Tag Archives: Counselors Audience

Counselors Audience

2017’s most-read articles

January 3, 2018

What were counselors reading in 2017?

The year’s most-read post at Counseling Today online was a first-person article that shared insights on recovering from — and avoiding — practitioner burnout. Readers were also interested in pieces that shared professional insights on social issues, strengthening the therapeutic relationship, client issues such as trauma and anxiety, navigating technology, counselor licensure and other topics.

Interestingly, the top five search terms that brought online searchers to the Counseling Today website were “countertransference,” “self-care for counselors,” “multicultural competence,” “empathy fatigue” and “dual relationships in counseling.”

More than 150 articles, both online-exclusive pieces and articles that also appeared in Counseling Today’s print magazine, were posted at ct.counseling.org in 2017.


Most-viewed articles posted in 2017 at ct.counseling.org

  1. A counselor’s journey back from burnout” (Member Insights, April magazine)
  2. Yalom urges ACA attendees to hold fast to self-care and the therapeutic alliance” (Online exclusive coverage of Irvin Yalom’s keynote speech at ACA 2017 Conference & Expo in San Francisco; posted in March)
  3. Informed by trauma” (Cover story, October magazine)
  4. Facing the fear of incompetence” (Feature, April magazine)
  5. ACA continues push forward for licensure portability” (Feature, July magazine)
  6. Fetal alcohol spectrum disorders (FASD): A guide for mental health professionals” (Member Insights, July magazine)
  7. Living with anxiety” (Cover story, June magazine)
  8. Facing the realities of racism” (Cover story, February magazine)
  9. The (misguided) pursuit of happiness” (Feature, February magazine)
  10. Creative and novel approaches to empathy” (Knowledge Share, February magazine)
  11. Mental health implications of undocumented immigrant status” (Knowledge Share, April magazine)
  12. A protocol for ‘should’ thoughts” (Online exclusive, posted in October)
  13. Technology Tutor: Revisiting the ethics of discussing clients online” (Column, November magazine)
  14. Nonprofit News: Self-care for caregivers” (Online column, posted in March)
  15. When brain meets body” (Cover story, March magazine)
  16. Key concepts from Gestalt therapy for non-Gestalt therapists” (Knowledge share, June magazine)
  17. Becoming shameless” (Cover story, May magazine)
  18. The selfish act of forgiving” (Feature, May magazine)
  19. Observations from a licensing board” (Online exclusive, posted in July)
  20. Conversion therapy: Learning to love myself again” (Online exclusive, posted in February)

 

 

 

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What was your favorite article of 2017? What would you like to see Counseling Today and CT Online cover in 2018? Leave a reply in the comment section below, or email us at CT@counseling.org

 

 

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

 

The people whisperers

By Laurie Meyers December 26, 2017

Licensed professional counselor (LPC) Hallie Sheade can’t remember a time when she didn’t love horses. She has been told that her equine passion started when she was 2 and begged to be allowed to ride a carnival pony without her mother holding her hand. Sheade, an American Counseling Association member, has taken riding lessons since she was 5, but it was at age 9 that she first encountered the path that would eventually lead her to specialize in animal-assisted therapy.

One day, a horse named Cowman who had been labeled difficult and stubborn showed up at the barn where Sheade took lessons. True to his reputation, Cowman didn’t get along with the other horses — or with people. But Sheade believed that Cowman was just misunderstood. She could relate. After all, she was feeling misunderstood by her own parents. Sheade began spending hours with Cowman, often grooming the horse as she poured out her troubles to him. A bond formed between them, and Sheade became the only person with whom Cowman would cooperate.

Then something interesting occurred. After months of spending time with Sheade, Cowman started to get along with other horses and to take direction from other people. And Sheade? Her relationship with her parents began to improve. “I felt calmer and more at peace after spending time with Cowman,” Sheade says. “I think it goes back to the fact that horses naturally embody [Carl] Rogers’ core conditions — empathic, nonjudgmental and able to offer unconditional positive regard. Therefore, just being with them can help us to feel more connected and understood, making it easier to tolerate life’s stresses.” She recalls that being the person Cowman chose to respond to also made her feel confident, capable and special.

Sheade’s memory of what she and Cowman shared would grow into a fascination for the human-animal bond and a desire to use that connection to help others who are hurting. Although her story illustrates the potential power of that bond, it does not stand as an example of actual animal-assisted therapy (AAT). Simply bringing your dog to work so that clients can pet it is not the equivalent of AAT, say the specialists interviewed for this article. Counselors — and the animals with which they work — need the proper training for true therapeutic benefits to be realized.

Instinctive helpers

Therapy animals need the right temperament and training to work with people who are experiencing stress and distress, says Cynthia Chandler, director of the Consortium for Animal Assisted Therapy at the University of North Texas. In other words, a skittish and difficult-to-control pet dog is not a therapy animal, no matter how beloved it may be.

Well-trained therapy animals can help counselors establish therapeutic bonds with their clients more quickly and can also alert counselors to emotions that clients may not have expressed yet verbally. However, counselors must be properly trained to read these signals and work effectively with therapy animals, says Chandler, a member of ACA.

“Using AAT requires understanding how animals interact as social beings and what that interaction can contribute to the psychodynamics of a counseling session,” says Chandler, whose book Animal-Assisted Therapy in Counseling is in its third edition. Counselors using AAT must have an understanding of species-specific behaviors — for example, how particular types of animals signal distress or give support — and an in-depth awareness of their own animals’ personalities.

Possible therapy animals include pocket pets (such as hamsters), rabbits, reptiles, llamas, dolphins and cats, but the most common are dogs and horses. Chandler, co-leader of ACA’s Animal-Assisted Therapy in Mental Health Interest Network, believes that dogs and horses make the best therapy animals because they come from family systems and have lived with humans for such a long time. Their natural instinct is to include the counselor and client in their herd or pack, she explains.

Like humans, dogs and horses also seek positive nurturing interactions. “[The desire for nurture] has a physiological basis,” Chandler says. “When we’re engaging in a nurturing touch, it releases oxytocin and endorphins.” When clients reach out to touch a therapy animal, they feel more socially connected, and their stress hormones go down, she explains. “[This] allows clients to feel safer to engage and discuss difficult issues,” says Chandler, who has another book, Animal-Assisted Interventions for Emotional and Mental Health: Conversations With Pioneers of the Field, currently in press.

Horses and dogs are also excellent distress detectors, Chandler says. Both species are extremely good at sensing stress, through smell and body language, and then reflecting that stress is present in an environment, she explains. They communicate this through their body language, such as moving toward an anxious client to soothe the person or moving away when the situation feels overwhelming to them. They also give off other signals to alert counselors to important information, she says. For instance, a horse might prick up its ears or a dog might bark or repeatedly look back and forth between the client and counselor.

Chandler jokes that horses and dogs are existentialists. They don’t like angst, uncertainty or resistance, and their natural inclination is to resolve issues, she explains. Chandler’s former therapy dog, Rusty, a red and white cocker spaniel, was known to walk over to clients who were resistant, put his head on their knees and just stare at them. Typically, Chandler says, tears would start forming in these clients’ eyes within about 30 seconds, and they would then begin to open up. Rusty would indicate his approval — and support — by jumping up into their laps.

Through her personal practice, research and interviewing other animal therapy experts, Chandler has studied the human-animal bond and how it works in therapeutic settings. In the process, she has developed what she calls human-animal relational theory. When humans and social animals come together within the therapeutic setting, she says, a whole series of relational happenings occur, even if a dog is across the room or a horse is across a pasture. “How an animal engages or doesn’t engage will bring out something big in the client,” Chandler says.

Being able to recognize the significance of the therapy animal’s behavior is the job of the counselor, Chandler says. “Hey, Jesse [Chandler’s current therapy dog, also a cocker spaniel] just woke up and jumped up in your lap. Why do you think she did that?” Chandler might ask a client. For Chandler, Jesse’s reaction might hint at resistance on the part of the client. Jesse, like Rusty, doesn’t like it when she senses that clients are holding back and will often jump into their laps and nuzzle them until they talk about what is bothering them. However, the client might assign a different meaning to Jesse’s action. Either way, Chandler marks the moment, and then she and the client process it together.

Risk reduction

Leslie Stewart, whose research focuses on AAT, emphasizes that it is important for counselors to recognize that AAT is a specialized form of counseling — just like play therapy or art therapy — that requires specific knowledge. Because animal behavior is never 100 percent predictable, AAT also carries an increased risk of harm, she acknowledges. But Stewart, who helped write the Animal-Assisted Therapy in Counseling Competencies endorsed by the ACA Governing Council in 2016, believes that in the hands of competent providers, the potential benefits of AAT far outweigh the risks.

Risk reduction begins with informed consent. Counselors should always talk to clients about what they can expect if they decide to use animals in their counseling sessions and caution them about any potential risks, Stewart says. For instance, clients with previously unknown allergies could be at risk of anaphylaxis. Many animals shed, so clients should be prepared to find fur and hair on their clothing. Something as simple as a game of catch could cause accidental injury if a client takes a wrong step and pulls a muscle or breaks a bone.

Then there are the larger risks. “Horses are big and move quickly. When they are scared, they react quickly, and we can’t always stop them,” Stewart cautions. “They also can’t see their feet, so they can’t see our feet.”

And even trained therapy dogs will bite under certain circumstances, Stewart notes. “In cases when animals’ needs aren’t perceived and met, they feel they need to react in ways humans see as aggressive,” she says. Becoming competent in AAT requires counselors to learn to recognize the early signs that an animal needs some space or has had enough and needs to take a break.

Client assessment is also crucial, she says. Stewart, who has counseled survivors of sexual assault and juvenile offenders, doesn’t bring any of her therapy animals with her when assessing clients. Some clients are afraid of or simply don’t want to work with animals, she explains, whereas certain clients — such as those with a history of violent, impulsive behavior — perhaps shouldn’t engage in AAT.

Stewart teaches AAT at Idaho State University, where she is an assistant professor of counseling. She works with three therapy animals: Killer the rabbit, a border collie named Star Sapphire and a German shepherd named Sophie. She emphasizes that knowing an individual animal’s personality is just as important as knowing species behavior.

“Sophie is a big gentle dog, typical of her breed, sort of no-nonsense, friendly and enjoys getting human attention,” Stewart says. “She’s not a lap dog and is not going to be all over you, whereas Star Sapphire is going to be all over you.” The dogs show affection differently, and Stewart highlights the contrast to help students recognize that clients also express needs differently.

Students learn what it means to be affectionate with Sophie. When she curls up four feet away, she’s showing affection. Stewart also asks them to figure out how to communicate affection to Star, even when they might prefer that Star not be all over them. Stewart also has the students use positive reinforcment-based obedience techniques to teach Star something new, such as sitting in a chair in class. By teaching Star, students are learning how to better communicate and deal with frustration when working with clients, she says.

Stewart also provides education about how certain species view the world and what does and does not make a particular type of animal comfortable. “For example, a lot of humans want to hug dogs, but most dogs don’t like being hugged. It stresses them out,” she says. Students are tasked with redirecting a client’s need to show affection into an action that will not cause the therapy animal stress. For instance, Sophie likes to put her head on someone’s knee and get her ears scratched.

Stewart also brings Killer to class. Rabbits’ actions are more subtle and require close attention — which also happens to be a necessary skill for counselors when working with human clients.

Talking horses

As part of her path to specializing in AAT, Sheade studied with Chandler while getting her doctorate at the University of North Texas. She developed two models of equine-assisted therapy: equine-assisted play therapy and equine relational therapy. She now runs Equine Connection Counseling, a private practice that specializes in equine therapy.

Sheade uses equine therapy with both children and adults. Equine Connection Counseling’s partner, Wings of Hope Equitherapy — an accredited therapeutic horseback riding facility — provides the space and horses. The therapy takes place primarily on the ground through interaction with the horses rather than on horseback.

With children ages 3 to 9, Sheade uses equine-assisted play therapy, which incorporates horses into child-centered play therapy. Sessions are one-on-one in a play area that contains various toys and multiple miniature horses, which are slightly bigger than a very large dog. Sheade lets the child choose how (or whether) to interact with the horses. Many children want to immediately engage with the horses, while other children prefer to start with toy horses, she says. The children are allowed to groom the horses with brushes that Sheade provides or they can integrate the horses into play using various toys. For example, children might use the medical kit to give the horses a “checkup” or dress the horses up by putting a lei or boa around their necks or balancing a hat on their heads.

Some children don’t interact with the miniature horses at all, choosing merely to play with the toys on their own. However, Sheade says the parents of those children often report that the horses are all their children talk about afterward.

The horses serve as potent change agents, Sheade says. “They [clients] want the horse to want to be around them,” she says. Horses do not like chaos, however. It isn’t uncommon for children to run up and greet the horses, but if a child is emotionally dysregulated — for example, displaying behaviors such as defiance and opposition, uncontrolled energy or excitement — the horses will react in ways that do not communicate to the child “let’s play,” Sheade says. One horse might run off to the other side of the arena, whereas others might stand in place but show no interest in interacting, she explains. This is the horses’ way of giving feedback, but it is less threatening to a child coming from an animal than it is coming from a grown person, Sheade says.

For example, one of Sheade’s clients was a young girl who was oppositional and defiant. She would approach the horses and get very frustrated when she couldn’t get them to do what she wanted them to do. Sheade helped her become aware that her actions, such as rushing up to the horses in a demanding and impatient manner, were actually driving the horses away.

Children with social difficulties sometimes find that the horses don’t want to interact with them. When this happens, Sheade has them examine how they approached the horses. Was it in a physically threatening way? Did they speak in an angry tone of voice? As the children learn how to interact with the horses, they can take what they are learning and apply it to other relationships in their lives, Sheade says.

The horses also offer emotional support. For instance, if a child is playing alone in the sandbox because he or she is sad or upset, one or more of the horses tends to gravitate toward the child to give comfort through their presence, Sheade says.

Sheade also works with adults, particularly military veterans and others with posttraumatic stress disorder or other trauma. These sessions, using the equine relational therapy model, are also one-on-one and take place mainly on the ground with a herd of horses. Clients choose which horse they want to work with and usually stay with that horse throughout the therapeutic relationship. By inviting clients to pick a horse and have it be “theirs,” Sheade says she is encouraging a bond based on the therapeutic relationship.

Although the primary bond is between the client and the chosen horse, the herd still participates, Sheade says. When clients are distressed, it isn’t only “their” horse that typically reacts. Often, the whole herd will gather.

The sessions are usually a mix of activities and talking, Sheade explains. As clients speak, Sheade is watching the horses’ reactions. This can tell her more about how clients are feeling and often gives her an avenue to broach uncomfortable topics. For example, sometimes when veterans are talking about trauma, their horse might signal the herd to leave. Sheade then asks clients what they think prompted the retreat. Usually, the answer is that the clients’ anxiety was building because they were struggling with a topic they didn’t want to talk about but knew they needed to address.

With equine-assisted counseling, clients don’t necessarily have to talk specifically about what is troubling them, because interpersonal challenges are revealed in the way the horse and client interact, Sheade says. For instance, someone who is a survivor of sexual violence might not know how to assert themselves and say “no” to a horse. Or new clients might think that when the horses walk away from them, it is automatically an indication that they dislike the person.

“What we’re targeting … is [the clients’] thoughts and feelings in the moment — what they believe about themselves or the horses,” Sheade says.

Working with trauma

LPC Shawna Corley’s therapy dog, Rylie, a Great Pyrenees-golden retriever mix, plays a vital role in establishing a sense of safety and trust with Corley’s clients, most of whom are trauma survivors. Children, in particular, find it easier to “talk” to Rylie, Corley says.

One client, a 7-year-old girl who had been sexually assaulted by a relative, kept insisting that she was fine, even though she had been experiencing flashbacks. Corley, who doesn’t include Rylie in her intakes, gradually began bringing her into sessions with the girl. Once the client established a bond with Rylie, the girl could tell her anything she wanted, just like she was talking to a friend. Corley, who presented a session on incorporating therapy animals into counseling at the 2016 ACA Conference & Expo in Montréal, would sit apart from the client and Rylie, but close enough to hear.

The child would audibly whisper into Rylie’s ear that she felt bad or sad. Corley, a private practitioner in San Antonio, would then ask the girl for permission to speak to Rylie. After “listening” to Rylie, Corley would say something like, “Rylie tells me that you have been feeling sad. Can you tell me about that?” Relaying the conversation through Rylie helped the girl begin to talk to Corley about her trauma.

Rylie has other ways of telling Corley about what a client is feeling. If Rylie perceives a lot of sadness and stress, she will lie on Corley’s feet. To communicate the presence of anger or frustration, she sits on Corley’s feet. Rylie’s physical signals — natural behaviors that Corley reinforced through training — can be especially helpful for adult trauma survivors who have difficulty recognizing and labeling their own emotions. When clients are talking about their trauma, Rylie can let Corley know that clients are becoming upset before their distress triggers a traumatic reaction.

Rylie also sometimes gently urges clients to talk. If clients sit in session for an extended period of time without talking, Rylie often will go over and push their knees with her paw. She will keep doing this until they say something, Corley says.

Because Corley sees clients who are experiencing physical abuse or engaging in self-harm, Rylie is trained to spot injuries such as superficial cuts and bruises underneath clothing. Rylie will then alert Corley, using her nose to pinpoint an area with injuries. Rylie will keep coming back to the area until Corley acknowledges the signal. Rylie’s information provides Corley an opportunity — either immediately or in the future — to initiate a conversation about the injuries.

Rylie also strives to provide a sense of safety, according to Corley. If clients are feeling vulnerable, Rylie will move toward them to physically surround them in a protective manner. She will also protect them by accompanying them to the door when it is time to go.

Safety and training

It is crucial for counselors who are interested in AAT to understand how proper training protects both their clients and the therapy animals themselves, Chandler says. She and Stewart emphasize the importance of recognizing signs of stress in a therapy animal and realizing when an animal doesn’t want or isn’t able to work.

“An animal with the right temperament and attitude can handle counseling quite well,” Chandler says. However, absorbing all the stress and pain that is part of the therapeutic process wears them out, she says. “Jesse only sees a few clients a day [and] not every day,” she says. “Sometimes therapists have more than one dog or horse so they can rotate.”

Although programs that grant certificates for AAT — such as the one at Idaho State — are becoming more common, it can still be difficult to find training, Stewart acknowledges. Courses are available online, but she says that those alone are not sufficient; counselors must do formal coursework. She recommends that counselors who are having trouble finding appropriate coursework contact ACA’s Animal-Assisted Therapy in Mental Health Interest Network (see “Additional resources” sidebar, below).

 

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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:

Competencies (counseling.org/knowledge-center/competencies)

  • Animal-Assisted Therapy in Counseling Competencies

ACA Interest Networks (counseling.org/aca-community/aca-groups/interest-networks)

  • ACA Animal-Assisted Therapy in Mental Health Interest Network

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

  •  “Animal Assisted Therapy in Counseling” by Leslie Stewart & Catherine Y. Chang

Counseling Today (ct.counseling.org)

Journal articles (counseling.org/publications/counseling-journals)

  • “Therapy Dogs on Campus: A Counseling Outreach Activity for College Students Preparing for Final Exams” by Sandra B. Barker, Randolph T. Barker & Christine M. Schubert, Journal of College Counseling, October 2017

 

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

Letters to the editorct@counseling.org

 

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Understanding adult ADHD

By Donna Mac November 20, 2017

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

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

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

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

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

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

 

Growing out of ADHD?

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

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

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

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

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

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

 

Childhood vs. adulthood scenarios

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

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

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

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

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

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

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

 

Other experiences

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

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

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

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

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

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

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

 

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

 

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

Bringing Syrian hospitality into your counseling practice

By Shadin Atiyeh November 8, 2017

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

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

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

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

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

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

 

Bridging cultural boundaries

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

 

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

 

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

A protocol for ‘should’ thoughts

By Brandon S. Ballantyne October 31, 2017

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

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

 

Framework

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

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

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

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

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

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

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

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

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

 

Protocol/intervention

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

 

S-H-O-U-L-D

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

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

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

 

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

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

Client: “I will try my best.”

 

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

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

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

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

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

 

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

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

 

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

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

 

Conclusion

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

 

 

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

 

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

 

 

 

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