely stored as opioid prescriptions.

In addition, parents need to know what sites their teens are accessing online. A parallel line of defense involves checking browser histories and having clear rules about what teens can access online. Drug use is a leading cause of death among teens (resulting in more than 5,000 deaths per year according to figures from the National Institute on Drug Abuse). Parents wouldn’t want their teens searching for firearms or lethal poisons online, and no parent should want their teen searching for how to get high from DXM. Parents may not be comfortable with this advice. After all, it may feel like snooping, and teens are likely to resist as well. Even so, what teens access online can be one of the biggest telltale signs of drug use.

Establishing rules for computer/internet usage (e.g., allowing a teen to use the internet for two hours a day after completing homework), installing a firewall and setting locks or passwords for downloads can all be safety measures that contribute to prevention or, when needed, intervention. The earlier that parents establish household internet rules, the better. Proactive planning and putting rules in place before children reach their teen years may prove much easier than trying to establish new rules once teens are in late adolescence.

Talking to teens about drug use is often uncomfortable for parents. Many parents do not know where to begin. Some parents are worried that talking about drugs will increase their children’s curiosity about using. Other parents simply find the topic embarrassing or awkward. As counselors, we need to help parents develop communication skills with their children and teens, but especially starting in middle childhood. Counselors can provide parents with resources for where to find information about drugs of abuse, and we can intervene if a teen has already started using. It is almost a certainty that teens talk to other teens about getting high on OTC cough and cold medication. As counselors, we need to encourage parents to talk to their children about choosing not to get high on it.

If Sharon Davis, as both a counselor and parent, had recognized the signs of DXM abuse in her son, he might have gotten help sooner. The message we want parents and counselors to hear is that DXM is one of the most popular drugs for teens, and despite it being legal and easy to get, it is not safe when misused. Sharon was unable to prevent all the damage done to her son, but we hope that her story will help parents of children and teens across the country to protect their own sons and daughters.

 

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Emily Weaver is a graduate student in the clinical mental health counseling program at Arkansas State University. She plans to graduate in the spring, become a licensed professional counselor and pursue a career in addictions counseling. Contact her at emily.weaver@smail.astate.edu.

Sharon J. Davis is a professor at Arkansas State University and a certified rehabilitation counselor. Contact her at sharondavis@astate.edu.

David Saarnio is a professor of psychology at Arkansas State University with a specialty in developmental psychology.

 

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.

Fear and anxiety at the ballot box

By Laurie Meyers October 22, 2020

Word began to filter out late morning on Tuesday, Oct. 13, the last day that Virginia residents could register to vote in the 2020 general elections. A severed fiber-optic cable had brought down the commonwealth’s voter registration portal. Officials said the cut was an accident caused by roadwork; skeptics on Twitter had “accidentally” trending. Paper registration was still available — if postmarked or dropped off at local voter registration offices.

By midafternoon, after an approximately six-hour outage, the site was back up. A federal judge ordered an extension of the deadline to compensate would-be voters for lost time. Everyone would still be able to register to vote. All’s well that ends well, right?

And yet. To many people, the snafu seemed like just one more alarming plot twist in the tale of an election season — and year — so fraught with unprecedented crises that it would most likely evoke reader skepticism if found within the pages of a novel.

The U.S. national elections are already set to serve as a proxy for the country’s stance on climate change, universal health care, racism, police brutality and (dueling visions of) democracy. The maelstrom of events that is 2020 has brought everything to the forefront in Technicolor. The death of George Floyd under the knee of a police officer. The ensuing protests against police brutality and the continuing demands for an end to racial injustice. The spread of violence by white supremacist groups. Record-breaking wildfires in California and Oregon. An incredibly active — and ongoing — hurricane season. The death of Supreme Court Justice Ruth Bader Ginsburg and the rush to appoint her successor. All of it amidst a pandemic unlike any other seen in the past 102 years.

When most Americans started staying home in March in hopes of bringing down the levels of infection by the novel coronavirus, they most likely didn’t expect that almost everything about COVID-19 would become partisan. The degree of threat posed by the virus. Whether to close businesses and restrict community movement. To mask or not to mask? In some quarters — albeit fairly fringe ones — the very existence of the novel coronavirus became a partisan matter. Now, less than one month before the election, more than 225,000 Americans are dead — a total that includes a disproportionate number of Black, Indigenous and people of color — and voters have spent months wondering about the best way to cast their vote.

In response to voter anxiety about going to the polls in person, most states expanded absentee mail-in voting by allowing anyone to use COVID-19 to justify their request. But the U.S. Postal Service, which had been preparing for the surge, was subject to organizational and equipment changes that made the mail less timely. So, many voters worried: If they requested an absentee ballot, would it arrive in time? The requirements for mail-in ballots vary from state to state, leaving some voters baffled and bemused. A process that is usually fairly straightforward has become yet another tangle to unravel in a year that has been fraught with knots.

“Our ability to cope with uncertainty is maxed out,” says licensed professional counselor (LPC) Keri Riggs, an American Counseling Association member with a private practice in Richardson, Texas. The pandemic has also effectively put most of our previously established timelines in question.

“We can’t make plans,” Riggs, whose areas of specialization include depression and anxiety, says. “The thing about the election is that we have a theoretical deadline.” We’ve always thought we understood when voting for the election was over, but this year, we can’t even have a sense of certainty about when it might end and when an undisputed winner in the presidential election might be declared, she says. Part of this year’s election anxiety is tied to not being able to rely on that usual deadline as an endpoint to at least one source of uncertainty.

With the exception of the contested vote count in Bush vs. Gore in 2000, modern Americans are used to learning who the winner of the presidential election is on election night or the morning after. But because so many people are voting by mail this year and it will take time to process those ballots, the votes amassed on Election Day will not be the final tally.

“If there is a contested election, it could drag on for a very long time,” Riggs points out. “Everything has already been dragging on for a very long time.”

And it’s not just about the endpoint. Many voters see this election as more than a mere partisan contest; to these voters, it is something upon which the future of bigger picture issues such as climate change, immigration and racial justice rests. In fact, a recent Pew Research Center survey found that 83% of registered voters say it really matters who wins the presidency. These results are an increase from the 74% of voters who said the same thing four years ago and the highest share of voters saying this in two decades of Pew Research Center surveys. In keeping with the anxiety surrounding the election, approximately 50% of survey respondents said they expected that voting will be difficult.

The stories that we tell ourselves play a critical role in how we cope with stress, anxiety and the seeming chaos around us, Riggs says. Too often, clients focus on the “what ifs” of a doomsday future that may or may not come to pass, she explains.

“The Islamic theologian, Sufi mystic and poet Rumi once said, ‘The words you speak become the house you live in,’’’ notes Ryan Thomas Neace, an LPC who is the founder and CEO of Change Inc., a St. Louis counseling practice that focuses on healing and personal growth in the face of pain. A similar dictum is contained in the Hebrew Scriptures, “The power of life and death is on the tongue,” he continues. “In other words, what we say matters.”

Neace is not denying that voters are facing weighty issues as they cast their ballots, but he maintains that the narratives we construct are not solving anything. Instead, people get caught in the trap of thinking that constant worry and panic are somehow equal to civic engagement or political purpose.

Clients can break their “doom” loops with present-moment awareness, Riggs says. For example, when fear of the future and visions of disaster threaten to take over, she has clients practice telling themselves that they and everyone they love are safe in that moment.

Riggs also advises clients to consume social media and news in moderation and to take breaks. She urges clients to channel their energy into productive action, either by engaging in the political process with a campaign donation or volunteering at the polls, or via a smaller personal outlet such as journaling or even cleaning the bathroom.

Riggs says it is also essential to exercise self-compassion and what one of her clients calls “grace.”

“We need to give ourselves and each other grace — the benefit of the doubt,” she says. “We’re not all on our A-game.”

Neace reminds clients that it is OK — indeed helpful — to tell themselves resilience-building stories such as, “There’s a lot at stake here, but we’re going to get through this together, no matter what.”

President Donald Trump and former Vice President Joe Biden, pictured in a nationally-televised debate on Sept. 29.

Fear of racial violence

“There is a lot of evidence that there are a number of groups that actively want to hurt and disenfranchise Black Americans,” says Harrison Davis, an LPC in Atlanta who specializes in depression, anxiety, resentment and helping people overcome personal obstacles. These groups have come out of the shadows and appear to feel empowered by what they — and many Black Americans — perceive as support from the police and from forces within certain parts of the government and judicial system, he says.

The clients and community members he’s spoken to say their sense of security has diminished over the past year because they feel betrayed by people they believed were their allies. Some of his Black clients have told Davis that instead of standing by them in the fight for racial justice and an end to police brutality, some of their white neighbors and friends supported these law enforcement actions and were actively critical of the ensuing protests.

On top of this vulnerability, some of his Black clients have expressed concern that President Trump has not committed to a smooth transition of power if he loses, while white supremacists are threatening violence or even war, Davis says.

Some clients have an almost panicky need to prepare for an emergency — as if by doing so they can keep their darker fears from manifesting, he continues. This sense of catastrophe is fueled not just by the election, but by the many deaths the coronavirus has brought to the Black community.

Although the threat is real, his clients’ response — living in a constant state of anxiety and panic — is neither healthy nor sustainable, Davis says.

Like Riggs and Neace, when working with clients struggling with election anxiety, Davis zeroes on how much news and social media they are consuming. Not only are clients being bombarded with a sense of overall catastrophe—they are engaging in conversations that are often vitriolic and damaging.

“When I grew up, you would just watch the polictical coverage on the TV networks,” he says. Now, everyone can watch a developing story or scandal in real time. So Davis asks clients to notice how they are responding as they track this torrent of information. “Is it causing you to tense up?” he asks. “Lose sleep?” Clients also report irritability and constant worry–not just about the election, but everything. Right now, the constant urgency and concern of news and social media has such a marked effect on clients, that Davis has moved away from recommending that they balance their use. Instead, he has them do a complete detox.

“Channel that energy into positives instead of arguing with people,” he urges clients. Rather than trying to convince others of their viewpoint, they could be helping people register to vote or get to the polls on Election Day. Davis also encourages clients to find hobbies and outlets that have nothing to do with politics or current events.

On a deeper level, he finds that clients are struggling to accept the world as it is. They may have believed that we had grown as a nation and society over the past decade but now may see that things haven’t changed significantly. One way to cope with that reality and find greater peace is to identify ways to help the community, Davis says.

In his own life, Davis’ father, who was an activist in the civil rights era, told him and his siblings that they might have thought things had changed, but they really hadn’t. Black Americans are still engaged in the struggle for racial equality that has been denied them for generations.

That doesn’t mean that clients need to live in fear, Davis says. Living like that only gives power to those who want Black people to be afraid. He urges clients to find a space where they feel like they belong and to be thoughtful about who they invite into their inner world. They may not yet be able to change the world, but they can control elements of their world by removing unsupportive friends or by leaving environments which make them feel triggered or unsafe—such as social groups or toxic work environments.

A number of his clients are very spiritual, Davis adds. They find strength through the Bible, which holds many stories of people who experienced tragedy and injustice but prevailed by relying on faith and their community.

Power and connection amid chaos

Although many of us view the cacophony of the election cycle as something to endure while keeping our sanity in check, ACA member Laura Brackett is encouraging clients to find their personal power in the chaos.

The year 2020 and the years leading up to it have been traumatic in myriad ways, and exploring personal power is a constant component of trauma work, she says. “The beauty of it is that personal power takes countless forms,” says Brackett, the director of community engagement at Change, Inc., in St. Louis. “For some clients, this has meant outward action in the form of voting, protesting and becoming active in the community. For others, it has meant embracing their own emotional reactions and how that is influencing their behavior and empathy toward self and others.”

Often the process involves a combination of both external and internal work, she says. Brackett’s goal is to encourage clients to embrace their personal power without losing sight of how its expression affects others.

“If there is one thing this year has shown us, it’s that we don’t live in a vacuum,” she says. “Our words and actions have real impact on others. I want to help my clients see this interconnectedness and learn how they can best live within it in a way that is compassionate as well as empowered.”

 

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Related reading, from ACA’s Department of Government Affairs and Public Policy: “Counselors Are Voting in 2020

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

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

The return of psychedelics to counseling: Are we ready?

By Benjamin Hearn October 6, 2020

Those of us who are professional counselors are perhaps most likely to recognize psychedelic drugs by their recreational or street names — acid, magic mushrooms, ecstasy — and to consider them to be drugs of abuse that may be dangerous to our clients. This is indeed the narrative that has been forwarded since the Controlled Substances Act (CSA) of 1970 classified all psychedelic drugs as Schedule I, indicating that they have a high potential for abuse, have no purposeful medical use and are highly dangerous.

It is sometimes surprising how public perceptions shift and how quickly knowledge can be forgotten. Prior to the CSA, psychedelics were of keen interest to many psychiatrists and psychologists. These professionals were curious about the ability of psychedelics to help patients with substance abuse and to elicit spiritual experiences. Dozens of research studies with thousands of patients were completed using LSD and psilocybin prior to 1970 with promising results, providing evidence in direct opposition to their Schedule I designation.

Considering these research studies, it is more likely that psychedelics’ scheduling status was related to their use outside of medical contexts, especially given their association with the counterculture and anti-war movements that the sociopolitical powers of that time perceived to be threatening. As the decades passed, public perceptions also changed and discussion of psychedelic research within academia became taboo, although researchers familiar with their potential retained interest.

Potential and use in treatment

Eventually, psychedelic research began again in the early 2000s to investigate the safety and uses of psychedelic drugs in substance use and mental health treatment. Psychedelic drugs that are currently being researched or used as treatments include MDMA (also known as molly), LSD, psilocybin (the active compound in magic mushrooms), ibogaine (a compound found in the iboga root) and ayahuasca (a brew of numerous psychoactive plants containing DMT). Results have indicated promise for all of these drugs in the treatment of a wide range of disorders, including posttraumatic stress disorder (PTSD); end-of-life anxiety; social anxiety in adults with autism; depression; obsessive-compulsive disorder; and alcohol, opiate, nicotine and polysubstance use disorders. Psychedelic drugs are also being evaluated as treatments for Alzheimer’s disease and other neurodegenerative diseases due to their apparent neuroprotective factors and ability to enhance neuroplasticity. Outside of their use as treatments in clinical populations, psychedelics have been found to enhance self-acceptance, increase openness and improve social relationships. Their recreational use has even been correlated with reduced reincarceration and past-year suicidality.

Psychedelic-assisted counseling in treatment-oriented settings typically consists of a few preparation sessions with a pair of counselors (most often a male and a female). These sessions are more similar to traditional counseling sessions. During preparation sessions, rapport is built, skills are taught, and intentions and expectations for the psychedelic session are reviewed.

The counselor pair then support the client throughout the entire drug administration session, which lasts between six and eight hours. The client is provided with eyeshades, headphones and specially selected music by the counselors, who offer support through their presence and instruct the client to follow their own internal experience as the drug takes its course. These counselors later meet with the client for shorter integration sessions beginning the day after drug administration and then occurring weekly for a few weeks before treatment is complete.

Time and time again, research has demonstrated these drugs to be safe and viable treatment options that are worthy of significant attention from mental health practitioners. In fact, psychedelics’ potential as treatments for mental health and substance use disorders has led to two drugs, psilocybin and MDMA, being designated as “breakthrough” treatments by the Food and Drug Administration for treatment-resistant depression and PTSD, with full approval estimated to occur sometime during the next two years.

Implications and challenges for the profession

These research findings have been garnering public attention and have been featured in shows such as 60 Minutes and in the 2018 New York Times bestseller How to Change Your Mind by Michael Pollan. Pollan has since led a featured session discussing his book and the future of psychedelics at the American Psychological Association Convention in 2019. The counseling profession has been gravely silent on this topic, however, with no research utilizing psychedelics occurring within any university counseling program. Instead, psychedelic research is taking place primarily through the fields of psychiatry and pharmacology, despite the fact that counselors and other master’s-level mental health practitioners actually help prepare for, facilitate and integrate the psychedelic experience in treatment-oriented settings.

As research continues within these fields, psilocybin mushrooms have been decriminalized or legalized already to varying degrees in the California cities of Santa Cruz and Oakland, in the city of Denver and in the state of New Mexico. In addition, they may be integrated into the state mental health care infrastructure in Oregon through a 2020 ballot initiative (see voteyeson109.org). It is readily apparent that what has come to be known as the “psychedelic renaissance” is occurring at breakneck speeds without the counseling profession’s voice or values being heard and integrated. This poses challenges because the counseling profession is implicated and affected by these developments regardless of whether we choose to participate.

First and foremost, outcome-driven research has neglected to consider the characteristics and competencies of counselors who will administer psychedelic-assisted counseling. This poses serious risks for clients, given that harm is far more likely to occur from practitioners inappropriately using psychedelic-assisted counseling than from the drug itself, due to the extremely vulnerable states elicited while clients are under the influence.

Furthering this position is the fact that the use of certain psychedelics, such as ayahuasca and mescaline, is legal under the context of religious practices. Some individuals have capitalized on this reality by advertising these psychedelics as treatments or spiritual sacraments, leading to underground networks of neo-shamans or guides whose qualifications to treat mental health and substance use disorders may be questionable or nonexistent. For example, consider Steve Hupp’s Aya Quest retreat center, as seen on the VICE TV show Kentucky Ayahuasca, where Hupp uses ayahuasca to treat opiate use, eating disorders, depression and other issues.

As psilocybin, MDMA and other psychedelics gain wider approval, it will be necessary to develop competencies, regulations and a professional infrastructure to distinguish and delineate their use as treatments from their use as spiritual sacraments. As necessary as these steps may be, such a process is inherently difficult because of the apparent relationship between psychedelic use and spirituality. Participants in studies that use psychedelics have reported enhanced spirituality, morality and mindfulness. They often describe the experience as being profoundly influential in their lives and on par with other formative experiences such as witnessing the birth of their children.

Clearly, counselors involved with psychedelic-assisted counseling must be able to work with clients to process such intense experiences. This requires a distinct skill set and outlook that may be wildly different from our traditional toolbox of approaches such as cognitive behavior therapy or solution-focused brief therapy. Determining whether that skill set is best developed through having had personal experience using psychedelics will also pose a challenge, although many current and past researchers have suggested that experience is beneficial.

The role and historical stigma of ‘mystical’ experiences

In clinical research, the degree to which participants have a “full” mystical experience has been positively correlated with treatment outcomes. Mystical experiences often involve “nondual” states, in which people may experience a sense of unity between their outer and inner worlds and feel that they have experienced “the infinite” or “ultimate reality.” Individuals may believe their experience to have transcended time and space, and they may feel a deep sense of peace, ecstasy or awe. Perhaps the most unifying feature of mystical experiences is that language cannot adequately capture them; to describe the experience is to exert a form of “violence” upon it.

It is important to note that while psychedelics have been used in Indigenous cultures the world over for millennia to access such states of consciousness, similar experiences have also been prominently described in many major religions, including Christianity, Judaism, Islam, Hinduism, Taoism and Buddhism. Within these religions, such experiences are accessed through the development of spiritual practices, increased devotion or, at times, spontaneously.

Although the subjective experience of spontaneous, practiced or psychedelic-occasioned mystical experiences may appear similar, many may argue that the latter are not valid, that they are “just” drug experiences. These claims lie in stark contrast to user reports of mystical experiences and the lasting effects attributed to them. One recent study found psychedelic-occasioned mystical experiences to be more intense and beneficial than those occurring through other means.

Such dismissal of psychedelic-occasioned mystical experiences may stem from centuries-old stigma, which began when the conquistadors forced Indigenous practices using psilocybin mushrooms (known to the Mazatec people as “the flesh of God”) underground, considering the practice to be blasphemous to Christianity. After the conquistadors’ suppression of psilocybin mushroom use, psychedelics remained forgotten to Western culture until their rediscovery in the 1940s and 1950s, with the synthesis of LSD and publication of an article titled “Seeking the Magic Mushroom” in Life magazine. Psychedelics then enjoyed a brief spotlight in medicine and the counterculture before once again being suppressed by the authorities due to concern over their effects on society. Groups such as the Native American Church and Santo Daime, which used these plants for religious purposes, were subsequently forced to argue with the Supreme Court that prohibition of specific plants and drugs inhibited their religious freedom. These groups were granted exceptions to allow for their use in religious contexts.

Closing thoughts

Given the apparent relationship between psychedelics and spirituality, we must take stock of how we intend to use these tools and what skills are needed to do so. We must also critically consider who these tools are for or belong to. As a profession, we operate from a wellness model and have a duty to promote both client safety and social justice. Psychedelic-assisted counseling presents a tremendously complex issue with respect to these three aspects of our profession, given that psychedelics may be beneficial to nonclinical populations, are closely tied to certain religious practices that have historically been oppressed, and present a risk to client safety from both a medical and practical standpoint.

Analyzing each of these issues as they relate to psychedelics and the counseling profession must be done intentionally and preemptively to develop psychedelic-assisted counseling in a manner that is safe, ethical and just. Such an endeavor takes time, expertise, care and critical thought — which we have yet to begin. Regardless, psychedelics are returning to counseling in the very near future, and we must ask “Are we ready?” If we are not, the profession may be forced to react rather than plan and to follow rather than lead in the exciting but high-stakes “psychedelic renaissance.”

 

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Benjamin Hearn is a doctoral student at the University of Cincinnati, where he is developing approaches for the counseling profession to use psychedelic-assisted therapies for mental health and substance use disorders. He is also interested in the integration of spirituality to counseling and is an active member of the Association for Spiritual, Ethical and Religious Values in Counseling. He has practiced in a variety of settings, including school-based mental health, private practice and wilderness therapy. Contact him at hearnbg@mail.uc.edu.

 

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.

A beginner’s guide to client confabulation

By Jerrod Brown and Megan N. Carter September 15, 2020

In the context of mental health treatment, client confabulation refers to the unintentional recollection and formation of false memories, ranging from subtle embellishments to grandiose elaborations. Confabulation may take the form of a true memory being inserted into an incorrect temporal, spatial or event context. In other words, confabulated memories can be based on an actual memory taken out of temporal context, or they can result from the creation of a completely fabricated memory (one not based on a previously held belief, experienced event or memory). Confabulation may also involve the incorporation of confabulated details or events as part of a true memory.

It is important for mental health professionals to remember that people who confabulate are unaware that they are engaging in this memory phenomenon and have no intent to deceive. Clients who confabulate have no conscious awareness that their memory is false; in fact, they often strongly believe that their memory is true. Confabulation can also manifest in verbal or behavioral displays of unintentional dishonesty.

Confabulation is distinct from delusions, which are firmly held false beliefs that follow a consistent theme and result from psychosis, often involving an alteration of lifestyle to accommodate the false beliefs. It is also distinct from malingering, the purposeful deviation from the truth to achieve a desired outcome (e.g., reporting mental health symptoms that are not present to receive disability payments). Although confabulations and delusions may share a common pathophysiology (i.e., they can present similarly), they are separate phenomena.

Confabulation is a complex and confusing topic with an uncertain etiology, and it remains under-investigated within the context of mental health treatment. It is loosely associated with a number of neurobehavioral/neurodevelopmental disorders (e.g., fetal alcohol spectrum disorder [FASD], intellectual disability) and neuropsychiatric (e.g., schizophrenia), neurocognitive (e.g., dementia, traumatic brain injury) and medical health conditions (e.g., Korsakoff’s syndrome, various brain diseases). Adding to this confusion is the fact that confabulation can also occur among individuals with no identified impairments, disorders or diseases when certain factors are present (e.g., memory confusion, an attempt to fill in a memory gap, high-pressure and stressful interviews).

Although the underlying brain processes associated with confabulation are currently unknown, possible causes have been suggested in the research literature. These include:

  • Attempt to preserve self-coherence
  • Attempt at self-enhancement
  • Competing memories varying in strength and emotional significance
  • Executive functioning deficits
  • Fast-paced and stressful interviewing approaches
  • Frontal lobe dysfunction
  • Guided imagery
  • Hypnosis
  • Impaired attentional control
  • Impulsivity
  • Memory encoding and retrieval deficits
  • Memory loss
  • The mistaking of imagined events for real ones
  • Overconfidence
  • Attempt to preserve a sense of self-identity and self-esteem
  • Reality-monitoring deficits
  • Repeated lines of questioning
  • Self-monitoring deficits
  • An eagerness to please (i.e., wants to demonstrate an ability to answer all the questions)

Most commonly observed in the retrieval of autobiographical memories, confabulations can include information inspired by peers, television, movies and social media. Inspirations for confabulation may also occur from overhearing conversations from other individuals (e.g., inpatient treatment settings, group treatment programs, sober support meetings).

Mental health professionals are often unaware of this topic and typically receive little to no training in the implications of confabulation on client populations. Because of its potential to compromise screening, assessment, treatment efforts, discharge planning and placement, confabulation is a crucial clinical phenomenon for mental health professionals to understand and address in practice.

Types of confabulation

There are two principal forms of confabulation: provoked and spontaneous. Provoked confabulations are incorrect responses to questions or situations in which a person feels compelled to respond. Examples of such situations include intake assessments, investigative interviews and testifying in court.

Research has established that the more stressful a situation is perceived to be, the more likely confabulation is to occur. This is why mental health professionals working in criminal justice or forensic mental health settings need to pay particular attention to a patient’s possibility of confabulation, which may lead to inaccurate diagnosis or symptom identification. Additionally, unintentionally misremembered information can derail the legal process if the person provides inaccurate eyewitness information, prematurely waives Miranda rights, provides false confessions to police or enters inaccurate testimony in court. In the worst-case scenario, it could even result in wrongful convictions.

Spontaneous confabulations are not linked to a particular cue. They range from misremembering insignificant information to generating fantastic and grandiose details. They are believed to result from a reality-monitoring deficit in the frontal lobe combined with organic amnesia. Spontaneous confabulations also differ from provoked confabulations in that most patients eventually stop engaging in the behavior.

Provoked and spontaneous confabulations can be expressed either verbally or through behavior. Verbal confabulation involves articulating a false memory, whereas behavioral confabulation involves acting on a false memory (e.g., going to the wrong home because the person believes it is where they live). Regardless of the form they take, false memories can evoke real emotions from clients, who may have a high level of confidence in the accuracy of their recall despite evidence to the contrary.

An example that one of us experienced occurred in the course of a forensic mental health interview with a woman who was subsequently diagnosed with Korsakoff’s syndrome. During the course of the evaluation, it was clear that she had significant difficulty developing new memories but was able to recall long-term historical memories (e.g., childhood autobiographical memories). She described recently babysitting a neighbor’s three preschool-age children, including fixing them snacks and letting them watch television. A report was made to child protective services because of the woman’s significant impairments and concerns about the safety of the young children in her care. A subsequent investigation concluded that the woman had not been left to babysit the neighbor’s young children; this was an apparently confabulated memory.

Screening and treatment

There are various theoretical models to explain confabulation. One implies a failure to suppress memory traces that were used in the past but that are no longer relevant to what the person is currently trying to remember. Another theory posits that the person simply failed to retrieve the relevant memory. Finally, another theory is that the person failed to locate the memory for that time and context and essentially inserted another memory in its place.

Numerous conditions can increase the likelihood of confabulation, including:

  • Dementia
  • Encephalitis
  • FASD
  • Frontal lobe tumors
  • Frontotemporal dementia
  • Herpes simplex encephalitis
  • Learning disabilities
  • Nicotinic acid deficiency
  • Korsakoff’s syndrome
  • Multiple sclerosis
  • Schizophrenia
  • Subarachnoid hemorrhage
  • Traumatic brain injury

Given that confabulation has an unclear etiology, multiple definitions, and statistical and clinical associations with a range of neurobehavioral, neurodevelopmental, neurocognitive and neuropsychiatric conditions, the use of a valid and reliable screening procedure is essential. This will help mental health professionals avoid inaccurate diagnoses and the development of ineffective treatment plans that could exacerbate underlying conditions. Screening areas for consideration during confabulation evaluations include:

  • Abstract and sequential thinking
  • Attention-deficit/hyperactivity disorder
  • Executive functioning
  • History of trauma
  • Sleep
  • Learning capabilities
  • Social skills
  • Memory
  • Receptive and expressive language
  • Sensory processing
  • Source monitoring
  • Suggestibility
  • Prenatal alcohol exposure

While confabulation can occur for a variety of reasons, early identification, support and monitoring are key. Possible screening tools that may be useful include the Nijmegen-Venray Confabulation List and the Confabulation Screen. Use of these tools may provide a beginning analysis for further exploration of this issue. If confabulation occurs but is thought to be due to an organic condition such as Alzheimer’s disease, dementia or FASD, referral for neurological testing is appropriate and can provide insight into which areas of the brain are most affected. This can assist in determining the best treatment approach given the individual’s particular areas of need.

Regarding treatment, specific intervention strategies have been found to be useful with clients or patients who confabulate. These strategies involve:

  • Avoiding confrontation
  • Avoiding leading questions
  • Avoiding sensory overload
  • Avoiding closed-ended questions
  • Using a slow-paced interview format
  • Using collateral sources to confirm self-report
  • Using developmentally appropriate language
  • Reassuring that it is acceptable not to know an answer
  • Checking for comprehension
  • Minimizing stress
  • Providing family/support-person education
  • Allowing for extra processing time
  • Allowing for long pauses and silence
  • Treating underlying mental health conditions
  • Treating underlying physiological conditions
  • Teaching memory diary use
  • Teaching reality-monitoring techniques
  • Teaching self-monitoring techniques

Establishing a therapeutic relationship with such clients requires acknowledgment that their misremembering is not intentional and that it lacks malice. This can be challenging for clinicians for several reasons: countertransference, frustration at not knowing whether a client’s documented previous diagnoses or symptoms are accurate, and an unconscious bias that assumes the recollection of inaccurate memories is the result of the client trying to gain something else (i.e., malingering) such as money or attempting to get out of trouble.

Clinicians should avoid minimizing what the client is reporting or prematurely assuming that the client is deliberately being noncompliant. In fact, clinicians should recognize that the content of confabulations may even provide useful information regarding the client’s perceptions and behavioral approaches. Additionally, as previously mentioned, the confabulated information may result in real emotions for the client that will need to be acknowledged and processed.

Clinicians must be sensitive to the fact that individuals who confabulate may inadvertently thwart treatment efforts because they lack recognition that their recalled memories are false. To both address this lack of insight and ensure the collection of valid and reliable assessments, clinicians should obtain collateral information to support or refute a client’s claims (especially when a false recollection could result in significant consequences). When clear evidence of confabulation is found, clinicians should appropriately document this in the client’s case file and consider this during the entire treatment process (e.g., intake, screening, treatment planning, discharge planning).

Adaptive functioning

Confabulation can affect a person’s ability to take care of oneself (e.g., personal hygiene, dressing, cooking), carry out activities of daily living (e.g., home cleaning, clothing care, financial management), and effectively maintain a social life (e.g., empathizing, reading nonverbal behavior, establishing a social group, engaging in effective communication). These adaptive functioning deficits can also lead to issues with filing forms to obtain government services (e.g., disability benefits, subsidized housing) and gaining access to medical records to ensure high-quality continuity of care, as well as an increased vulnerability to victimization. Hence, those who chronically confabulate may be less likely to be able to live independently and more likely to require a high level of support.

Therefore, clinicians working with individuals who confabulate should consider administering a “gold standard” adaptive behavior inventory to help guide and inform treatment planning. Among these inventories are the Scales of Independent Behavior-Revised, the Vineland Adaptive Behavior Scales Third Edition and the Diagnostic Adaptive Behavior Scale. Similarly, clinicians working with clients who exhibit significant deficits in adaptive functioning, particularly in higher-level skills such as money management, should be alert to possible confabulations.

Although using a standardized assessment to evaluate adaptive skills can be useful in treatment assessment and planning, clinicians should also be aware of certain disorders, such as FASD, in which confabulation may be common and in which standardized testing does not necessarily identify deficits. For example, those with FASD may be able to complete tasks of daily living such as grocery shopping or managing personal hygiene, but they may have poor judgment (and social judgment in particular) that is not measured on typical adaptive functioning scales. For instance, they may be tricked out of money by someone who is “friendly” to them and then have difficulty understanding or explaining the missing money, so they engage in confabulation to account for it.

In such instances, in addition to using standardized testing, clinicians should carefully assess using qualitative analysis of abilities and interactions. This may be particularly important for those with FASD with regard to social skills or other areas of functioning that are difficult to measure. Confabulation may be demonstrated as a way to present a more functional ability with regard to a wide range of adaptive abilities and may need to be addressed through careful clinical interventions.

If adaptive behavior deficits are found, it is the responsibility of the administering clinician to educate the client’s support systems (family, friends, education system) about the practical implications of these deficits. These support systems may need to be relied upon in cases of severe confabulation to ensure client safety and follow-through on the client’s daily life affairs such as attending appointments and medication compliance. Unfortunately, strong support systems can be less common among this client population. Family, friends and teachers may feel distrustful of the confabulating individual because of a misperception that he or she is willfully attempting to deceive them. Clinicians play an important role in intervening in such misperceptions by educating clients’ support systems on the unintentionality of the confabulations and explaining that they are the consequence of cognitive and neurological deficits.

Conclusion

Confabulation can be a serious obstacle in mental health professionals providing effective care and services. It can have a negative impact on intake, screening, assessment, treatment planning, medication/treatment compliance and discharge planning. For this reason, we urge clinicians to pursue self-study and continuing education training via in-person and online courses to expand their knowledge on this complex and multifaceted phenomenon. When a case of potential confabulation is identified, professionals should seek the guidance of recognized subject matter experts who routinely review key research findings on confabulation on at least a quarterly basis.

Finally, additional research is needed to continue establishing evidence-based screening and intervention procedures to identify individuals who may be at increased vulnerability for confabulation. Such screening procedures could be applied prior to clinical interviewing and in the treatment planning process to ensure that the information obtained is of higher fidelity. The use of such protocols would also familiarize users with the social and cognitive risk factors for confabulation, of which many mental health providers currently lack awareness. Through the adoption of such policies and procedures, the possible negative impact of confabulation can be minimized, appropriate intervention approaches can be implemented, and the likelihood of positive outcomes can be increased.

 

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Jerrod Brown is an assistant professor, program director and lead developer for the master’s degree in human services with an emphasis in forensic behavioral health for Concordia University in St. Paul, Minnesota. He has also been employed with Pathways Counseling Center in St. Paul for the past 16 years. He is the founder and CEO of the American Institute for the Advancement of Forensic Studies and is editor-in-chief of Forensic Scholars Today. Contact him at jerrod01234brown@live.com.

Megan N. Carter is a board-certified forensic psychologist who practices in Washington state. Her career focus has been on forensic psychological evaluations in both civil and criminal court proceedings. She has also focused on providing education about fetal alcohol spectrum disorders to mental health professionals.

 

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.

Grappling with compassion fatigue

By Lindsey Phillips August 31, 2020

Compassion fatigue presents a paradox for counselors and others in the helping professions. As Alyson Carr, a licensed mental health counselor and supervisor in Florida, points out, it compromises their ability to do the very thing that motivated many of them to enter the field in the first place — empathically support those in pain.

Empathy and compassion are attributes those in the helping professions are particularly proud to possess and cultivate. Yet those same characteristics may leave some professionals more susceptible to becoming traumatized themselves as they regularly observe and work with those who are suffering.

Jennifer Blough provides counseling services to other helping professionals as owner of the private practice Deepwater Counseling in Ypsilanti, Michigan. She says many of her clients experience compassion fatigue. One of her former clients, an emergency room nurse, witnessed trauma daily. One day, the nurse treated a child who had suffered horrendous physical abuse, and the child died shortly after arriving at the hospital.

This incident haunted the nurse. She had nightmares and intrusive thoughts about the child’s death and abuse. She started to isolate to the point that she had to step away from her job because she refused to leave her house. She couldn’t even bring herself to call Blough. She just sent a text asking for help instead.

Blough, a licensed professional counselor (LPC) and certified compassion fatigue therapist, asked the nurse to come to her office, but the nurse said she was comfortable leaving her home only when accompanied by her dog. So, Blough told her to bring her dog with her to the session. That got the nurse in the door.

From there, Blough and the nurse worked together to help the client process her trauma. Blough also taught the client to recognize the warning signs of compassion fatigue so that she could use resiliency, grounding skills, relaxation, boundary setting, gratitude and self-compassion to help keep her empathy from becoming unmanageable again.

Defining compassion fatigue

“One of the most important ways to help clients who might be struggling with compassion or empathy fatigue is to provide psychoeducation,” Blough says. “A lot of people don’t even realize there’s a name for what they’re going through or that others are going through the same thing.”

Blough, author of To Save a Starfish: A Compassion-Fatigue Workbook for the Animal-Welfare Warrior, didn’t understand that she was experiencing compassion fatigue when she worked at an animal shelter and as an animal control officer before becoming a counselor. After she started feeling depressed, she decided that she was weak and unfit for her job and ultimately left the field entirely. It wasn’t until she was in graduate school for counseling that she learned there was a name for what she had experienced — compassion fatigue.

According to the American Institute of Stress, compassion fatigue is “the emotional residue or strain of exposure to working with those suffering from consequences of traumatic events.” This differs from burnout, which is a “cumulative process marked by emotional exhaustion and withdrawal associated with workload and institutional stress, not trauma-related.”

Although compassion fatigue is the more well-known and widely used term, there is some debate about whether it is the most accurate one. Some mental health professionals argue that people can never be too compassionate. Instead, they say, what people experience is empathy fatigue.

In an interview with CT Online in 2013, Mark Stebnicki described empathy fatigue as resulting from “a state of psychological, emotional, mental, physical, spiritual and occupational exhaustion that occurs as the counselors’ own wounds are continually revisited by their clients’ life stories of chronic illness, disability, trauma, grief and loss.”

April McAnally, an LPC in private practice in Austin, Texas, is among those who believe that people can’t have too much compassion. Compassion involves having empathy and feeling what the other person does, but we have a screen — an internal boundary — that protects us, McAnally says. “Empathy, however, can be boundaryless,” she continues. “We can find ourselves overwhelmed with what the other person is experiencing. … So, what we actually become fatigued by is empathy without the internal boundary that is present with compassion.”

As Blough puts it, “Empathy is the ability to identify with, or experience, another’s emotions, whereas compassion is the desire to help alleviate suffering. In other words, compassion is empathy in action.”

McAnally, a certified compassion fatigue professional, also suggests using the term secondary trauma. She finds that it more accurately describes the emotional stress and nervous system dysregulation that her clients experience when they are indirectly exposed to the trauma and suffering of another person or animal.

Symptoms and risk factors

Anyone can be susceptible to burnout, but compassion fatigue most often affects caregivers and those working in the helping professions, such as counselors, nurses, social workers, veterinarians, teachers and clergy.

Working in a job with a high frequency of trauma exposure may increase the likelihood of developing compassion fatigue, McAnally adds. For example, a nurse working in an OBGYN office may have a lower risk of developing compassion fatigue than would an emergency room nurse. Even though they both share the same job title, the impact and frequency of trauma is going to be higher in the ER, McAnally explains.

Counselors should also consider race/ethnicity and contextual factors when assessing for compassion fatigue. Racial injustices that members of marginalized populations regularly experience are sources of pervasive and ongoing trauma, McAnally notes. And unresolved trauma increases the likelihood of someone experiencing empathy fatigue, she adds.

Carr, an American Counseling Association member who specializes in complex trauma and anxiety, and Blough both believe the collective trauma resulting from the COVID-19 pandemic and exposure to repeated acts of racial violence and injustice could lead to collective compassion fatigue for all helping professionals (if it hasn’t already).

McAnally, a member of the Texas Counseling Association, a branch of ACA, says the current sociopolitical climate has also affected the types of clients she is seeing, with more individuals who identify as activists and concerned citizens seeking counseling of late. She has found that these clients are experiencing the same compassion fatigue symptoms that those in the helping professions do.

Blough and Victoria Camacho, an LPC and owner of Mind Menders Counseling in Lake Hopatcong, New Jersey, say symptoms of compassion fatigue can include the following:

  • Feelings of sadness or depression
  • Anxiety
  • Sleep problems
  • Changes in appetite
  • Anger or irritability
  • Nightmares or intrusive thoughts
  • Feelings of being isolated
  • Problems at work
  • A compulsion to work hard and long hours 
  • Relationship conflicts
  • Difficulty separating work from personal life
  • Reactivity and hypervigilance
  • Increased negative arousal
  • Lower frustration tolerance
  • Decreased feelings of confidence
  • A diminished sense of purpose or enjoyment
  • Lack of motivation
  • Issues with time management
  • Unhealthy coping skills such as substance use
  • Suicidal thoughts

There are also individual risk factors. According to Camacho, a certified compassion fatigue professional, individuals with large caseloads, those with limited or no support networks, those with personal histories of trauma or loss, and those working in unsupportive environments are at higher risk of developing compassion fatigue.

In fact, research shows a correlation between a lack of training and the likelihood of developing compassion fatigue. So, someone at the beginning of their career who feels overwhelmed by their job and lacks adequate training and support could be at higher risk for experiencing compassion fatigue, McAnally says.

One assessment tool that both Blough and Camacho use with clients is the Professional Quality of Life Scale, a free tool that measures the negative and positive effects of helping others who experience suffering and trauma. Blough says this assessment helps her better understand her clients’ levels of trauma exposure, burnout, compassion fatigue and job satisfaction.

Regulating the body and mind

“Having an awareness of our emotions and experiences, especially in a mindful way, can serve as a barometer to help protect us against developing full-blown compassion fatigue,” says Blough, a member of ACA and Counselors for Social Justice, a division of ACA.

Part of this awareness includes being mindful of one’s nervous system and the physical changes occurring within one’s body. When someone experiences compassion fatigue, their amygdala, the part of the brain involved in the fight-or-flight response, gets tripped a little too quickly, McAnally explains. So, their body may react as if they are in physical danger (e.g., heart racing, sweating, feeling panicky) even though they aren’t.

If clients get dysregulated, McAnally advises them to use grounding techniques to remind themselves that they are safe. She will often ask clients to look all over the room, including turning around in their chairs, so they can realize there is nothing to fear at that moment. She also uses the 5-4-3-2-1 technique, in which clients use their senses to notice things around them — five things they see, four things they hear, three things they feel, two things they taste and one thing they smell.

Research has shown that practicing mindfulness for even a few minutes a day can increase the size of the prefrontal cortex — the part of the brain responsible for emotional regulation, McAnally adds.

Blough often uses the square breathing technique to ground clients and get them to slow down. She will ask clients to breathe deeply while simultaneously adding a visual component of making a square with their eyes. They breathe in for four seconds while their eyes scan left to right. They hold their breath for four seconds while their eyes scan up to down. They breathe out for four seconds while their eyes scan right to left. And they hold their breath for four seconds while their eyes move down to up.

Counselors can also teach clients to do a full body scan to regulate themselves, Blough and Camacho suggest. This technique involves feeling for tension throughout the body while visualizing moving from the head down to the feet. If the person notices tension in any area, then they stop and slowly release it.

Camacho once had a client lean forward and grab the armrest of the chair they were sitting in while talking. She stopped the client and asked, “Do you notice you are gripping the armrest? Why do you think you are doing that?”

The client responded, “I wasn’t aware of it, but I find it comfortable. I feel like I’m grounding myself.”

Camacho, an ACA member who specializes in posttraumatic stress disorder, trauma, and compassion fatigue in professionals who serve others, used this as a teachable moment to show the client how to ground themselves while also having relaxed muscles. She asked the client to release their grip on the chair and instead to lightly run their fingers across it and focus on its texture.

Carr finds dancing to be another useful intervention. “Engaging in dancing and moving communicates to our brains that we are not in danger. [It] allows us to develop and strengthen affect regulation skills as well as have a nonverbal, integrated body-mind experience,” she explains.

Creating emotional boundaries

Setting boundaries can be another challenge for helping professionals. Blough says many of her clients report feeling guilty if they say “no” to a request. They often feel they have to take on one more client or take in one more animal. But she asks them, at whose expense?

Blough reminds clients that saying “no” or setting a boundary just means saying “yes” to another possibility. For example, if a client wants to schedule an appointment on Thursday night at the same time that the therapist’s child has a soccer game, then telling the client “no” just means that the therapist is saying “yes” to their family and to their own mental health.

Blough and McAnally recommend that people create routines to help themselves separate work from home. For example, clients and counselors alike could listen to an audiobook or podcast during their commute home, or they could meditate, take a walk or even take a shower to signify the end of the workday, Blough suggests. “Anything that helps them clear their head and allows them to be fully present for themselves or their families,” she adds.

People can also establish what Carr calls an “off switch” to help them realize that work is over. That action might involve simply shutting the office door, washing one’s hands or doing a stretch. At the end of the workday, Carr likes to put her computer in a different room or in a drawer so that it is out of sight and mind. Then, she takes 10 deep breaths and leaves work in that space.

Exercising self-compassion

“Because a lot of helping professionals are highly driven and dedicated, they tend to have unrealistic expectations and demand a lot from themselves, even to the point of depletion,” Blough says. “Having low levels of self-compassion can lead to compassion fatigue, particularly symptoms associated with depression, anxiety and posttraumatic stress disorder.”

In other words, self-compassion is integral to helping people manage compassion fatigue. “Self-criticism keeps our systems in a state of arousal that prevents our brains from optimal functioning,” Carr notes, “whereas self-compassion allows us to be in a state of loving, connected presence. Therefore, it is considered to be one of the most effective coping mechanisms. It can provide us with the emotional resources we need to care for others, help us maintain an optimal state of mind, and enhance immune function.”

According to Kristin Neff, an expert on self-compassion, caregivers should generate enough compassion for themselves and the person they are helping that they can remain in the presence of suffering without being overwhelmed. In fact, she claims that caregivers often need to focus the bulk of their attention on giving themselves compassion so that they will have enough emotional stability to be there for others.

People in the helping professions can become so focused on caring for others that they forget to give themselves compassion and neglect to engage in their own self-care. Blough often asks clients to tell her about activities that they enjoy — ones that take their mind off work, help them relax and allow them to feel a sense of accomplishment. Then she asks how often they engage in those activities. Clients often tell her, “I used to do it all the time before I became a professional caregiver.”

She reminds them that they can help others only if they are also taking care of themselves. That means they need to take time to engage in activities that relax and recharge them; it isn’t a choice they should feel guilty making.

Self-regulating in session

As helpers, counselors are likely to experience symptoms of compassion fatigue at some point. This is especially true for clinicians who frequently see clients who are dealing with trauma, loss and grief.

For McAnally, that experience came early in her career. During practicum, she had a client with a complex trauma history who couldn’t sleep at night. In turn, McAnally found herself waking up in the middle of the night, worrying about the client. She knew this was a warning sign, so she reached out to her supervisor, who helped her develop a plan to mitigate the risk of compassion fatigue.

It almost goes without saying that counselors should take the advice they give to their own clients: They should establish a self-care routine. They should seek their own counseling and support. They should set boundaries and find ways to recharge outside of work. And they should exercise self-compassion.

But counselors also need to find ways to self-regulate during sessions. “If you are tense and you’re hearing all of these heavy stories, you’re at a much greater risk of being vicariously traumatized,” Blough says. Self-regulation can provide a level of protection from that occurring, she notes.

Blough often uses the body scan technique while she is in session. Doing this, she can quietly relax her body without it drawing the attention of her clients. In addition, as she teaches relaxation skills to her clients, she does the skills with them. For example, she slows her own breathing while teaching clients guided breath work. That way, she is relaxing along with them.

Likewise, McAnally has learned to be self-aware and regulate her nervous system when she is in session. If she notices her heart rate accelerating and her stomach clinching when a client is describing a painful or traumatic event, then she grounds herself. She orients herself by wiggling her toes and noticing what it feels like for her feet to be touching the ground. She also looks around the room to remind her brain that she is safe.

McAnally also uses internal self-talk. She will think, “I’m OK right now.” As with the body scan, this is a subtle action that clinicians can take to ground themselves without the client even being aware that they are doing it.

Helping the helpers during COVID-19

Recently, Carr received a text from a counseling mentor who has been practicing for 40 years that said, “I am falling apart. I am lost. I don’t know what to do, but sending a text to someone I trust felt right. Write or call when you can.”

Carr quickly reached out, and her colleague said he was experiencing a sense of hopelessness that he hadn’t in many years. He worried about his clients and feared he wasn’t doing everything he could for them. He was also anxious about finances; several of his clients had become unemployed because of the COVID-19 pandemic, so he started seeing them pro bono. All of this was taking a toll on him personally and professionally.

Before the pandemic, McAnally managed her compassion fatigue symptoms in part by checking in with other therapists who worked down the hall from her office and by participating in in-person consultation groups. Now that she is working from home full time because of the pandemic, she says that she has to be more intentional about practicing self-care and accessing support. She calls her colleagues to check in, practices mindfulness, and schedules breaks to go outside and play with her dog.

Even when counselors recognize that they need help, they can encounter barriers similar to those their clients face. For instance, they may not be able to find in-network providers, and only a small portion of the hourly rate may be covered by their insurance. This problem made Carr pose some questions: “Who is helping the helpers right now? How can we take care of others if we aren’t able to more easily take care of ourselves?”

Then she decided to take action. She created Counseling for Counselors, a nonprofit organization dedicated to raising awareness about the emotional and psychological impact on mental health providers during a time of collective trauma. The organization’s aim is to generate funding that would allow self-employed licensed mental health professionals in need of treatment to more easily access those services.

“Although the heightened state of anxiety around the pandemic may have exposed this critical need, the demand for quality, affordable mental health care for counselors is ongoing,” Carr says. “Counselors are not immune to trauma and, now more than ever, licensed mental health professionals need access to mental health services in order to effectively treat the populations we serve and to continue to play an instrumental part in contributing to the well-being of society at large.”

Fostering compassion satisfaction

People in the helping professions often feel guilty or ashamed about struggling with compassion fatigue. They sometimes believe they should be immune or should be able to find a way to push through despite their symptoms. But that isn’t the case.

“I think the biggest takeaway when it comes to compassion fatigue is that it’s a normal, almost inevitable consequence of caring for and helping others. It’s not a character flaw or a sign of weakness. It’s not a mental illness. It affects the best and brightest and those who care the most,” Blough says.

For that matter, compassion fatigue isn’t something you “have” or “don’t have,” she adds. Instead, it operates on a spectrum, which is why it is so important for helping professionals to be aware of its warning signs and symptoms.

Blough acknowledges that compassion fatigue is always present in some form for her personally. She often manages it well, so it just simmers in the background. But sometimes it boils over. When that happens, she knows to regulate herself, to increase her self-care and to get support.

It is easy for a negative experience to overshadow a helping professional’s entire day and push aside any positive aspects. That’s why Blough and McAnally both recommend setting aside time daily to list three positive things that happened at work. A counselor or other helping professional could focus on the joy they felt when they witnessed an improvement in their client that day or when they witnessed the “aha!” moment on their client’s face.

Blough often advises clients to journal or otherwise reflect on these positive experiences before they go to bed because it can help prevent rumination and intrusive thoughts that may disrupt sleep. Celebrating these “little victories” will help renew their passion for their job, she adds.

As Blough points out, “Empathy can definitely lead to compassion fatigue, but if properly managed, it can also foster compassion satisfaction, which is the antithesis of compassion fatigue. It’s the joy you get from your work.”

 

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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.

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