Tag Archives: Counselors Audience

Counselors Audience

Why neurocounseling?

Compiled by Bethany Bray March 12, 2018

Decades ago, you might have gotten some funny looks or raised eyebrows if you used the word “neurocounseling” in a professional setting. In recent years, however, counselors have become increasingly interested in using concepts from neuroscience to inform and support their work with clients.

What makes professional counseling compatible with neuroscience? How can it help counselors gain insights into human behavior and the challenges that clients bring into counseling sessions?

Counseling Today asked three practitioners for whom neurocounseling is an area of expertise, Thomas A. Field, Laura K. Jones and Lori A. Russell-Chapin, what draws them to this topic.

The trio are co-editors of the ACA-published book Neurocounseling: Brain-Based Clinical Approaches. Field is an associate professor in the master’s counseling program at the City University of Seattle; Jones is an assistant professor at the University of North Carolina at Asheville; and Russell-Chapin is professor of counselor education at Bradley University in Illinois.

 

Q+A: Why neurocounseling?

 

Laura Jones: Coming into the field with graduate degree in cognitive neuroscience, I have always playfully said that I do not know how to be a counselor without considering what is happening in the brains and bodies of my clients — both the physiological factors that have led to their struggles and resilience as well as the neurophysiological corollaries of their growth. As a counselor-in-training and later a student in counselor education, I could find very little work discussing this connection and became passionate about trying to bridge the two fields.

One of my foremost professional endeavors is to facilitate the intentional and informed integration of neuroscience into our field in a way that honors our professional identity (as I am also quite passionate about professional advocacy as well) and in doing so enrich and increase accessibility to training in this area. I am endlessly excited by the emerging science that can, has and will continue to influence the mental health field. For example, how can we ignore research that suggests that levels of certain gonadal hormones (steroids) have the potential to influence an individual’s susceptibility to suicidal ideation and attempts, drug relapse, responses to traumatic stress, etc., or the burgeoning research that implicates dysbiosis (imbalance) of our gut microorganisms (e.g., bacteria) in our mental health, or the fact that our body’s immune response has implications on mental and emotional wellbeing.

Although Descartes’ mind-body dualism has long been disproved, we (mental health and medical practitioners alike) often still function, largely implicitly, from this paradigm. Each and every day, researchers are substantiating just how complex this connection truly is, thereby underscoring how we can no longer work in health silos. This integrative perspective is the future of mental health.

Counselors have the opportunity to learn from other fields and use this information to strengthen our work with clients and our field as a whole. I firmly believe that counselors are well positioned to provide valuable and unique contributions to broader deliberations, research initiatives and policy efforts in the national mental health sector, and in doing so, secure our position as a leader among the mental health professions.

Another reason that I have become so passionate about this work stems directly from clinical experiences, much of which has centered around work with trauma survivors and individuals struggling with substance use disorders. I cannot express how powerful and empowering it has been for clients with whom I have worked to understand how processes in brain and body may be contributing to their struggles. The phrases, “So, you mean I’m not crazy?” “It makes so much sense!” and “Can you please explain that to my family?” have been used more than once. As counselors, we also are well aware of the pervasive and damaging stigma shrouding mental health challenges and those who are struggling. Most individuals with clinically diagnosable disorders never get the help they need, owing largely to this stigma.

Providing a physiological rationale for mental health challenges can significantly reduce mental health stigma; make mental health, often considered an enigmatic concept, more tangible; and alleviate the blame and shame that those who are struggling frequently experience.

 

 

Thom Field: Neuroscience attracts me for several different reasons. First, I think neuroscience provides a scientific basis for understanding important foundational concepts about human development, the impacts of oppression and marginality and the centrality of the counseling relationship. It has already provided us with significant insights into why certain problems develop at different stages (e.g., why the emerging adulthood years make a person susceptible to develop bipolar disorder or schizophrenia; see Seth Grant’s genetic lifespan calendar). Second, certain clinical issues are better understood and addressed through the lens of neuroscience, such as traumatic brain injury, posttraumatic stress, substance use, autism, attention-deficit/hyperactivity and even depression. One of my close family members has a diagnosis of schizophrenia and another autism, so understanding how to prevent and treat these conditions is important to me personally. Third, neuroscience helps to explain why we respond to certain events, such as why our physiological systems become activated in response to threats in the environment, leading to quick and often automatic decision-making and action such as aggression. I am part of a team that has developed a therapy model around this concept (neuroscience-informed cognitive behavioral therapy (CBT); see the website http://www.n-cbt.com/ for more information). Fourth, many of my fellow counselors and students continue to underprioritize Maslow’s basic needs like sleep, and sometimes do not ask about this during the first meeting with a client/student. Fifth, and perhaps most important, neuroscience offers promise for the discovery of new information about the brain and body that can make us more effective professionals.

Most psychotherapy research is limited by self-reported data (which is largely unreliable) and has largely failed thus far to distinguish specific behaviors and interventions on the part of the counselor that lead to more effective client outcomes. For example, meta-analyses have found that most counseling theoretical approaches are equivalently effective, and component studies have found that specific components of a model (e.g., the trauma narrative in trauma-focused CBT) are relatively unimportant to overall effectiveness. Thus, while psychotherapy generally appears to be effective, we still have little clue as to what factors make counseling more/less effective.

I believe that the objectivity of brain imaging and measures of neurological activity may help us to better measure what makes counseling more/less effective in the future.

 

 

Lori Russell-Chapin: I have been teaching and practicing counseling for at least three decades. It seems that many clients are searching for methods to help them feel better. So many of my clients have been to several counselors who have been helpful, but the clients are needing, wanting and searching for “one more thing” to help with their psychological and physiological concerns. Neurocounseling, or bridging our brain to behaviors, is the missing piece or “thing” of the puzzle.

As I teach students, clients and other helping professionals about neurocounseling, an all-encompassing phenomenon seems to occur. Without exception when people begin to learn more about the brain and body connections, they often comment, “If I can control my breathing or heart rate or skin temperature, then perhaps I can control so much more in my life!” Offering people self-regulation skills teaches intrinsic locus of control and personal accountability. Neurocounseling strategies demonstrate on an individual basis quantitative measures to show counseling efficacy measures. An example of this is a client who enters the counseling office with a skin temperature of 75 degrees. With one skin temperature imagery exercise, the client may be able to raise the skin temperature 5 to 10 degrees. I have had clients literally skipping out my office because they have learned this simple but essential biofeedback tool. This is an outcome measure at every counseling session.

Another fun example of neurocounseling: I wear biofeedback/temperature control nail polish. I am constantly getting feedback about what is going on in my day. This is a constant reminder for me to diaphragmatically breathe, slow down and self-regulate!

Teaching others about neurocounseling doesn’t just help them with situational symptom reduction, but it teaches a unique approach to wellness, life and a method for adapting and regulating through life’s difficulties.

 

 

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Related reading, from the Counseling Today archives:

 

 

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Want to connect with other counselors who are interested in neuroscience? Join ACA’s Neurocounseling Interest Network. Contact Lori Russell-Chapin at lar@fsmail.bradley.edu or visit neurocounselinginterestnetwork.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.

 

 

 

 

 

Assessing depression in those who are chronically ill

By Cathy L. Pederson, Kathleen Gorman-Ezell and Greta Hochstetler Mayer March 7, 2018

You receive a referral for a new client from a local physician. Great! As you review the materials, it is clear that the physician thinks the client’s issues are “all in her head.” Perhaps she is depressed. A good strengths-based and ecologically grounded counselor is just what she needs.

On the day of the first appointment, you wonder about this 24-year-old woman. You make a quick assessment upon meeting. Diane is pale, thin and has bags under her eyes. She looks exhausted and almost fragile. Yet she is neatly dressed in jeans and a T-shirt, and her light brown hair is pulled into a ponytail. She is not wearing makeup and is naturally pretty. She has an easy smile and is quite pleasant.

As you begin your work with Diane, you realize that a number of her complaints sound like the somatization of depression. She clearly suffers from fatigue. She has also struggled with insomnia the past several months, adding to her exhaustion. Diane reports a decreased appetite and has lost 10 pounds in the past couple of months without effort. Furthermore, she suffers from neuropathic pain in her legs — a chronic pain condition from abnormalities in the sensory nerves that often results in constant pain that may feel like explosions, stings or burning aches. In addition, she frequently has abdominal pain and headaches.

Because of these symptoms, Diane was often absent at work and was subsequently fired. She now relies on her parents for financial support and has moved back home. Diane is clearly depressed … or is she?

Overlapping symptoms

Many people suffering from invisible illnesses such as chronic fatigue syndrome, myalgic encephalomyelitis, Ehlers-Danlos syndrome, fibromyalgia, Lyme disease, mast cell activation disorder, postural orthostatic tachycardia syndrome (POTS) and Sjögren’s syndrome are first diagnosed, often incorrectly, as suffering from depression. Although troubling, this is understandable because the symptoms for these chronic illnesses overlap with somatic complaints associated with depression.

Many people in the general population who are depressed suffer changes in appetite, sleep and weight, and have increased fatigue and pain. Among individuals in the chronic illness community, these are common symptoms related to their physical illness. They may also suffer from other symptoms that make gainful employment or social relationships difficult. These symptoms include brain fog that makes concentration and processing of information challenging, orthostatic intolerance (increased symptoms when standing), exercise intolerance, joint subluxations and dislocations, severe allergic reactions to foods or chemicals, hot flashes, and muscle and joint stiffness or pain.

Many current depression screening instruments have at least a third of their questions related to somatization of depression. This can artificially elevate the depression score in those individuals with a chronic, invisible illness because of the physical symptoms they experience.

For instance, consider the free version of the Beck Depression Inventory. The last seven questions of this popular instrument ask about physical, rather than psychological, changes. Thinking about those with chronic invisible illnesses, imagine their scores for the following somatization of depression items.

  • I can work about as well as before (0). … I can’t do any work at all (3).
  • I can sleep as well as usual (0). … I wake up several hours earlier than I used to and cannot get back to sleep (3).
  • I don’t get more tired than usual (0). … I am too tired to do anything (3).
  • My appetite is no worse than usual (0). … I have no appetite at all anymore (3).
  • I haven’t lost much weight, if any, lately (0). … I have lost more than 15 pounds (3).
  • I am no more worried about my health than usual (0). … I am so worried about my physical problems that I cannot think of anything else (3).
  • I have not noticed any recent change in my interest in sex (0). … I have lost interest in sex completely (3).

There are 21 questions total on the Beck Depression Inventory, each ranging in point value from 0 to 3, with the higher numbers reflecting an increased possibility of depression. For how many of the seven questions above do you think that Diane might report a 2 or a 3 because of her physical ailments? If she chose the most severe response (a score of 3) for each of these seven questions, this would give her 21 points — placing her in the category of moderate depression on the Beck Depression Inventory — without even considering the first 14 questions on the survey.

It is important to realize that some clients who might appear moderately, severely or extremely depressed on a screening instrument such as the Beck Depression Inventory are actually suffering from an undiagnosed physical illness. We urge counselors to explore these somatic symptoms with their clients, particularly if the counselor notices an imbalance in the affective versus somatic parts of the instrument. With an integrated conceptualization of the person within her or his environmental context, counselors can go beyond addressing surface symptomology to explore underlying concerns.

Taking time to build a therapeutic alliance is critical, especially as many in the health care industry feel pressure from insurance companies to conduct quick patient exams. Unfortunately, many health care practitioners don’t get reimbursed for really listening to their patients and probing these multifaceted issues to arrive at a correct diagnosis. As counselors, you have the opportunity to give your clients something that they have been lacking — someone who is willing to take the time to truly listen and piece together the complexity of their problems.

Chronic illness and depression can be comorbid

Just as someone with chronic illness may not have depression, comorbidity of depression with chronic illness is possible and must be ruled out. There is a known link between chronic medical illness and depression for people with heart disease, cancer and a variety of other well-understood medical issues. Approximately 50 percent of people with chronic invisible illnesses also suffer from clinical depression. The trick is to separate those individuals with elevations purely from physical symptoms from those individuals who are truly depressed. There is a paucity of literature to guide clinical practice in this area.

Chronic illness encompasses more than just the physical symptoms. Many clients/patients become socially isolated because they can’t work or go to school. Friends and family members may slowly drift away as the illness drags on for months, years or decades. In the case of invisible illnesses, these clients often look “normal,” so it is not uncommon for people to completely dismiss their affliction. Many of these disorders are not well-understood, and a stigma can be attached to them that adds shame and guilt for being ill.

Poor treatment from health care workers can compound the problem. Many people with these illnesses have perfectly normal blood and urine tests, electrocardiograms and MRIs. If the tests are normal, then the symptoms must be “all in the person’s head,” right? Can people truly be suffering when traditional testing can’t find the cause? Many individuals working in the health care professions would say no. As a result, many of these patients are labeled as being high maintenance, and their own physicians may not believe that they are truly ill. Even for those individuals with a chronic or invisible illness who are not depressed, counseling can be important to increase their hope, improve their quality of life, help them gain perspective and help them work through social issues as they learn to deal with their new reality.

Properly diagnosing clinical depression for people with chronic illnesses is important, just as it is in the general population. Interestingly, not all people in the chronic illness community who die by suicide are clinically depressed. Research has shown that individuals with chronic invisible illnesses, particularly women, are at an increased risk for suicide. Some studies have reported that nearly 50 percent of people with POTS or fibromyalgia report suicidal ideation. Among those with chronic fatigue syndrome and myalgic encephalomyelitis, approximately 20 percent are at high risk for suicide. These are staggering numbers.

Although most counselors routinely assess for suicide, it is important to know that individuals with chronic invisible illnesses often do not present with the same symptomatology. Whereas most people in the general population who are suicidal tend to have comorbid depression, people with chronic invisible illnesses may not present this way.

Suicide risk factors for individuals with chronic invisible illness include loneliness, perceived burdensomeness and thwarted belongingness. The acquired capability for lethal self-injury is a critical area of risk to explore for those with chronic invisible illness due to repeated exposure to painful or fearsome experiences. These risk factors should be routinely assessed and worked into the treatment plan to target the underlying suicidality and reasons for living. Determining specific goals and objectives on the treatment plan, as well as providing regular check-ins on these topics, may help to decrease the risk of suicide.

The individual’s support system, including the treating physician, should also be made aware of the link between these risk factors and suicide. By facilitating this conversation between clients who are chronically ill and their support systems, some of the concerns related to loneliness, perceived burdensomeness and thwarted belongingness may be addressed proactively and conversely serve as protective factors rather than risk factors.

Counseling clients who are chronically ill

Many individuals with chronic illnesses need a safe place to vent their frustrations while receiving validation for their emotional, social and physical suffering, even if they are not clinically depressed. You may be the only person who believes them as they explain their symptoms and how the chronic illness impacts their daily life.

The therapeutic relationship and the ability to establish rapport are imperative to initiating change in the treatment process. Individuals with chronic invisible illnesses may benefit from individual therapy, couples or family-based interventions, multidisciplinary case coordination and group therapy with other people who are chronically ill. Integrating teletherapy or online therapy can ensure that these individuals, particularly those who are partially or completely homebound, have access to the care that they need.

Some people with chronic invisible illnesses struggle to get through the day. Because of their physical struggles, they often miss activities that they enjoy and may feel disconnected from their social circles. Feelings of loneliness and isolation may develop. As their illness progresses, individuals may require more assistance to perform tasks of daily living (e.g., showering, cooking, cleaning, shopping), which can lead to feelings of burdensomeness. As counselors, it is important to help these individuals find strong support networks and to provide psychoeducational information to the significant people in their lives. It is also crucial to assure these clients that they are resilient and have inherent value that is untouched by their illness.

Many individuals with chronic invisible illness are accurately diagnosed later in life. This fact illustrates how the course of chronic illness can impact the developmental process and quality of life at different stages. The diagnosis and ensuing disability can alter many of these individuals’ plans for the future, including college, career, family life and, at times, independence. This may cause them to redefine themselves within the scope of their chronic illness. Often, they must develop new roles in school, at work and within their families and friendships as they live within the confines of their health issues. As a result, their self-esteem and identity may be negatively impacted and must be addressed within the therapeutic context at different points in time.

This may be done by challenging negative self-talk, focusing on intrinsic motivation and using techniques such as radical acceptance, acceptance and commitment therapy, mindfulness-based stress reduction and a strengths-based, ecological perspective. By focusing on these individuals’ strengths, counselors may empower them to create new roles that will provide joy while also embracing the changes in their physical abilities.

In addition to the physiological changes that they are experiencing, clients who are chronically ill may simultaneously be going through the grief process. It is important for counselors to work with these clients to acknowledge the reality of the loss of their physicality, address feelings associated with their loss and help them to adjust to a new “normal.” Magical thinking often accompanies the process of grief and loss and occurs when an individual creates an improbable theory or belief system (often self-deprecating) around why a loss might have occurred. This often serves as an initial defense mechanism but can become detrimental over time. As a result, it is important for counselors to work with chronically ill patients to challenge any magical thinking that may be in place.

Finding normalcy after loss takes time. It is important to remind those with chronic invisible illnesses that there will be good days and bad days, while simultaneously working with them to instill hope for the future. Counselors can play a valuable role in helping people with chronic invisible illnesses to accept their physical limitations, while also empowering them to live rewarding and fulfilling lives.

 

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Cathy L. Pederson holds a doctorate in physiology and neurobiology. She is a professor of biology at Wittenberg University and is the founder of Standing Up to POTS (standinguptopots.org). Contact her at cpederson@wittenberg.edu.

Kathleen Gorman-Ezell holds a doctorate in social work. She is a licensed social worker and an assistant professor of social work at Ohio Dominican University. Contact her at gorma111wnek@ohiodominican.edu.

Greta Hochstetler Mayer holds a doctorate in counselor education and is a licensed professional counselor. She is CEO and initiated suicide prevention coalitions for the Mental Health & Recovery Board of Clark, Greene and Madison Counties in Ohio. Contact her at greta@mhrb.org.

 

Letters to the editor: ct@counseling.org

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

 

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Related reading, from the Counseling Today archives: “The tangible effects of invisible illness” by Cathy L. Pederson and Greta Hochstetler Mayer

 

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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.

 

Understanding and treating survivors of incest

By David M. Lawson March 6, 2018

Adults with histories of being abused as children present unique challenges for counselors. For instance, these clients often struggle with establishing and maintaining a therapeutic alliance. They may rapidly shift their notion of the counselor from very favorable to very unfavorable in line with concomitant shifts in their emotional states. Furthermore, they may anxiously expect the counselor to abandon them and thus increase pressure on the counselor to prove otherwise. Ironically, attempts at reassurance by the counselor may actually serve to validate these clients’ fears of abandonment.

The motivating factor for many of these clients is mistrust of people in general — and often for good reason. This article explores the psychological and interpersonal aspect of child sexual abuse by a parent and its treatment, with a particular focus on its relationship to betrayal trauma, dissociation and complex trauma.

Incest and its effects

Child abuse of any kind by a parent is a particularly negative experience that often affects survivors to varying degrees throughout their lives. However, child sexual abuse committed by a parent or other relative — that is, incest — is associated with particularly severe psychological symptoms and physical injuries for many survivors. For example, survivors of father-daughter incest are more likely to report feeling depressed, damaged and psychologically injured than are survivors of other types of child abuse. They are also more likely to report being estranged from one or both parents and having been shamed by others when they tried to share their experience. Additional symptoms include low self-esteem, self-loathing, somatization, low self-efficacy, pervasive interpersonal difficulties and feelings of contamination, worthlessness, shame and helplessness.

One particularly damaging result of incest is trauma bonding, in which survivors incorporate the aberrant views of their abusers about the incestuous relationship. As a result, victims frequently associate the abuse with a distorted form of caring and affection that later negatively influences their choice of romantic relationships. This can often lead to entering a series of abusive relationships.

According to Christine Courtois (Healing the Incest Wound: Adult Survivors in Therapy) and Richard Kluft (“Ramifications of incest” in Psychiatric Times), greater symptom severity for incest survivors is associated with:

  • Longer duration of abuse
  • Frequent abuse episodes
  • Penetration
  • High degree of force, coercion and intimidation
  • Transgenerational incest
  • A male perpetrator
  • Closeness of the relationship
  • Passive or willing participation
  • Having an erotic response
  • Self-blame and shame
  • Observed or reported incest that continues
  • Parental blame and negative judgment
  • Failed institutional responses: shaming, blaming, ineffectual effort
  • Early childhood onset

Incest that begins at a young age and continues for protracted periods — the average length of incest abuse is four years — often results in avoidance-based coping skills (for example, avoidance of relationships and various dissociative phenomena). These trauma-forged coping skills form the foundation for present and future interpersonal interactions and often become first-line responses to all or most levels of distress-producing circumstances.

More than any other type of child abuse, incest is associated with secrecy, betrayal, powerlessness, guilt, conflicted loyalty, fear of reprisal and self-blame/shame. It is of little surprise then that only 30 percent of incest cases are reported by survivors. The most reliable research suggests that 1 in 20 families with a female child have histories of father-daughter child sexual abuse, whereas 1 in 7 blended families with a female child have experienced stepfather-stepdaughter child sexual abuse (see the revised edition of The Secret Trauma: Incest in the Lives of Girls and Women by Diana E. H. Russell, published in 1999).

In 1986, David Finkelhor, known for his work on child sexual abuse, indicated that among males who reported being sexually abused as children, 3 percent reported mother-son incest. However, most incest-related research has focused on father-daughter or stepfather-stepdaughter incest, which is the focus of this article.

Subsequent studies of incest survivors indicated that being eroticized early in life disrupted these individuals’ adult sexuality. In comparison with nonincest controls, survivors experienced sexual intercourse earlier, had more sex partners, were more likely to have casual sex with those outside of their primary relationships and were more likely to engage in sex for money. Thus, survivors of incest are at an increased risk for revictimization, often without a conscious realization that they are being abused. This issue often creates confusion for survivors because the line between involuntary and voluntary participation in sexual behavior is blurred.

An article by Sandra Stroebel and colleagues, published in 2013 in Sexual Abuse: A Journal of Research and Treatment, indicates that risk factors for father-daughter incest include the following:

  • Exposure to parent verbal or physical violence
  • Families that accept father-daughter nudity
  • Families in which the mother never kisses or hugs her daughter (overt maternal affection was identified as a protective factor against father-daughter incest)
  • Families with an adult male other than the biological father in the home (i.e., a stepfather or substitute father figure)

Finally, some qualitative research notes that in limited cases, mothers with histories of being sexually abused as a child wittingly or unwittingly contribute to the causal chain of events leading to father-daughter incest. Furthermore, in cases in which a mother chooses the abuser over her daughter, the abandonment by the mother may have a greater negative impact on her daughter than did the abuse itself. This rejection not only reinforces the victim’s sense of worthlessness and shame but also suggests to her that she somehow “deserved” the abuse. As a result, revictimization often becomes the rule rather than the exception, a self-fulfilling prophecy that validates the victim’s sense of core unworthiness.

Beyond the physical and psychological harm caused by father-daughter incest, Courtois notes that the resulting family dynamics are characterized by:

  • Parent conflict
  • Contradicting messages
  • Triangulation (for example, parents aligned against the child or perpetrator parent-child alignment against the other parent)
  • Improper parent-child alliances within an atmosphere of denial and secrecy

Furthermore, victims are less likely to receive support and protection due to family denial and loyalty than if the abuser were outside the family or a stranger. Together, these circumstances often create for survivors a distorted sense of self and distorted relationships with self and others. If the incest begins at an early age, survivors often develop an inherent sense of mistrust and danger that pervades and mediates their perceptions of relationships and the world as a whole.

Betrayal trauma theory

Betrayal trauma theory is often associated with incest. Psychologist Jennifer Freyd introduced the concept to explain the effects of trauma perpetrated by someone on whom a child depends. Freyd holds that betrayal trauma is more psychologically harmful than trauma committed or caused by a noncaregiver. “Betrayal trauma theory posits that under certain conditions, betrayals necessitate a ‘betrayal blindness’ in which the betrayed person does not have conscious awareness or memory of the betrayal,” Freyd wrote in her book Betrayal Trauma: The Logic of Forgetting Childhood Abuse.

Betrayal trauma theory is based on attachment theory and is consistent with the view that it is adaptive to block from awareness most or all information about abuse (particularly incest) committed by a caregiver. Otherwise, total awareness of the abuse would acknowledge betrayal information that could endanger the attachment relationship. This “betrayal blindness” can be viewed as an evolutionary and nonpathological adaptive reaction to a threat to the attachment relationship with the abuser that thus explains the underlying dissociative amnesia in survivors of incest. Under these circumstances, survivors often are unaware that they are being abused, or they will justify or even blame themselves for the abuse. In severe cases, victims often have little or no memory of the abuse or complete betrayal blindness. Under such conditions, dissociation is functional for the victim, at least for a time.

Consider the case of “Ann,” who had been repeatedly and severely physically and sexually abused by her father from ages 4 to 16. As an adult, Ann had little to no memory of the abuse. As a result of the abuse, she had developed nine alternate identities, two of which contained vivid memories of the sexual and physical abuse. Through counseling, she was able to gain awareness of and access to all nine alternate identities and their functions.

Although Ann expressed revulsion and anger toward her father, she also expressed her love for him. At times, she would lapse into moments of regret for disclosing the abuse, saying that “it wasn’t so bad” and that the worst thing that had happened was that she had lost her “daddy.” During these moments, Ann minimized the severity of the abuse, wishing that she had kept the incest secret so that she could still have a relationship with her father. This was an intermittent longing for Ann that occurred throughout counseling and beyond.

Thus, understanding attachment concepts is critical for understanding betrayal traumas such as incest. Otherwise, counselors might be inclined to blame survivors or might feel confused and even repulsed by survivors’ behaviors and intentions. For many survivors, the caregiver-abuser represents the best and the worst of her life at various times. She needs empathy and support, not blame.

Dissociation

As defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, dissociation is “a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, perception, body representation, motor control and behavior.” Depending on the severity of the abuse, dissociative experiences can interfere with psychological functioning across the board. Survivors of incest often experience some of the most severe types of dissociation, such as dissociative identity disorder and dissociative amnesia (the inability to recall autobiographical information). Dissociative experiences often are triggered by perceived threat at a conscious or unconscious level.

As previously noted, betrayal trauma theory holds that for incest survivors, dissociative amnesia serves to maintain connection with an attachment figure by excluding knowledge of the abuse (betrayal blindness). This in turn reduces or eliminates anxiety about the abuse, at least in the short run. Conversely, many survivors of childhood incest report continuous memories of the abuse, as well as the anxiety and felt terror related to the abuse. Often, these individuals will find a way to leave their homes and abusers. This is less frequently the case for survivors who experience dissociative amnesia or dissociative identity disorder.

Depersonalization and derealization distort the individual’s sense of self and her sensory input of the environment through the five senses. For example, clients who have experienced incest often report that their external world, including people, shapes, sizes, colors and intensities of these perceptions, can change quickly and dramatically at times. Furthermore, they may report that they do not recognize themselves in a mirror, causing them to mistrust their own perceptions.

As one 31-year-old incest survivor stated, “For so many years, everything within me and around me felt and looked unreal, dull, dreary, fragmented, distant.” This is an example of depersonalization/derealization. She continued, “This, along with the memory gaps, forgetfulness and inability to recall simple everyday how-tos, like how to drive a car or remember the step-by-step process of getting ready for the day, made me feel crazy. But as I improved in counseling, my perceptions of my inside and outside worlds became clearer, more stable, and brighter and more distinct than before counseling. It all came to make more sense and feel right. It took me years to see the world as I think other people see it. From time to time I still experience that disconnection and confusion, but so much less frequently now than before.”

Initially, some real or perceived threat triggers these distorted perceptions of self and outer reality, but eventually they become a preset manner of perceiving the world. Reports such as this one are not uncommon for survivors of incest and often are exacerbated as these individuals work through the process of remembering and integrating trauma experiences into a coherent life narrative. For many survivors, a sense of coherence and stability is largely a new experience; for some, it can be threatening and trigger additional dissociative experiences. The saying “better a familiar devil than an unfamiliar angel” seems to apply here.

The severity of dissociation for survivors of incest is related to age onset of trauma exposure and a dose-response association, with earlier onset, more types of abuse and greater frequency of abuse associated with more severe impairment across the life span. Incest is associated with the most severe forms of dissociative symptoms such as dissociative identity disorder. Approximately 95 to 97 percent of individuals with dissociative identity disorder report experiencing severe childhood sexual and physical abuse.

Fragmentation in one’s sense of self, accompanied by amnesia of abuse memories, is particularly functional when children cannot escape the abuse circumstances. These children are not “present” during the abuse, so they often are not aware of the physical and emotional pain associated with the abuse. Yet this fragmented sense of self contributes to a sense of emptiness and absence, memory problems and dissociative self-states. Many survivors of incest are able to “forget” about the abuse until sometime later in adulthood when memories are triggered by certain events or when the body and mind are no longer able to conceal the memories. The latter results from the cumulative effect of lifelong struggles related to the incest (for example, interpersonal problems and emotional dysregulation). It takes a great deal of psychological and physical resources to “forget” trauma memories.

Dissociation, especially if it involves ongoing changes in perceptions of self and others, different presentations of self and memory problems, may result in difficulty forming and maintaining a therapeutic alliance. Dissociation disrupts the connection between the client and the counselor. It also disrupts clients’ connections with their inner experience. If these clients do not perceive themselves and their surroundings as stable, they will mistrust not only their counselors but also their own perceptions, which create ongoing confusion.

Thus, counselors must remain alert to subtle or dramatic fluctuations in survivors’ presentation styles, such as changes in eye contact or shifts in facial features from more engaged and animated to flat facial features. Changes in voice tone quality and cadence (from verbally engaged to silent) or in body posture (open versus closed) are other signs of possible dissociative phenomena. Of course, all or none of these changes may be indicators of dissociative phenomena.

Complex trauma

Incest, betrayal trauma and dissociative disorders are often features of a larger diagnostic categorization — complex trauma. Incest survivors rarely experience a single incident of sexual abuse or only sexual abuse. It is more likely that they experience chronic, multiple types of abuse, including sexual, physical, emotional and psychological, within the caregiving system by adults who are expected to provide security and nurturance.

Currently, an official diagnostic category for complex trauma does not exist, but one is expected to be added to the revised International Classification of Diseases (ICD-11) that is currently in development. Marylene Cloitre, a member of the World Health Organization ICD-11 stress and trauma disorders working group, notes that the new complex trauma diagnosis focuses on problems in self-organization resulting from repeated/chronic exposure to traumatic stressors from which one cannot escape, including childhood abuse and domestic violence. Among the criteria she highlighted for complex trauma are:

  • Disturbances in emotions: Affect dysregulation, heightened emotional reactivity, violent outbursts, impulsive and reckless behavior, and dissociation.
  • Disturbances in self: Defeated/diminished self, marked by feeling diminished, defeated and worthless and having feelings of shame, guilt or despair (extends despair).
  • Disturbances in relationships: Interpersonal problems marked by difficulties in feeling close to others and having little interest in relationships or social engagement more generally.
    There may be occasional relationships, but the person has great difficulty maintaining them.

Early onset of incest along with chronic exposure to complex trauma contexts interrupts typical neurological development, often leading to a shift from learning brain (prefrontal cortex) to survival brain (brainstem) functioning. As explained by Christine Courtois and Julian Ford, survivors experience greater activation of the primitive brain, resulting in a survival mode rather than activation of brain structures that function to make complex adjustments to the current environment. As a result, survivors often exhibit an inclination toward threat avoidance rather than being curious and open to experiences. Complex trauma undermines survivors’ ability to fully integrate sensory, emotional and cognitive data into an organized, coherent whole. This lack of a consistent and coherent sense of self and one’s surroundings can create a near ever-present sense of confusion and disconnection from self and others.

Regular or intermittent complex trauma exposure creates an almost continual state of anxiety and hypervigilance and the intrinsic expectation of danger. Incest survivors are at an increased risk for multiple impairments, revictimization and loss of support.

Treatment issues

Although a comprehensive description of treatment is well beyond the scope of this article, I will close with a general overview of treatment concepts. Treatment for incest parallels the treatment approaches for complex trauma, which emphasizes symptom reduction, development of self-capacities (emotional regulation, interpersonal relatedness and identity), trauma processing and the addressing of dissociative experiences.

Compromised self-capacities intensify symptom severity and chronicity. Among these self-capacities, emotional dysregulation is a major symptom cluster that affects other self-capacity components. For example, if a survivor consistently struggles with low frustration tolerance for people and copes by avoiding people, responding defensively, responding in a placating manner or dissociating, she likely will not have the opportunity to develop fulfilling relationships. The following core concepts, published in the May 2005 Psychiatric Annals, were suggested by Alexandra Cook and colleagues for consideration when implementing a treatment regimen for complex trauma, including with incest survivors and with adaptations for clients with dissociative identity disorder.

1) Safety: Develop internal and environmental safety procedures.

2) Self-regulation: Enhance the capacity to moderate and rebalance arousal across the areas of affective state, behavior, physiology, cognition, interpersonal relatedness and self-attribution.

3) Self-reflective information processing: Develop the ability to focus attentional processes and executive functioning on the construction of coherent self-narratives, reflecting on past and present experience, anticipation and planning, and decision-making.

4) Traumatic experiences integration: Engage in resolution and integration of traumatic memories and associated symptoms through meaning making, traumatic memory processing, remembrance and mourning of traumatic loss, development of coping skills, and fostering present-oriented thinking and behavior.

5) Relational engagement: Repair, restore or create effective working models of attachment and application of these models to current interpersonal relationships, including the therapeutic alliance. Emphasis should be placed on development of interpersonal skills such as assertiveness, cooperation, perspective taking, boundary and limit setting, reciprocity, social empathy and the capacity for physical and emotional intimacy.

6) Positive affect enhancement: Work on the enhancement of self-worth, self-esteem and positive self-appraisal through the cultivation of personal creativity, imagination, future orientation, achievement, competence, mastery seeking, community building and the capacity to experience pleasure.

Typically, these components are delivered within a three-phase model of counseling that is relationship-based, cognitive behavioral in nature and trauma focused:

  • Safety, self-regulation skill development and alliance formation
  • Trauma processing
  • Consolidation

The relational engagement component is particularly critical because for many survivors, to be attached often has meant to be abused. Furthermore, accompanying feelings of shame, self-loathing and fear of abandonment create a “failure identity” that results in low expectations for change. Additionally, it is important for counselors to attend to client transference issues and counselor countertransference issues. Courtois suggests that ignoring or assuming that such processes are irrelevant to the treatment of survivors can undermine the treatment process and outcome.

In addition, strength-based interventions are critical in each phase to help survivors develop a sense of self-efficacy and self-appreciation for the resources they already possess. A strength-based focus also contributes to client resilience.

For some clients, dissociated self-states or parts will emerge. Counselors should assume that whatever is said to one part will also be heard by the other parts. Therefore, addressing issues in a manner that encourages conversation between parts, including the core self-structure, is critical. It is also important to help parts problem-solve together and support each other. This is not always an easy proposition. A long-term goal would be some form of integration/fusion or accord among alternate identities. Some survivors eventually experience full unification of parts, whereas others achieve a workable form of integration without ever fully unifying all of their alternate identities (for more, see Treating Trauma-Related Dissociation: A Practical, Integrative Approach by Kathy Steele, Suzette Boon and Onno van der Hart).

Finally, it must be mentioned that repeated exposure to horrific stories of incest can overwhelm counselors’ capacity to maintain a balanced relationship with clear boundaries. A client’s transference can push the boundaries of an ethical and therapeutic client-counselor relationship. Furthermore, the frequent push-pull dynamics between counselor and client can be exhausting, both physically and mentally for counselors. Therefore, it is important for counselors to frequently seek supervision and consultation and to engage in self-care physically, psychologically and spiritually.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences

David M. Lawson is a professor of counselor education and director of the Center for Research and Clinical Training in Trauma at Sam Houston State University. His research focuses on childhood sexual and physical abuse, complex trauma and dissociation related to trauma. He also maintains an independent practice focusing on survivors of posttraumatic stress disorder and complex trauma. Contact him at dml3466@aol.com.

Letters to the editorct@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.

 

Behind the book: Neurocounseling: Brain-Based Clinical Approaches

Compiled by Bethany Bray February 20, 2018

The influence of neuroscience on the counseling profession is growing. So much so that the American Counseling Association has an interest network of members devoted to its exploration and discussion.

Neuroscience can be both a tool — one of many — in a counselor’s toolbox and a game-changing way to conceptualize clients, conduct assessments and select interventions, write Thomas A. Field, Laura K. Jones and Lori A. Russell-Chapin in their new book Neurocounseling: Brain-Based Clinical Approaches (published by the American Counseling Association).

“Neuroscience can help counselors understand how relationships are forged, leading to deeper and more meaningful working relationships with clients; recognize the persisting impact of systemic barriers such as oppression, marginalization and trauma on clients’ ability to achieve their goals; and take a wellness and strengths-based perspective that serves to empower clients and increase optimal performance,” they write in the book’s preface. “In other words, neurocounseling is commensurate with the orientation and identity of the counseling profession.”

Field is an associate professor in the master’s counseling program at the City University of Seattle; Jones is an assistant professor at the University of North Carolina at Asheville; and Russell-Chapin is professor of counselor education at Bradley University in Illinois. Counseling Today sent the trio some questions, via email, to learn more.

 

Q+A: Neurocounseling

(Responses written individually as indicated; some responses have been edited, including for length)

 

Besides your book, what resources do you recommend for counselors who want to learn more about neurocounseling?

Lori Russell-Chapin: We are learning more about the fascinating brain every day through research and brain scanning. Counselors need to know as much as possible about the brain, especially as it relates to the skills of counseling. The very first thing helping professionals can do is refresh their knowledge base and skills. Take a course or workshop on neurocounseling. That material is out there. At Bradley University, there is an online course called “Neurocounseling: Bridging Brain and Behavior.” Perhaps readers might have a desire to even take an introductory course on human anatomy and physiology. Almost any university will offer this course. Even if you took a similar course years ago, take a new one. So much has changed in the last decade. Attend any ACA Conference and participate in the many workshops scheduled on neurocounseling. The number has tripled in the last 10 years.

Decide what aspect of neurocounseling interests you, [and] then ask colleagues for potential courses to take, from heart rate variability to biofeedback or neurofeedback. Many excellent for-profit corporations are offering these biofeedback and neurofeedback courses.

Of course, join any of the professional networks that have been created to connect with others who have similar interests: ACA Neurocounseling Interest Network; AMHCA (American Mental Health Counselors Association) Neuroscience Interest Network and ACES (Association for Counselor Education and Supervision) Neuroscience Interest Network. At the ACA conferences, these three groups join forces to connect and share information.

 

In the preface, you write that neurocounseling is “commensurate with the orientation and identity of the counseling profession.” Can you elaborate? How do you feel neuroscience is a good fit for professional counseling? How are counselors particularly suited to adopt its principles into their work?

Thom Field: Counseling has been defined as “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education and career goals.”

Neuroscience supports and strengthens the counseling profession’s values, as reflected in the above definition:

1) The relationship takes precedence.

2) Diversity is affirmed and actions are taken to modify the societal conditions and environments that cause dysfunction.

3) Wellness and mental health are as much a focus of intervention as remediating psychopathology.

4) A person’s strengths and challenges are conceptualized within the developmental context in which they occur.

First, neuroscience has and can provide information to us about what conditions are most important for a therapeutic relationship to be established. Information about client neurophysiological responses in the counseling room can help us understand what helping behaviors are facilitative, such as establishing safety and security. Chapter 5 of our book, written by Allen Ivey, Thomas Daniels, Carlos Zalaquett and Mary Bradford Ivey, is instructive in this regard. While theories of effective relational characteristics exist (e.g., interpersonal neurobiology, polyvagal theory), we believe more research is needed in this regard.

Second, epigenetics provides rich information about the neurophysiological impact of systematic marginality, oppression and trauma. Kathryn Douthit’s chapter on the biology of marginality (chapter 3) and Laura Jones’ chapter on traumatic stress (chapter 4) provide an excellent overview of this topic.

Third, neurocounseling supports the importance of adequate sleep, diet, exercise, social involvement and spiritual engagement in optimal functioning. Ted Chapin’s chapter on wellness and optimal performance (chapter 8) provides an extremely helpful clinical case study that emphasizes what a wellness-oriented neurocounseling approach might look like in practice.

Fourth, neurocounseling emphasizes the importance of understanding the development of the brain and body over the life span. Laura Jones’ first two chapters emphasize how to conceptualize client issues through the lens of neurophysiological development.

Lastly, we would be remiss if we did not mention that the text was organized around the Council for Accreditation of Counseling & Related Educational Programs’ 2016 standards. We believe that principles from neuroscience are relevant and applicable to the eight common core CACREP areas (human growth and development, social and cultural foundations, helping relationships, assessment, research, group counseling, ethical practice and even career development) as well as specialization areas (e.g., psychopharmacology, addiction, etc.).

 

In your opinion, how far has the profession come in understanding and incorporating neuroscience into counseling practice? Is it being readily adopted, or are there counselors who misunderstand it or don’t feel that it is useful?

Laura K. Jones: There is the question of how far has the profession come in incorporating neuroscience into counseling practice, and then there is the question of how far we have come in incorporating neuroscience into the profession as a whole, which are two related but distinct questions.

With regard to the profession, interest in neuroscience has expanded significantly in the past 10 years, since Allen Ivey and Mary Bradford Ivey gave one of the first talks on brain-based counseling at ACA’s 2008 Conference & Expo in Honolulu. One example is simply the number of conference sessions that integrate a discussion of neuroscience. At the 2008 conference, there were only around five that discussed the brain in some manner; at the 2017 conference [in San Francisco], there were not only three learning institutes but 17 educational sessions. This pattern of growth is visible across every sector of the counseling field, including both clinical training and practice areas. The 2016 CACREP standards delineate an increased focus on training in the neurological foundations of client development, well-being, presenting concerns and the counseling process, with over three times the number of references to the application of neurobiology and neuroscience than were cited in the 2009 standards.

AMHCA is also strengthening its focus on neuroscience, not only expanding its training and clinical practice standards in such areas, but also now allocating a section of its flagship journal, the Journal of Mental Health Counseling, to articles detailing the integration of neuroscience into counseling research or clinical practice. There are three national neuroscience interest networks, one representing each of the core organizations (namely ACA, AMHCA and ACES), as well as a new neuroscience virtual meetup group based out of Northwestern University, BRAINSTORM, which has monthly meetings to discuss neuroscience research and translate such research into clinical implications. Each of these groups now has hundreds of members — a significant change from the two pages of handwritten names I collected at the 2013 ACES conference in Denver, which were used to start the first neuroscience interest network within the field.

And this is a trend being mirrored across all mental health professions. As research surrounding the physiological underpinnings and outcomes of mental health struggles continues to expand (the roles of inflammation, the microbiome-gut-brain axis, the endocrine system, etc.), mental health providers are being called to reexamine our conceptualizations of mental health and mental health disorders, and neurophysiology is a significant construct within this new paradigm. Occasionally I will still hear individuals refer to this shift as a “fad,” but that perspective appears to quickly be fading.

One of the cautions, however, is that while there is certainly an ever-growing interest and acceptance within the field, as is often the case with an interest that grows quickly, there is also misinformation and to some degree a misrepresentation and overextension of the science that is also occurring. This is why, from my perspective, one of the especially exciting trends I am seeing in this area within our field is the rapidly growing number of master’s- and doctoral-level students who are eager to gain training in neuroscience. This interest, and subsequently the training of these future counselors and counselor educators, is the catalyst for continued growth and research [concerning how we as a profession can integrate neuroscience into our field in a manner that honors our unique professional identity.

To continue to accurately, ethically and successfully incorporate neuroscience into the profession, we need to enhance our efforts at training counselors and counselor educators in the basic principles of neuroscience and how this information can be applied to our work with clients, supervisees and students. As such, we cannot sustain this interest within the field and our reputation in the larger mental health world without having a body of counselor educators who are accurately trained in neuroscience and able to teach future generations of practitioners and educators.

This is one of my primary interests in this movement and was a significant impetus for me in working on this book. This gets back to the original distinction I made between a growing emphasis in the field versus in clinical practice. Where we see the preponderance of the integration of neuroscience into counseling practice now is in client conceptualizations, psychoeducation, wellness practices, social justice and, to some degree, assessment. Research has also substantiated that psychotherapy has the ability to enhance brain functioning in the alleviation of client symptoms. However, additional outcome-based research is needed within the counseling field in particular to further our understanding of how we can use neuroscience to further substantiate our theories and techniques, as well as build new, more efficacious interventions.

We have made significant progress in the last 10 years, and yet we still have plenty of room to grow, as do the other mental health professions in this area. I am excited to see the continued expansion of neuroscience within our field and counselors become even more established as leaders in neurophysiologically informed research, practice and mental health policy in the future.

 

What misconceptions might counselors have about neurocounseling?

Laura K. Jones: There are a number of common misconceptions that individuals have when it comes to the integration of neuroscience into clinical training and practice. One of the primary misconceptions is that neurocounseling is a new branch of counseling, often likening it to a new theoretical orientation of sorts. In reality, the integration of neuroscience into clinical practice can best be conceptualized more as a metatheory of the clinical process that can be applied to every theoretical orientation.

This distinction has led some individuals to suggest that the term “neurocounseling” is to some degree misleading. Understanding the neurophysiological correlates of clients’ developmental levels, struggles, strengths and progress can all be used to inform and enhance all aspects of the clinical process, from case conceptualization and assessment to interventions and advocacy. It is a layer of information that we as mental health providers can use to enrich our understanding and work with clients. This knowledge of the brain and body can also be used to develop new theoretical approaches, such as neuroscience-informed cognitive behavior therapy (CBT), but it is not in and of itself a separate form of clinical practice.

Another misconception is that integrating neuroscience into our field and practice is just another way of medicalizing the profession. Relatedly, some have voiced fears that it takes too much of a reductionist view of clients and client struggles. Understanding the neurophysiological pathways of addiction, for example, does not negate or diminish the importance of the therapeutic relationship, but it can help us to decrease the internalized stigma some of our clients may have of being weak and, similarly, empower our clients in their own recovery. As another example, take some of the developing theories around depression. Researchers are working to further substantiate the divergent pathophysiology between possible subtypes or phenotypes of depression. This information can be used to help us develop more effective therapeutic approaches for our clients. Neuroscience is not a threat to our professional orientation; if anything, it can be used to strengthen what we uniquely do as counselors.

An additional misconception is that in order to integrate neuroscience into your practice, you need specialized and expensive equipment. Although biofeedback and neurofeedback are growing in popularity, efficacy and accessibility, and can certainly be used as part of informing and enhancing your work with clients, this is not the only way of integrating neuroscience. This is something that I like to really emphasize when discussing the role of neuroscience within the field. You do not need any fancy toys to benefit from all that neuroscience has to offer.

Just having the information related to how the brain and body respond to trauma completely changes the way that counselors conceptualize trauma survivors who are struggling with symptoms of posttraumatic stress. Similarly, knowing how the brain is developing during adolescence not only demystifies the struggles children and parents may face during this seemingly tumultuous time, but also changes how we approach working with individuals during this developmental period. The knowledge in and of itself can simply make us more intentional in our work.

The final misconception is one that is still somewhat debated even among those of us working in this area. I often get the question, “Do I actually need to learn the anatomy or physiology?” My answer to this is always a resounding “yes,” but I certainly do not speak for everyone working in this area. I am not suggesting that counselors need to be experts in neuroscience, but knowing the basic physiology and nomenclature allows counselors to understand the basis behind why a particular approach may be more beneficial for a particular client and be more intentional in that decision. It also allows counselors to continue reading the research that is coming out on a near-continuous basis. What we believe we know about the brain today may very well change tomorrow.

Also, fields that translate “hard” neuroscience research into applied contexts (education, peak performance, counseling, etc.) can at times fall victim to overextending and misrepresenting the original research as they attempt to retranslate other translations of the science. This may sound a bit convoluted, but what I mean is that one practitioner who is well-versed in neuroscience will translate the possible implications of some neuroscientific finding into practical and applied information for their particular field. Then another practitioner in an allied area may take that information and try to reapply the initial implications in a new way to the new field. This is the root cause of a number of the “neuromyths” that are currently circulating and why there are so many “brain training” games available today. In essence, we become too far removed from the actual science.

Our field needs to be able to do some of that translation firsthand and, ideally, build interdisciplinary research teams to collaborate in conducting the research rather than rely on translations from other fields.

One final rationale for training in basic anatomy and physiology is that we are seeing a growing number of integrated care practices and interdisciplinary treatment teams. Having a basic knowledge of the physiology allows counselors to collaborate more effectively with the other specialties and advocate for the best care of their clients.

 

What made you collaborate on a book about neurocounseling? Why do you feel it’s relevant and needed?

Lori Russell-Chapin: There are many neurocounseling experts throughout the United States. By joining forces, we can share this knowledge with so many other professionals who are interested. Integrating the concepts of neurocounseling from our book into my counseling has made me a more efficacious practicing counselor, counselor educator and counseling supervisor. The following short examples are offered to demonstrate why neurocounseling is relevant and needed in our counseling field.

Neurocounseling interventions strengthen the intentionality of counseling. Understanding the brain and its functions make skill selection and strategies even easier. Teaching self-regulation skills such as diaphragmatic breathing or physiological and emotion regulation requires many brain connections to connect together from the prefrontal cortex, the insula and the anterior cingulate cortex. The next time you teach any self-regulation skill, think about all the brain centers you are activating.

Understanding that rapport building and therapeutic alliance is essential to counseling and change is central to the tenets of neurocounseling and counseling. Both rapport and therapeutic alliance create emotional and physiological safety using the vagus system and interoception, helping the body be more aware of its senses. There is nothing more important to clients’ change than rapport and emotional safety.

Even as my clients are introducing themselves to me for the first time, I begin to experience them in a more holistic manner. With that first handshake, I can feel if their hand is cool, warm, sweaty or limp. Each of these symptoms is a clue to a person’s sympathetic and parasympathetic nervous system. If the client’s hand is very cold, then it might be that he or she is anxious, [thus] activating the sympathetic nervous system. I could easily teach diaphragmatic breathing, heart rate variability and skin temperature control to help initiate the parasympathetic nervous system where we are supposed to be most of the time.

Still another neurocounseling example is essential for building healthier neuroplasticity. Because of negative bias and the system’s evolutionary nature to survive, counselors must use our positive reflections lasting at least 10-20 seconds to deepen this change and build positive neuroplasticity. We remember a negative experience almost instantly. To remember a positive experience takes much longer.

Lastly, counselors must better understand that skills such as summarizations assist the client and the counselor to activate the default mode network. This network helps us see the world of self and others in a more comprehensive manner. Identifying the neuroanatomy aspect of our counseling skills allows for more intentionality and strategy in counseling. This is neurocounseling at its best. Then collaborating with others gives greater access to all this knowledge. Working together again offers the best method to expand the depth and breadth of neurocounseling.

 

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To join the ACA Neurocounseling Interest Network, contact Lori Russell-Chapin at lar@fsmail.bradley.edu. For more information, see neurocounselinginterestnetwork.com.

 

 

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Neurocounseling: Brain-Based Clinical Approaches is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-347-6647 x222

 

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

 

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

 

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

 

A counselor looks at football

By Kevin Doyle January 29, 2018

I have been a lifelong football fan. I remember playing outside in the snow, emulating the National Football League (NFL) stars of the 1960s and then going inside to watch some of the fabled rivalries of the time, like the Kansas City Chiefs versus the Oakland Raiders. I grew up on Joe Namath’s Super Bowl guarantee, Franco Harris’s “Immaculate Reception,” and the undefeated Miami Dolphins team of 1972. My beloved Washington football franchise (yes, that name is a problem — but that is for another story) owned the 1980s (along with the San Francisco 49ers), and my brother and I sported Charley Taylor (42) and Larry Brown (43) jerseys in the previous decade. My two sons played the game at the high school level, both excelling and taking much from the experience. In short, I was raised on football in many ways.

All of these things will stay with me, but recent events have conspired to lead me to question of whether the sport in its current form is morally defensible. Recently, coverage of the death by suicide of former New England Patriots player, and convicted murderer, Aaron Hernandez, noted that his brain had advanced chronic traumatic encephalopathy (CTE), and a study published in 2017 in JAMA found evidence of CTE in 110 of 111 former NFL players.

Former NFL player Antwaan Randle El, a nine-year NFL veteran who is now in his late 30s, recently spoke out about his memory problems. He became the latest in a series of both high- and low-profile professional players known or alleged to have had serious brain issues possibly due to their football careers. This includes well-known players such as Junior Seau, Dave Duerson, Mike Webster and Frank Gifford.

The national discourse has been stirred by Steve Almond’s searing Against Football: One Fan’s Reluctant Manifesto; the film Concussion, based on the work of forensic pathologist Bennet Omalu and the work of Jeanne Marie Laskas in her article for GQ titled Game Brain; as well as pro football works such as Gregg Easterbrook’s The Game’s Not Over: In Defense of Football and Mark Edmundson’s Why Football Matters: My Education in the Game.

What, then, is the role of the professional counselor in this debate — or is there one? I submit that counselors in a variety of settings have a responsibility to be aware of this issue that is currently facing our culture, and there are several reasons why.

First, this appears to be a significant safety issue for a segment of our population, namely those individuals who have either played football in the past or are currently playing. No less an authority than the Mayo Clinic has reported that symptoms such as aggression, motor impairment, tremor, memory loss, irritability and focusing problems are associated with CTE.

If an adult male were to report symptoms such as these in counseling, it could be prudent to check to see if the client was once a football player. Referral for additional medical assessment could be an appropriate course of action, although currently, no effective treatments for CTE-related symptoms seem to be available. In fact, a definitive diagnosis cannot be made until tests of the brain can be conducted after an individual’s death.

For players currently involved in football, repeated concussions could be placing those individuals at increased risk and should be monitored. Most levels of play, including the NFL and NCAA, have put so-called “concussion protocols” in place to prevent players from continuing to play until they have received medical clearance. Although counselors would likely not play a leading role in these determinations, it would be advisable for counselors working on college campuses, with professional football players or even at lower levels (high school, middle school, youth football) to be aware of them and to support efforts to protect player safety.

Second, the question of whether to allow children to play football has become an emotional and sometimes conflict-ridden debate within families. Participation rates in both high school and youth football have widely been reported to be declining and show no signs of changing in the near future, according to numerous sources.

Counselors routinely work with children and families, and reaching a decision about whether a child should play football can be difficult. An informed decision must balance the potential safety concerns associated with the sport and the potential benefits of playing the sport, including physical activity and learning about teamwork and discipline. In some families, football is seen as a rite of passage — something that adolescent males (and, in some cases, females) engage in as part of the maturation process. In some cases, it may be the child who desperately wants to play, while the parents are warier. In other cases, parental pressure on a child to participate may be the driving issue. In either instance, a counselor, whether school-based or community-based, may be in a position to help the family make this decision. Knowledge of some of the relevant issues is essential to any effort to be of assistance.

Third is the reality that any societal issue can make its way into a counseling session. This is not to imply that we as counselors need to be experts on any and all social and societal issues. However, we do have a responsibility to be aware of burgeoning issues facing our culture and to be ready to discuss or address them —or at least to listen to our clients do so.

Many of us no doubt had clients with opinions about the most recent presidential election. Their thoughts naturally made their way into counseling sessions. Our own personal feelings aside, we had a responsibility as counselors to listen, to consider our clients feelings and opinions, and to ponder what role, if any, these thoughts contributed to the stressors they were facing. Likewise, we must strive as counselors to stay informed about myriad issues of relevance to our clients. Societal question such as same-sex marriage, health care, immigration and employment barriers for those with criminal convictions, to name a few, play out in our clients’ lives on a daily basis.

Granted, the issue of football may pale in comparison to some of these, but we have a responsibility nonetheless to pay attention, to inform ourselves and to monitor the debate, because it may well come up in a counseling session with an individual or family. If we are unaware of this issue (or another one), we may need to do further research in between sessions or, in extreme cases, even consider referring our client to another provider with more knowledge of the issue he or she is facing.

Finally, there are social justice issues to be considered, consistent with the counseling profession’s recent emphasis in this area. One would have to have been living under the proverbial rock not to have noticed the emotional national dialogue around NFL players sitting or kneeling during the playing of the national anthem. Started by former San Francisco 49er quarterback Colin Kaepernick in 2016, this protest has spread to other players and teams and led to an increasingly hostile “conversation” about the form of the protest itself, overshadowing the issue of police brutality that Kaepernick sought to highlight.

The various authors I noted earlier identified numerous concerns more specifically related to football that are of a social justice nature. Approximately 68 percent of NFL players are African American, and the treatment of players has been criticized by some as evoking memories of slavery by the so-called “owners” of the franchises. Anyone who has ever watched the “meat market” known as the NFL Combine, which consists partly of athletes’ bodies being examined by prospective employers (owners), and which is now nationally televised, cannot help but notice this parallel. With the average NFL career lasting less than four years and contracts, even when lucrative, not being guaranteed in case of injury, discerning individuals can easily raise legitimate social justice questions.

In summary, a growing national conversation about football, its viability, its safety and its future is becoming difficult to ignore. Counselors at various levels and in various settings have a responsibility not only to be aware of this conversation, but also to consider its significance in relation to the clients with whom we work. Engaging in this conversation is consistent with current calls within the profession for social justice.

 

 

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Kevin Doyle is a licensed professional counselor in Virginia and an associate professor in the counselor education program at Longwood University. He has also coached youth, high school and adult sports for the past 30 years. Contact him at doyleks@longwood.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.