Tag Archives: medication

Talking through the pain

By Laurie Meyers January 30, 2018

By the time the 43-year-old man, a victim of an industrial accident, limped into American Counseling Association member David Engstrom’s office, he’d been experiencing lower back pain for 10 years and taking OxyContin for six. The client, whose pain was written in the grimace on his face as he sat down, was a referral from a local orthopedic surgeon, who was concerned about the man’s rapidly increasing tolerance to the drug.

“He often took twice the prescribed dose, and the effect on his pain was diminishing,” says Engstrom, a health psychologist who works in integrated care centers.

The man’s story is, unfortunately, not unusual. According to the National Institutes of Health, 8 out of 10 adults will experience lower back pain at some point in their lives. As the more than 76 million baby boomers continue to age, many of them will increasingly face the aches and pains that come with chronic health issues. And as professional counselors are aware, mental health issues such as depression, anxiety and addiction can also cause or heighten physical pain.

Those who suffer from chronic pain are often in desperate need of some succor, but in many cases, prescription drug treatments or surgery may be ineffective or undesirable. Fortunately, professional counselors can often help provide some relief.

Treating chronic pain

At first, the client had only one question for Engstrom: “I’m not crazy, so why am I here?”

Although the man’s physician did not think that the pain was all in the man’s head, it is not uncommon for sufferers of chronic pain to encounter skepticism about what they are experiencing. “It was important … to defuse the idea that I might think he was imagining his pain,” Engstrom says. “So I [told him] that I accepted that his pain was real and that all pain is experienced from both body and mind. I told him that we would be a team and work on this together.”

Engstrom and the client worked together for five months. As they followed the treatment plan, the man’s physician slowly eased him off of the OxyContin.

Engstrom began by teaching the client relaxation exercises such as progressive muscle relaxation. “When in pain, the natural inclination of the body is to contract muscles,” Engstrom explains. “In the long term, this reduces blood flow to the painful area and slows the healing process. Contracted muscles can be a direct source of pain.”

Engstrom also began using biofeedback to promote further relaxation. In biofeedback sessions, sensors are attached to the body and connected to a monitoring device that measures bodily functions such as breathing, perspiration, skin temperature, blood pressure, muscle tension and heartbeat.

“When you relax, clear your mind and breathe deeply, your breathing slows and your heart rate dips correspondingly,” Engstrom explains. “As the signals change on the monitors, you begin to learn how to consciously control body functions that are normally unconscious. For many clients, this sense of control can be a powerful, liberating experience.”

As Engstrom’s client learned to control his responses, he began reporting a decrease in pain following the relaxation exercises.

Engstrom also used cognitive behavior therapy (CBT) methods, including asking the man to keep a daily journal recording his pain level at different times of the day, along with his activity and mood. Through the journal, the man started recognizing that his pain level wasn’t constant. Instead, it varied and was influenced by what he was doing and thinking at the time.

Engstrom highly recommends CBT for pain treatment because it helps provide pain relief in several ways. “First, it changes the way people view their pain,” he says. “CBT can change the thoughts, emotions and behaviors related to pain, improve coping strategies and put the discomfort in a better context. You recognize that the pain interferes less with your quality of life and, therefore, you can function better.”

In this case, the client was trapped by thoughts that “the pain will never go away” and “I’ll end up a cripple,” Engstrom says. He and the client worked on CBT exercises for several months, keeping track of and questioning the validity of such negative future thoughts. They also practiced substituting more helpful thoughts, including “I will take each day as it comes” and “I will focus on doing the best I can today.”

Chronic pain often engenders a sense of helplessness among those who experience it, Engstrom says, so CBT also helps by producing a problem-solving mindset. When clients take action, they typically feel more in control of their pain, he says.

CBT also fosters new coping skills, giving clients tools that they can use in other parts of their lives. “The tactics a client learns for pain control can help with other problems they may encounter in the future, such as depression, anxiety or stress,” Engstrom says.

Because clients can engage in CBT exercises on their own, it also fosters a sense of autonomy. Engstrom often gives clients worksheets or book chapters to review at home, allowing them to practice controlling their pain independently.

Engstrom notes that CBT can also change the physical response in the brain that makes pain worse. “Pain causes stress, and stress affects pain-control chemicals in the brain, such as norepinephrine and serotonin,” he explains. “By reducing arousal that impacts these chemicals, the body’s natural pain-relief responses may become more powerful.”

Although Engstrom acknowledges that he could not completely banish the discomfort his client felt, he was able to lessen both the sensation and perception of the man’s pain and give him tools to better manage it.

Taking away pain’s power

Mindfulness is another powerful tool for lessening the perception of pain, says licensed professional counselor (LPC) Russ Curtis, co-leader of ACA’s Interest Network for Integrated Care.

Mindfulness teaches the art of awareness without judgment, meaning that we are aware of our thoughts and feelings but can choose the ones we focus on, Curtis continues. He gives an example of how a client might learn to regard pain: “This is pain. Pain is a sensation. And sensations tend to ebb and flow and may eventually subside, even if just for a little while. I’ll breathe and get back to doing what is meaningful to me.”

Engstrom agrees. Unlike traditional painkillers, mindfulness is not intended to dull or eliminate the pain. Instead, when managing pain through the use of mindfulness-based practices, the goal is to change clients’ perception of the pain so that they suffer less, he explains.

“Suffering is not always related to pain,” Engstrom continues. “A big unsolved puzzle is how some clients can tolerate a great deal of pain without suffering, while others suffer with relatively smaller degrees of pain.”

According to Engstrom, the way that people experience pain is related not just to its intensity but also to other variables. Some of these variable include:

  • Emotional state: “I am angry that I am feeling this way.”
  • Beliefs about pain: “This pain means there’s something seriously wrong with me.”
  • Expectations: “These painkillers aren’t going to work.”
  • Environment: “I don’t have anyone to talk to about how I feel.”

By helping people separate the physical sensation of pain from its other less tangible factors, mindfulness can reduce the suffering associated with pain, even if it is not possible to lessen its severity, Engstrom says.

According to Engstrom, mindfulness may also improve the psychological experience of pain by:

  • Decreasing repetitive thinking and reactivity
  • Increasing a sense of acceptance of unpleasant sensations
  • Improving emotional flexibility
  • Reducing rumination and avoidant behaviors
  • Increasing a sense of acceptance of the present moment
  • Increasing the relaxation response and decreasing stress

Curtis, an associate professor of counseling at Western Carolina University in North Carolina, suggests acceptance and commitment therapy (ACT) as another technique to help guide clients’ focus away from their pain.

“ACT can help people revisit what their true values are, whether it’s being of service, having a great family life or creating art,” he notes. Encouraging clients to identify and pursue what is most important to them helps ensure that despite the pain they feel, they are still engaging in the things that give their lives meaning and not waiting for a cure before moving forward, Curtis explains.

Teamwork and support

In helping clients confront chronic pain, Curtis says, counselors should not forget their most effective weapon — the therapeutic relationship. Because living with chronic pain can be very isolating, simply sitting with clients and listening to their stories with empathy is very powerful, he says.

Counselors have the opportunity to provide the validation and support that clients with chronic pain may not be getting from the other people in their lives, says Christopher Yadron, an LPC and former private practitioner who specialized in pain management and substance abuse treatment. The sense of shame that often accompanies the experience of chronic pain can add to clients’ isolation, he says. According to Yadron, who is currently an administrator at the Betty Ford Center in Rancho Mirage, California, clients with chronic pain often fear that others will question the legitimacy of their pain — for instance, whether it is truly “bad enough” for them to need extended time off from work or to miss social occasions.

Curtis says it is important for counselors to ensure that these clients understand that the therapeutic relationship is collaborative and equal. That means that rather than simply throwing out solutions, counselors need to truly listen to these clients. This includes asking them what other methods of pain relief they have tried — such as supplements, over-the-counter painkillers, physical therapy, yoga or swimming — and what worked best for them, Curtis says.

The U.S. health care system has led many people to believe that there is a pill or surgery for every ailment, Curtis observes. This makes the provision of psychoeducation essential for clients with chronic pain. “Let them know there’s no magic bullet,” he says. Instead, he advises that counselors help clients see that relief will be incremental and that it will be delivered via multiple techniques, usually in conjunction with a team of other health professionals such as physicians and physical therapists.

Curtis, Yadron and Engstrom all agree that counselors should work in conjunction with clients’ other health care providers when trying to address the issue of chronic pain. Ultimately, however, it may be up to the counselor to put the “whole picture” together.

A 60-something female client with severe depression was referred to Engstrom from a pain clinic, where she had been diagnosed and treated for fibromyalgia. After an assessment, Engstrom could see that the woman’s depression was related to continuing pain, combined with social isolation and poor sleep patterns. The woman was unemployed, lived alone and spent most of her day worrying about whether her pain would get any better. Some of her previous doctors had not believed that fibromyalgia was a real medical concern and thus simply had dismissed her as being lonely and depressed. Despite finally receiving treatment for her fibromyalgia, the woman was still in a lot of pain when she was referred to Engstrom.

Engstrom treated the woman’s depression with CBT and taught her to practice mindfulness through breathing exercises and being present. Addressing her mood and sleep problems played a crucial role in improving her pain (insomnia is common in fibromyalgia). By dismissing the woman’s fibromyalgia diagnosis, discounting the importance of mood and not even considering the quality of her sleep, multiple doctors had failed to treat her pain.

Engstrom points out that in this case and the case of his client with lower back pain, successful treatment hinged on cognitive and behavioral factors — manifestations of pain that medical professionals often overlook.

 

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

Letters to the editor: ct@counseling.org

 

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

 

Healthy conversations to have

By Kathleen Smith July 26, 2017

In the United States, 1 in 6 adults has a prescription for a psychiatric drug. That ratio only increases among individuals who walk into counselors’ offices, leaving many counselors feeling that they must perform a special type of tightrope act to talk about medications with their clients. Given that licensed professional counselors don’t possess prescription privileges, some counselors feel that they lack the training to carry on such discussions. Other counselors fear letting their own beliefs and biases show. Regardless of the reason, some counselors are quick to refer clients back to their doctors or psychiatrists rather than engaging clients in a thorough conversation about medication management themselves.

Because primary care physicians write almost 70 percent of antidepressant prescriptions, counselors may find that new counseling clients who are on medication have yet to have an extended conversation about medication management and their overall mental health. These clients may not have given much consideration to how long they want to stay on medication, or they may be uninformed about the possible risk of growing dependent on sedatives, anxiolytics and other medications.

Several counselor educators are taking up the charge of encouraging more informed and comfortable conversations in the counseling room about client medications. American Counseling Association member Dixie Meyer presented with colleagues at the association’s 2016 conference in Montréal on adjunctive antidepressant pharmacotherapy in counseling. Meyer dedicated her dissertation research to the sexual side effects of antidepressants and their effects on romantic couples. As her research expanded, she grew more and more fascinated with exploring the relationship between psychopharmacology and counseling.

Today, as an associate professor in the Department of Family and Community Medicine at St. Louis University, Meyer educates many primary care physician residents, and she notes that counselors sometimes forget that they have a unique ability to conceptualize clients. “Primary care physicians are expected to be able to know pretty much anything, but they do not have the same level of depth in their mental health training,” she says. “Counselors need to really think about what kind of information they can share with a primary care physician, and the answer is, a lot.”

Meyer explains that counselors may have a greater understanding of the impetus for the client’s condition, the specific symptoms the client has experienced, which of a medication’s potential side effects might be more of a challenge for the client and what additional resources the client may need to maintain medication adherence.

Biases and fears

Professional counselors carry their own biases and values related to psychiatric medications, often based on their individual experiences and training. It is easy to see how the counseling profession as a whole might feel threatened by the statistics, however. For example, nearly $5 billion is spent every year on TV ads for prescription drugs. Then there is the fact that more than half of all outpatient mental health visits involve medication only and no psychotherapy.

A physician assistant with a second master’s degree in counseling, ACA member Deanna Bridge Najera is frequently invited to talk to counselors about improving dialogue between medication prescribers and counseling professionals. She gave a presentation at the ACA 2017 Conference in San Francisco titled, “Medicine Is From Mars and Counseling Is From Venus: How to Make It Work for Everyone.”

Najera has heard skeptical counselors make many statements about psychopharmacology, including that such medications turn people into “zombies,” alter their personalities or simply produce placebo responses. As a master’s counseling student, she also heard many comments from fellow students about their negative relationship with medication or their family members’ negative experiences.

“We have to make sure that we have these conversations out loud,” Najera says. “We have to ask counselors what their concerns are. The way I explain it, the medicine is supposed to allow you to be who you’re supposed to be. It doesn’t change who you are; it just makes it more manageable to learn and grow.”

Although there is still no clear winner in the medication versus therapy debate, researchers are learning more about who might respond to one treatment better than the other. For example, a 2013 study in JAMA Psychiatry found that patients with major depression with low activity in a part of the brain known as the anterior insula responded well to cognitive behavior therapy and poorly to Lexapro. Those patients with high activity in the same region did better with medication and poorly with the therapy. Researchers have also concluded that patients who are depressed and have a history of childhood trauma do better with combined therapy and medication than with either treatment alone.

“We chose our profession because we believe in our profession,” Meyer says, “but the research is going to report no differences between counseling and medication. I do see a lot of bias, and one of my concerns is that our No. 1 goal should be to help the client. So whatever the client’s perspective is, whatever the client thinks is going to help them is probably what will help. They are the experts on their own life.”

Erika Cameron, an associate professor of counseling at the University of San Diego and an ACA member, presented with Meyer in Montréal. When they were enrolled in the same doctoral program, Cameron found herself sharing Meyer’s interest in psychopharmacology and considering how she could respond to the general wariness of school counselors around the topic of medication.

“There can be a bias that that’s not part of their role. They are not diagnosing or prescribing, so they don’t need to know about medication,” says Cameron, who once worked as a school counselor. “But by not talking about it, we might be harming the client. Or if you don’t know that a student is on a medication, then you don’t know what behavior sitting in front of you is normal or atypical for that particular student.”

Another common trepidation among counselors is the fear of stepping outside their lane when it comes to talking about psychiatric medication. Clients often ask for advice about certain medications or when starting any type of drug, but there is a temptation among some counselors to avoid the subject or simply to refer all questions in that vein to a psychiatrist or doctor.

Franc Hudspeth, associate dean of the counseling program at Southern New Hampshire University and also a licensed pharmacist, says that counselors should serve as educators and advocates when it comes to client medications. “We should never cross that line of telling a client what to do with that medication,” he says. “We have to refer back to the foundation of our profession. We help individuals overcome problems, and we don’t give them the solutions. It’s saying to the client, ‘If you have concerns, we can present this to your prescribing physician, and I will support you in any way, but I’m not going to tell you how to do it or what to do with the medication.’ I wouldn’t even do that as a pharmacist. We have to help people make the best decisions based on the best information.”

Hudspeth also says that he observes more of a general hesitancy at work than a fear of liability among counselors. “If someone advocates for their client and their voice gets squashed by a physician or a psychiatrist, there may be some hesitancy to get involved. But it never hurts to voice concerns and to be the advocate for your client,” he says. “[Still], I do think that some counselors fear the repercussions of helping a client speak up.”

Having the conversation

How exactly should counselors respond when clients want to talk about psychiatric medications? In an effort to provide effective psychoeducation, Meyer says, counselors shouldn’t be shy about asking thorough questions upfront concerning clients’ beliefs and ideas related to medication. She suggests asking questions such as, “How do you know that you want to be on a medication?” and “Are you likely to have another depressive episode?” Questions such as these can provide valuable insight into the client’s knowledge (and knowledge deficits) about medication. For example, a client who wants to take an antidepressant might not realize that half of all individuals with depression will not experience another episode.Most frequently prescribed psychiatric medications in the U.S.

Najera also encourages counselors to ask clients where they obtained their knowledge about particular medications. “Many people have the idea that newer is always better, which study after study has shown is not true,” she says. “A client might see a commercial for a new medication and ask if it will work. I’d rather them not break the bank for a new medication when there’s a $4 medication at the local pharmacy that’s just as effective.”

Hudspeth suggests that counselors do a medication check-in with clients at every session. He says the best question counselors can ask clients who are already on medication is, “How is your medication treating you?” This kind of general question can help counselors gather information without overeducating clients in a way that predisposes them to having side effects, Hudspeth explains.

Cameron agrees that the simplest approach is often the most empowering for clients. “Sometimes [it’s simply] asking, ‘Did you read the really long paper that came in the bag with your pills? What is the medication really treating? What are its side effects? What would be considered not normal for you?’ [It’s] educating clients to be critical consumers of their medication,” she says.

Cameron also encourages counselors to role-play conversations that clients could have with their prescribing doctors. Counselors can assist their clients with compiling a list of questions to ask and also encourage them to track their symptoms, thoughts and feelings while on a particular medication. Data can be a powerful tool for holding doctors accountable for connecting clients with the best medication options, but sometimes clients need to learn what to observe while on their medications, Cameron says.

Counselors may also need to have conversations with clients about the impact that their physical health can have on their mental status. Meyer encourages counselors to take time to consider how nutrition, physical illnesses, medications and other substances could potentially influence the mental health of their clients. Anything from high blood pressure medication to birth control pills to low iron could be a culprit, and Meyer worries that individuals who don’t provide their doctors with detailed information about their health are at risk of being prescribed medications that don’t fit their particular symptoms.

“If a client has not had a physical in a long time, then you do not know if there are cardiovascular concerns, hormonal concerns, cancer symptoms or one of the many other disorders that can have depressive side effects or present as depression,” Meyer points out.

Counselors are also charged to have open and honest conversations with parents who are worried about putting their children on psychiatric medications. When Hudspeth worked as a pharmacist in the early 1990s, he began noticing that many children were being medicated without solid reasoning to back it up. Thinking there might be a better approach, he went back to school to become a counselor and later a counselor educator. In his counseling work with children, he has fielded many questions from parents about whether their child should be evaluated for the need to take psychiatric medication.

“My perspective is that the evaluation isn’t going to hurt anything,” Hudspeth says. “I tell parents that they don’t have to make the decision to choose medication, but if the child is medicated, he or she will also do better if they’re in therapy. The two treatments are synergistic, and our goal as a team is to find the [right] balance of different components.”

Cameron adds that school counselors are presented with the complex task of advocating for developing kids who are on medication. “Because there’s so much hormonal change and physical growth, medication may need to be adjusted more frequently,” she says. “School counselors have the ability to see these students on a daily basis, and if we’re not paying attention to these changes, there could be a downward spiral before something
is corrected.”

Psychopharmacology in counseling classrooms

Counselor educators are tasked with preparing their students for the increased use of psychiatric medication among their clients. The 2016 CACREP Standards require clinical mental health counseling students to be educated about the “classifications, indications and contraindications of commonly prescribed psychopharmacological medications for appropriate medical referral and consultation.” Similarly, the CACREP Standards say that counselor education programs with a specialty area in school counseling should cover “common medications that affect learning, behavior and mood in children and adolescents.”

Hudspeth is of the belief that every master’s program in counseling should require a psychopharmacology course. “When 50 percent of our clients are on medication, we should have a basic foundation for understanding psychopharmacology,” he says. “New practitioners need to be better prepared for what they’re going to face in internship or post-master’s work, so they should be familiar with what medications are used for what disorders and what kind of side effects pop up.”

A 2015 article in the Journal of Creativity in Mental Health by Cassandra A. Storlie and others explored the practice of infusing ethical considerations into a psychopharmacology course for future counselors. The authors argue that counselor educators should engage students in talking about how their own values and perceptions about medication use could potentially affect the quality of counseling service they provide. The authors tracked the success of one psychopharmacology course that asked students to complete a variety of creative assignments, including reporting on a legal or ethical issue in the field of psychopharmacology, interviewing an individual who takes a psychotropic medication and discussing fictional client scenarios. At the end of the course, students reported greater confidence in how they understood their role related to discussing medication with clients.

Cameron agrees with the benefits of offering a psychopharmacology course to counseling students. She also sees value in inserting medication conversations into her supervision work with students. When her students bring in case conceptualizations during their internship work, she asks them to list what medications the client is taking. She then asks them to educate their peers about what each medication is treating, what the dosage is and any typical side effects.

“I have to model being comfortable bringing up the topic of medication so that my students get more comfortable,” Cameron says. “Often they don’t talk about medication because they feel that they don’t know it all. They don’t want to give bad information. But they can learn to take a proactive role by sitting with a client and saying, ‘Hey, let’s look this up. Let me get this resource guide or a consult on this.’ There’s this fear, especially with student counselors, that you have to know everything to be able to be helpful.”

Areas for growth

Of course the work of medication education doesn’t end with graduate school. New medications are steadily being introduced, and over time researchers will learn more about the long-term effects of popular ones. Cameron recommends that counselors keep a copy of the Physicians’ Desk Reference, a compilation of information on prescription drugs, in their office. “They update it pretty regularly, so when you have clients come in, you can open the book and figure out what’s going on,” she says.

Hudspeth says counselors should stay informed but also avoid the subtle ways in which they might give advice about any medication, including over-the-counter ones. “A client may come in and say, ‘I’m having difficulty sleeping,’ and a counselor says, ‘Have you tried melatonin?’ They just stepped over that line,” Hudspeth says. “Just because you can buy it at Target or Walmart doesn’t mean you should be asking those questions.”

Meyer suggests that counselors who feel overwhelmed with the breadth of information on medications begin with the client population they serve most frequently. “What information can help your particular clients?” she asks. “Start there and seek out information, depending on who’s coming in and how you can treat them to the best of your ability.”

Above all, Meyer recommends that counselors never forget to take the topic of medication seriously in their work and training. “When you are choosing to take a medication, you may be choosing to have potential side effects. You are choosing that you will alter your neurochemistry. That is not a decision that should be taken lightly. It is not an easy decision,” she says. “When a client makes a choice about whether to take a medication, they need to make it from a place where they are well-informed.”

 

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Kathleen Smith is a licensed professional counselor and writer in Washington, D.C. She is the author of The Fangirl Life: A Guide to All the Feels and Learning How to Deal. Contact her at kathleensmithwrites@gmail.com.

Letters to the editor: ct@counseling.org

 

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

Living with anxiety

By Bethany Bray May 24, 2017

Anxiety disorders are the most common mental illness in the United States, affecting 18 percent of the adult population, or more than 40 million people, according to the National Institutes of Health. Among adolescents the prevalence is even higher: 25 percent of youth ages 13 to 18 live with some type of anxiety disorder.

Anxiety disorders are often coupled with sleeplessness, depression, panic attacks, racing thoughts, headaches or other physical issues. Anxiety can run in families and be a lifelong challenge that spills over into all facets of life, from relationships and parenting to the workplace.

The good news is that anxiety disorders are manageable, and counselors have a plethora of tools to help clients lessen the impact of anxiety. Caitlyn McKinzie Bennett, a licensed mental health counselor, says she regularly talks this through with her clients at her private practice in Orlando, Florida. She often uses an analogy of ocean waves with clients: Anxiety comes in waves, and managing the disorder means learning coping tools and strategies to help surf those waves rather than expecting the waves to disappear entirely.

“Anxiety can be a long-term thing,” says Bennett, who is also a doctoral student in counselor education at the University of Central Florida. “With clients, I try and explain that [anxiety] is the body’s response that something’s not right — based off of what’s happened to you [such as past trauma] or what’s happening currently. Then we can work to accept it, cope and be happier in your life. Some things you can’t necessarily get rid of in their entirety, and that’s OK. It’s learning to be you and have a fulfilling life with anxiety, where you’re able to feel anxious and [still] be productive and be a mother, a student, a partner. I try and normalize that [anxiety is] going to come and go. It’s OK, and it’s human.”

Anxiety doesn’t happen in isolation

Everyone experiences anxiety from time to time, such as worry over an upcoming work responsibility, school exam or first date. Anxiety disorders, however, are marked by worry and racing thoughts that become debilitating and interfere with everyday functioning.

“It’s a normal part of life to experience occasional anxiety,” writes the Anxiety and Depression Association of America on its website (ADAA.org). “But you may experience anxiety that is persistent, seemingly uncontrollable and overwhelming. If it’s an excessive, irrational dread of everyday situations, it can be disabling. When anxiety interferes with daily activities, you may have an anxiety disorder.”

A number of related issues fall under the heading of anxiety disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), including specific phobia, panic disorder, separation anxiety disorder, social anxiety disorder, generalized anxiety disorder and others. According to the DSM-5, anxiety disorders “include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat.”

Racing thoughts, rumination and overthinking possibilities — from social interactions to decision-making — are central to anxiety. In addition, people with anxiety often struggle with insomnia or sleeplessness and physical symptoms such as a racing heart, sweaty palms and headaches, says Bennett, an American Counseling Association member who is currently leading a study for her doctoral dissertation on the effects of neurofeedback training on college students with anxiety. Adolescents sometimes turn to self-harming behaviors such as cutting or hair pulling to cope with anxiety. In adults and adolescents, anxiety can manifest in physiological issues such as stomachaches or irritable bowel syndrome. Although adults may channel their anxiety into physical problems, they’re also generally much more capable than adolescents and children of identifying and articulating the anxious thoughts, ruminations and social struggles that they’re facing, Bennett says.

Bennett worked with a 14-year-old female client whose anxiety had manifested as the behaviors of obsessive-compulsive disorder (OCD), including avoiding the number six, leaving her closet door open a certain way and struggling with crossing thresholds. Bennett worked with the client to identify her triggers and find coping mechanisms, such as connecting with friends and her Christian faith.

“A big part of her improvement was creating the awareness of what was happening,” Bennett says. “Typically there’s a large, irrational fear. With her, she was afraid that her mom was going to die. She would focus on it so much that it would cause her to start the [OCD] behavior. … For her, it felt so real. It was so scary for her that she felt compelled to do these behaviors to keep her mom alive, so to speak.”

Bennett worked with the young client to confront her fears in small doses through exposure therapy, such as listening to a song at volume level six and talking through how she felt afterward. This method allowed Bennett to first address the client’s OCD behaviors and then — once trust was built and the client had progressed — move on to work through the bigger, deeper issue of her fear of her mother’s death.

“It helped her to feel safe enough and have the confidence to work through some smaller things and move on to work on bigger things,” Bennett says. “For her it was talking it out, normalizing that for her and drawing attention to [her anxious behaviors].”

Christopher Pisarik is an associate professor in the Division of Academic Enhancement at the University of Georgia and a licensed professional counselor (LPC) who works with students in need of academic support. He says that stress and irregular sleep and eating patterns — which are often ubiquitous parts of college life — can go hand in hand with anxiety.

“Sleep is a big one — if they’re just not sleeping, or sleeping too much,” says Pisarik, who also treats many college-age clients at his private practice in Athens, Georgia. “This is really, really common — clients who can’t get to bed until 4 a.m., and then they can’t get to class, and it snowballs. Their thoughts just race with worry. … Sleep seems to be a big diagnostic indicator [for anxiety], and not being able to go to bed. [I ask clients,] ‘What are you thinking about, and can you stop thinking about this? Is that what’s keeping you from getting back to sleep?’ They get tired and fatigued, and it’s perpetuated.”

In addition, anxiety is often coupled with — or is an outgrowth of — other mental illnesses, most commonly depression. Counselors will need to treat a client’s anxiety alongside other diagnoses, Bennett says. For example, a client with schizophrenia will have hallucinations that provoke extreme anxiety. If the counselor doesn’t address the client’s anxiety, those symptoms will get worse, explains Bennett.

“Depression and anxiety are like brother and sister,” she adds. “They play off of each other and exacerbate the symptoms. You need to work through both. I don’t think I’ve ever worked with anyone who solely experienced anxiety.”

Stephanie Kuhn, an ACA member and LPC at the Anxiety Treatment Center of Greater Chicago, agrees. She regularly sees client anxiety paired with other issues such as specific phobias, insomnia, chronic pain issues, depression, panic disorders and OCD.

“It’s never really one thing,” Kuhn says. “It’s never just anxiety.”

Pumping the brakes on racing thoughts

The first step for many people who struggle with anxiety is to create awareness of their thoughts and then learn to manage those thoughts with a counselor’s help. Although the strategy of identifying negative self-talk and addressing one’s thoughts is old hat to most counselors, it may be an entirely new concept for some people, especially younger clients, says Pisarik, an ACA member who uses cognitive behavior therapy (CBT) in his private practice. Clients with anxiety often polarize, exaggerate or catastrophize details in their minds as they ruminate over them, he explains.

“Even being able to identify anxious thoughts is big,” Pisarik says. “They just assume it’s normal to walk around [feeling] anxious because of these thoughts. … It gives them a language and a real usable and rudimentary skill they can use in the moment when they’re walking in [to a stressful exam]. They can identify that their inner narrative isn’t healthy.”

For example, a college student might come to a counselor expressing worry about an upcoming exam in a class that he or she needs to pass for a major in pre-med. The student might have allowed negative and catastrophic thoughts to snowball: “If I get a C on this test, I will never get into medical school, which will derail my entire career plan and make my parents angry and disappointed.”

“For … a student who is 20 years old and [still] learning to think critically, it would be easy to blow everything out of proportion and catastrophize everything,” Pisarik says. “I am really big on helping them understand negative thinking and false cognitions, and getting them to self-monitor and renarrate [their unhealthy thoughts].”

Following the CBT approach, Pisarik says he would talk such clients through their thought patterns to identify and restructure their negative thoughts about the exam. He would also suggest that they focus on and remind themselves of prior successes, such as other exams or classes in which they earned A’s and B’s.

“I would try and systematically educate the client [about] what type of thinking that is,” Pisarik continues. “There are many doctors out there who got C’s and got into medical school, and probably [who] got C’s in medical school. I will explain that they are catastrophizing this … [and] try and get them to think about it in a different way, evaluate it carefully and create a different narrative about it. Are there people who have gotten C’s and gotten into medical school? If it stops you from getting into medical school, would that be the worst thing in the world?”

“It takes a consistent effort to practice and challenge one’s thinking,” adds Pisarik, who co-authored the article “A Phenomenological Study of Career Anxiety Among College Students.” The article will be published in the December issue of The Career Development Quarterly, the journal of the National Career Development Association, a division of ACA.

CBT works well for anxiety because “it lets people see that their own thinking and their behaviors are not productive for the way they want to live or the life they’re living right now,” says Kuhn, who uses both CBT and exposure therapy with her clients at the Anxiety Treatment Center of Greater Chicago. “It’s giving people an outside perspective — getting them to look at their own thoughts and behaviors objectively rather than letting those anxious thoughts take over everything, making it harder to function.”

One way Kuhn works with clients on challenging their unhealthy thoughts is by asking them to identify the best, worst and most likely outcomes of situations they are ruminating over. “I ask, ‘Would [the outcome] matter in a week, a month or a year from now?’ Typically the answer is no,” Kuhn says. “After we go through that, we reframe the original thought [and] transform it into something more rational, more realistic.”

Both Pisarik and Kuhn encourage their clients to keep thought logs to track anxious thoughts and the situations that triggered them. This exercise increases self-awareness, helps identify triggers and creates an opportunity to discuss how the client might change the negative narrative.

“Writing helps a lot because it slows people’s minds down, and they can go back and read about it,” Kuhn says. “Creating that awareness is the only way to understand yourself, understand what you’re worried about and be able to accept it and push it away.”

In addition to using thought logs, Pisarik gives his clients a list of automatic negative thoughts, or ANTs, to check themselves against. The collection lists the most common types of unhealthy, anxious thoughts and types of thinking, including catastrophizing and either-or thinking (polarizing).

Kuhn has a particular phrase that she often repeats with clients: “Handle it.” She acknowledges that it’s not the most empathic of mantras, but it does help to focus on the manageability of anxiety. With clients, she works toward a goal of “being able to sit with the uncomfortableness [of anxious thoughts] and tolerate the stress.”

Kuhn says her style when working with clients matches her personality: “Let’s go forward and hit our fears hard instead of tiptoeing around them.”

Exposure therapy, which introduces things in small, controlled increments in session that make a client anxious, is another good way to focus on handling anxiety, Kuhn adds. Whether the scenario is a fear of speaking up in class or a fear of being rejected by a loved one, exposure therapy can help clients learn to live with the issue and the anxious feelings that come with it.

“When I talk to people about ‘handling it,’ it’s creating that awareness and understanding [of] themselves that they’re able to manage or take on more than they think they can,” Kuhn says. “Anxiety a lot of the time makes us believe that we can’t handle the tiniest things. That’s why our body has created or learned how to respond to things in an overactive or hypersensitive way.” This is most commonly experienced in our fight-or-flight response, she says.

Managing worry and taming anxiety

From CBT and mindfulness to a focus on wellness and coping strategies, professional counselors have a wide range of tools to help clients who struggle with anxiety. Here are some ideas and techniques that can be particularly useful.

> Controlling the controllables. Kuhn says it can be helpful for clients to talk through and identify what is out of their control during situations that make them anxious. “A lot of times, anxious clients want control over everything, and that’s just not realistic,” Kuhn says. “It’s important to go over what’s controllable and what’s not. That creates awareness and a pathway to reevaluate [their] own thinking and behavior. I like to call it ‘controlling the controllables.’ I talk with clients about this a lot.”

Kuhn often uses an exercise with clients in which she draws a target with concentric circles. Things that clients can control, such as their own thoughts and behaviors, go in the center circle. Things that they partially control, such as their emotions or what they focus on sometimes, go in the middle ring. Things that are out of their control, such as what other people think or do, go in the outside circle. In a simpler alternative, Kuhn draws a center line down a piece of paper and works with clients to list what is and isn’t in their control in situations that make them anxious.

> Creating common ground. Kuhn says she also talks openly with clients about how common anxiety is, alerting them that they are among literally millions of Americans who are battling the same challenge. “I let them know they are not alone. It creates a universality,” Kuhn says. “To let people know that they’re not the only ones suffering like this can help. … It does create a common ground for people not to feel ashamed of [their anxiety] or feel like they can’t talk to someone about it. Just creating that education typically makes people feel a ton better.”

> Acknowledging and naming worry. Journaling and making lists to document anxious thoughts can help clients address and reframe the everyday rumination that accompanies anxiety. Kuhn offers two variations on this intervention: worry time and the worry tree.

With “worry time,” clients set aside a dedicated amount of time (Kuhn suggests 30 minutes) every day to write down any anxious thoughts that are troubling them. Clients don’t need to engage in long-form writing to complete this exercise, Kuhn says. Making a bulleted list or jotting thoughts down on sticky notes will work just as well. When the designated time is up, clients put all the notes in a box or container that they have set aside for this purpose. This action signifies that they are leaving those thoughts behind and can move on with the day.

“They have to leave those thoughts or sticky notes there and be done with them,” she says. “Obviously more [anxious] thoughts will come, but you have to remind yourself to leave them behind.”

With Kuhn’s “worry tree” intervention, clients create a flowchart of their anxious thoughts. With each item, clients ask themselves whether their worry is productive or unproductive (see image, below). “Is it something that you can actually do something about?” Kuhn asks. “If it’s unproductive, then you need to just let it go. Do something you enjoy or focus on something else to reset [your mind].”

 

> Mind-body focus and exercise. Mindfulness, meditation and other calming interventions can be particularly helpful for clients with anxiety. Kuhn recommends the smartphone app Pacifica, which prompts users with breathing, relaxation and mindfulness exercises, for both practitioners and clients. Kuhn, who has a background in sports counseling, and Pisarik, who is a runner himself, also prescribe exercise to anxious clients. Exercise boosts serotonin, a neurotransmitter connected to feelings of well-being, and comes with a host of other wellness benefits. In addition, exercise allows a person to get outdoors or disengage from work and home activities and other people for a brief period to “have time to hear your thoughts and challenge them,” Pisarik says. “You have to hear your thoughts if you’re going to challenge them.”

> The butterfly hug. Beth Patterson, an ACA member and LPC with a private practice in Denver, teaches deep breathing exercises to anxious clients to help them become grounded, focusing on the flow of energy through the body. She also recommends the “butterfly hug” technique. With this technique, clients cross their arms across their chests, just below the collarbone, with both feet planted firmly on the floor.

Clients tap themselves gently, alternating between their right and left hands. This motion introduces bilateral stimulation, the rhythmic left-right patterns that are used in eye movement desensitization and reprocessing. “It’s phenomenally self-soothing,” Patterson says. “Doing that with deep breathing really helps with anxiety. I love the idea that you’re hugging yourself. Even just doing that helps.”

> Walk it out. Along with deep breathing and grounding, Patterson also recommends walking and movement for clients who are feeling anxious. She instructs clients to focus on the feeling of each foot hitting the ground instead of their anxious thoughts. As with the butterfly hug, this action creates bilateral stimulation, Patterson notes.

Bennett also uses walking as a way to help clients refocus their thoughts. She will take clients out of the office during a session for a “mindful walk” up and down the block. During the walk, they talk about what they’re sensing, from the sunshine to the breeze to the smell of flowers. Bennett says this allows her to work with clients “in the moment,” recognizing and refocusing anxious thoughts as they come. Afterward, they process and talk through the experience back in the office.

“It’s a lesson that [anxious] thoughts are going to come up for you, and you can refocus on your sense of touch or hearing,” Bennett says. “Thoughts will come up, and it’s really easy to attach to those thoughts and become anxious, but we can acknowledge the thought, be accepting of it in the moment and refocus. Change and connection can come that way.”

> This is not that. Clients commonly transfer anxiety-provoking personal issues onto relationships or situations in other facets of life, including the workplace, Patterson says. For example, Patterson worked with a client who had a very domineering, controlling mother, and this client felt triggered by a female boss in her workplace. Patterson introduced the client to the mantra “this is not that,” and they worked on reframing the anxiety the client experienced when she felt her boss was being controlling.

“She had to work through it in a beneficial and compassionate way for herself and really remember ‘this is not that,’” Patterson says. “Our minds are brilliant, but they’re binary computers. When something happens, it will immediately associate it with something else it knows. If a co-worker is being overly competitive, it might trigger feelings about sibling rivalry. This [mantra] offers a great opportunity to work through family-of-origin issues [with clients] when you see them replicated in the workplace.”

> Abstain from negativity. Another empowering tool clients can use is to become conscious of and then avoid unhealthy or toxic situations and people who trigger their anxiety, Pisarik says. He advises clients to “stay away from groups of people or individuals who they know will engage in negative self-talk or negativity. If you’re feeling anxious already, the last thing you want to do is to go and talk to that toxic person.”

Similarly, he commonly advises anxious students to avoid waiting outside the room where they’re about to take a big exam, surrounded by 30 classmates who might be saying that they are going to fail, they didn’t study enough, they don’t feel prepared and so on. Counselors can coach anxious clients to think ahead and prepare ways to remove themselves from these types of situations, regroup and redirect their thinking, Pisarik says.

> Lifestyle choices. Counselors can also educate clients on the connection between anxiety and lifestyle choices such as sleep patterns, exercise and diet, Pisarik says. For young clients especially, this also includes social media use, he notes.

Pisarik says he frequently talks with his college-age clients about their alcohol consumption, drug use, irregular diet and other aspects of the modern university experience. “The lifestyle of a college student is absolutely conducive to generating anxiety,” he says. “While they are college students, I get that — their job is to have fun and sleep whenever [they] want. But building some sort of healthy routine is important, [including] getting enough sleep and making sure they eat well. I tell them to try and maintain the diet they had at home. … If you’re struggling with anxiety to begin with, any one of those [elements] can add to it, and those are really easy fixes.”

For Bennett, conversations with clients about lifestyle also include questions about smoking and caffeine use. Both tobacco and caffeine can make a person shaky or make his or her heart and mind race, which can trigger or exacerbate anxiety, she points out.

In addition to social media use, Pisarik also asks clients about their social engagement, such as participating in sports or other hobbies. Clients who struggle with anxiety often isolate themselves, he notes, so he works with them to identify social outlets, from volunteering to joining a school club. This sense of connection can reduce anxiety, he says.

> Narrative therapy and externalization. Patterson finds narrative therapy helpful when working with clients with anxiety because it allows them to externalize what they’re feeling. When clients uses phrases such as “I am worried” or “I am anxious,” Patterson will gently redirect them by saying, “No, you’re Susan, and you have a problem called worry.”

“Externalize the problem,” Patterson explains to clients. “Externalize it and dis-identify it. See it outside of yourself. … ‘I can deal with that because it’s not who I am.’ … If you’re carrying it around as if it’s you, you can’t do anything about it. The truth of the matter is, it’s not you.”

Counselors can also help clients with anxiety to focus on a time in their lives when they faced a similar challenge and got through it, Patterson says. She asks clients questions to help them probe deeper. For example: How did you handle that challenge? What worked, and what didn’t work?

 

Working with clients on medication

Anti-anxiety medications are commonly prescribed in the United States. Their prevalence means that counselors are likely to encounter clients who are taking medication to control their anxiety symptoms.

Regardless of their feelings about the use of psychotropic medications, practitioners must treat and support clients who are taking such medications the same as they would any other client, Kuhn says. “I never treat someone differently based on their medication. They get the same CBT therapy that anyone else would get,” she says, adding that the most important thing is to ensure that clients don’t feel judged by the counselor.

Kuhn has seen anti-anxiety medications work well for some clients. “It can take that little edge off that they need to get through the day and be able to function,” she says. At the same time, she also has clients who express a desire to be able to stop taking their medication eventually.

Pisarik notes that for anti-anxiety medication to work well, clients must remember to take it faithfully, keep track of how it makes them feel and schedule the repeated appointments needed to monitor and adjust dosage levels. Each of these elements can pose a challenge to college-age clients. “It’s a lot of work, and [college students] often lack the discipline and time to get it right,” Pisarik says.

Bennett agrees, suggesting that even though professional counselors are not the ones prescribing medications, they still need to discuss and explore medication use with their clients. She also stresses that practitioners should be knowledgeable about the different kinds of medications that clients may be taking and their possible side effects.

Bennett sometimes conducts conference calls with her clients and the medical professionals who are prescribing them medications so that she can help clients ask questions and otherwise be a support to them. “We [counselors] don’t prescribe, but at the same time it’s very important to collaborate with whoever is prescribing the [client’s] medication,” she says. “Be supportive and involve the client in conversations: How long have you taken it? Have you noticed any side effects? Has it been helping? Talk about how often they’re supposed to take it and if they’re adhering to that. There can be stigma about taking medications, so it’s important to normalize it. … It’s comforting too for the client to know that you’re on their side, and part of that is collaboration [about medication].”

 

See the person, not the anxiety

Given how common anxiety disorders are, it’s likely that any counselor’s caseload will be filled with clients presenting with symptoms of anxiety. It is important, however, for counselors to treat each client as an individual and to tailor the therapeutic approach to meet that client’s unique needs, Bennett emphasizes.

Building trust and a healthy therapeutic relationship are key in treating anxiety because clients can feel very vulnerable as they talk about what makes them anxious, Bennett points out. That is why it is critical to get to know these clients as individuals rather than through the lens of their anxiety.

“Don’t assume that because they’re anxious, they’re going to think and behave like other people with anxiety,” Bennett says. “Meet them where they are and find out what’s most effective for them based off of their interests. It can be empowering for clients to integrate their own interests and life experiences into the therapeutic process. Not only does this create buy-in for the client, but it can also help in creating a safe space to begin exploring the vulnerabilities that come along with anxiety. … Hear their story, find their strengths and give them a voice in the process. It’s important to honor them as individuals.”

 

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To contact the counselors interviewed for this article, email:

 

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

Letters to the editor: ct@counseling.org

 

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

What counselors can do to help clients stop smoking

By Bethany Bray November 29, 2016

Nearly half of the cigarettes consumed in the United States are smoked by people dealing with a mental illness, according to the Substance Abuse and Mental Health Services Administration. The federal agency says that rates of smoking are disproportionately higher — a little more than double — among those diagnosed with mental illness than among the general population.

It is widely accepted that the nicotine in cigarettes is highly addictive, but people struggling with mental health issues often turn to cigarettes for reasons that go beyond their addictive qualities. For instance, many people smoke as a coping mechanism to deal with difficult feelings. In addition, despite their negative health effects, cigarettes are still largely viewed by society as an “acceptable” addiction in comparison with other substances.

The reality? “[Smoking] is a devastating addiction and a difficult one to quit,” says Gary Tedeschi, clinical director of the California Smokers’ Helpline and a member of the American Counseling Association. “This clientele [those with mental illness], in particular, need the encouragement and support to go forward [with quitting], and many of them want to, despite what people might think. … To let people continue to smoke because ‘it’s not as bad’ [as other addictions] is missing a really important chance to help someone get healthier.”

To drive home his point, Tedeschi points to a statistic from the 2014 release of The Health Consequences of Smoking — 50 Years of Progress: A Report of the Surgeon General, which says that more than 480,000 people die annually in the United States from causes related to cigarette smoking. Close to half of the Americans who die from tobacco-related causes are people with mental illness or substance abuse disorders, Tedeschi says.

In Tedeschi’s view, the statistics connecting smoking to mental illness are “so obvious that it’s almost an ethical and moral responsibility to help this population quit.”

Part of a package

Ford Brooks, a licensed professional counselor (LPC) and professor at Shippensburg University of Pennsylvania, says he has never had a client walk in to therapy with a primary presentation of wanting to stop smoking.

Tobacco use “is always part of a package” that clients will bring to counseling, Brooks says. In his experience as an addictions counselor, smoking is often piled on top of a laundry list of other challenges that may include alcohol or drug addiction, depression, a marriage that is on the rocks, the loss of a job or financial trouble.

“They’re on the train to destruction, and their nicotine use, in their minds, is on the back end [in terms of importance]. … Is the smoking related to what their presenting issue is? Chances are it probably connects somehow. Don’t be afraid to bring it up,” advises Brooks, co-author of the book A Contemporary Approach to Substance Use Disorders and Addiction Counseling, which is published by ACA.

Tedeschi, a national certified counselor and licensed psychologist, notes that many people who call the California Smokers’ Helpline are struggling with comorbid conditions or mental illness in addition to tobacco use. The phone line is one in a system of “quitlines” operating in each of the 50 U.S. states, the District of Columbia, Puerto Rico and Guam.

For clients struggling with mental health issues, smoking may serve as a coping mechanism to deal with uncomfortable feelings or anxiety, Brooks says. Years ago, when smoking was still allowed in many indoor spaces, Brooks led group counseling in detox, outpatient and inpatient addictions facilities. “When powerful emotions would come up in group, [clients] would fire up cigarette after cigarette to deal with those feelings and quell anxiety,” he recalls.

With this in mind, counselors should help prepare clients for the irritability, anxiety and other uncomfortable feelings they are likely to experience when they attempt to stop smoking cigarettes. “Talk about what it will feel like to be really anxious and not smoke” and how they plan to handle those feelings, Brooks says. “… If a person has anxiety or depression and stops smoking, what initially happens is they could get more depressed or more anxious without nicotine to quell the emotion.”

The counselors interviewed for this article urge practitioners to ask every single client about their tobacco use during the intake process, no matter what the person’s presenting problem is. “If you’re helping them to get mentally and physically healthier, this [quitting smoking] is a very critical part of the overall wellness picture,” Tedeschi says.

Counselors shouldn’t be afraid to ask their clients whether they smoke, says Greg Harms, a licensed clinical professional counselor (LCPC), certified addictions specialist, and alcohol and drug counselor with a private practice in Chicago. “It can feel weird the first couple of times, especially if this is not your area of expertise,” says Harms, who does postdoctoral work at Diamond Headache Clinic in Chicago, an inpatient unit for people with chronic headaches. “A lot of times, clients have heard all the bad stuff about smoking. A lot of them, deep down, they know they’d be better off if they were to quit smoking. They may have failed so many times in the past that they’re discouraged. They might be hesitant to bring it up because this is a counselor and not the [medical] doctor. If you bring it up, more often than not, the client is going to engage with that. Even if they don’t, if it’s not the right time for them, you’ve planted that seed. … It might come to fruition down the road. I’d much rather plant that seed than not say anything at all.”

When Harms was a counseling graduate student, he completed an internship at the Anixter Center, a Chicago agency that serves clients with disabilities. While there, he worked as part of a grant-funded program for smoking cessation for people with disabilities that was spearheaded by the American Lung Association. He also presented a session titled “Integrating Smoking Cessation Treatment with Mental Health Services” at ACA’s 2013 Conference & Expo in Cincinnati.smoking

If a client doesn’t feel ready to begin the quitting process right away, the counselor can put the topic on the back burner to address again once the client has made progress on other presenting problems or has forged a stronger relationship with the practitioner. However, that shouldn’t mean that the topic is off the table completely, Harms says. A counselor should talk regularly with the client about quitting smoking, even if it’s only for a few minutes each session.

“Give them a little nugget of information [about quitting], and then you can focus on what they’re there for,” Harms says. “Help them find ways to deal with their presenting problem, then they’ll trust you. Once they’re in a better place, revisit [the idea of quitting]. We don’t have to address it and get their buy-in during the first session. It would be fantastic if that was the case, but it’s OK if it’s not. In most cases, time is on our side to develop the relationship, plant the seed and revisit it. If the client is not ready, we can harp on [quitting] all we want, [but] it won’t do anything.”

“You really have to take the client’s lead and go at the pace they’re willing,” Harms continues. “Don’t push. Respect their decision. Even if they’re not ready for [quitting], let them know that [you’re] there for them and respect their autonomy to make that decision.”

Positioned to help

Counselors are particularly suited to help clients quit smoking because the profession has an array of tools focused on behavior modification, Tedeschi asserts. Motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and other models can be useful in helping clients stop smoking. But techniques from any therapy model that counselors are comfortable using can be adapted to help clients navigate the challenge of quitting, Tedeschi says, especially when combined appropriately with pharmacologic aids approved by the Food and Drug Administration.

“We’re in the business of helping people change. The principles that a counselor uses to help someone understand an issue and begin to make steps toward change apply to smoking cessation as well,” Tedeschi says. “Counselors help people understand their motivation to change and help them come up with a plan to change.”

Harms agrees, noting that in most cases, a counselor will have significantly more time with a client than a medical professional will. Instead of “hitting [the client] over the head” with the dangers of smoking, Harms says, a counselor can afford to focus on the positive, use a strengths-based approach and build on what the client wants to work toward rather than what he or she wants to avoid.

“We [counselors] are so strengths-based. It’s our natural inclination to tell the client, ‘Yes, you’re strong enough to do this,’ rather than [taking] a scare approach,” Harms says. “We can find their strength and have that unconditional positive regard for them, regardless of how long it’s taking. We have the patience to sit with a client as they’re going through [quitting]. We can build that relationship and be a resource.”

Start small

Tedeschi recommends that counselors use the “five A’s” to discuss smoking with clients. In this approach, a practitioner should:

  • Ask each client about his or her tobacco use
  • Advise all tobacco users to quit
  • Assess whether the client is ready to quit
  • Assist the client with a quit plan
  • Arrange follow-up contact to mitigate relapse

Each of these steps is important, but providing support and follow-up as the client begins to quit is particularly critical, Tedeschi says.

“The first week of quitting is the hardest. If [a counselor] waits for a week to talk to the client, you could lose about 60 percent of people back to relapse,” he says. “If someone is able to quit for two weeks, their risk of relapse drops dramatically.”

If clients resist the idea of quitting or do not feel ready to quit entirely, Tedeschi suggests that counselors work with them to stop smoking for one day or even just an afternoon. During this time, have clients monitor how they felt: How was their anxiety level? What were their cravings like? This technique can introduce the idea of stopping and prepare clients for the quitting process, he says.

Brooks recommends using motivational interviewing to help clients make the life change to quit smoking. “Nicotine is a drug, and it’s no different than if [clients] were to say they want to stop drinking. Work with their motivation to identify what they can possibly do for that,” he says.

Part of the quitting process involves clients going through an identity shift, Tedeschi notes. Clients can be behaving as nonsmokers — abstaining from cigarettes — long before they make the mental leap that they are no longer smokers, he says. It is important for clients to make that mental shift from “a smoker who is not smoking” to a “nonsmoker,” Tedeschi says. Counselors need to work with these clients to identify as and accept the nonsmoker label. “As long as someone calls [himself or herself] a smoker, they will be open to turning back to cigarettes,” he explains.

Kicking the habit

Counselors can use the following tips and techniques to better equip clients to meet the challenge to stop smoking.

Set a quit date. This is an important step, but one that clients must take the lead on and choose for themselves, Tedeschi says. Research shows that simply cutting back without setting a quit date isn’t very effective, he adds. The behavioral patterns that often accompany smoking (for example, smoking after eating or taking smoke breaks at work) make it very hard to keep tobacco use at a low level. Setting a quit date creates accountability and is a “sign of seriousness,” he says. At the same time, be flexible. “For some people, it’s just too hard to think about [sticking to a quit date],” Tedeschi says. “For some — especially those who are struggling with other substances — they need to take one day at a time.”

Be aware of psychotropic medications. Counselors should be aware that if clients are taking prescription medicines for anxiety, depression, bipolar disorder or other mental illnesses, their dosages might need to be adjusted as they quit smoking. Nicotine is a stimulant, so it speeds up a person’s metabolism. This means a person who smokes will burn through psychotropic medications faster than someone who doesn’t smoke, Harms explains. Counselors should be certain to talk this through with clients and work with their doctors to modify their dosages, he says. “This is especially noticeable with mood stabilizers. It’s acute with bipolar disorder,” Harms says.

The same holds true with caffeine, Tedeschi notes. After they quit smoking, clients may notice that they get jittery from caffeine and may need to cut back on their coffee intake.

Use cognitive strategies. Counselors can help clients create a list of personal reasons why they want to stop smoking — beyond the health implications, Tedeschi says. The list doesn’t need to be long, but the reasons need to be compelling and motivating enough to carry clients through a nicotine craving. For example, one of Tedeschi’s clients wanted to quit because his young grandson asked him to. As a reminder, the client kept a toy car that belonged to his grandson in his pocket. “When he had a craving [for a cigarette], he would pull [the toy car] out of his pocket, look at it, hold it and squeeze it,” Tedeschi says. “It helped.”

Turn over a new leaf. As they quit smoking, encourage clients to organize, clean and purge their homes and cars of smoking-related materials such as ashtrays, advises ACA member Pari Sharif, an LPC with a practice in Franklin Lakes, New Jersey. That action will help clients turn a new page mentally and start fresh, she says. Sharif also encourages clients to air out their homes and clean their closets so their clothes and furniture no longer smell like smoke.

On a similar note, if clients have a certain mug that they always use to drink coffee while smoking, Harms suggests that they get a new mug. Or if they always stopped at a certain gas station to buy cigarettes, he suggests that they now change where they buy gas.

When cravings strike, breathe. Sharif, a certified tobacco treatment specialist, introduces breathing techniques to all of her smoking cessation clients. She asks these clients to take measured breaths for roughly two minutes, inhaling while slowly counting to four, then exhaling for four counts.

“Instead of the reflex habit to grab a cigarette, take a moment to stop and ask why. Be more in control of yourself and your mind,” she tells clients. “Pause to do breathing and body scanning from head to toe. Ask yourself, ‘What am I doing? Why do I need this [cigarette] to calm down?’ … [Through breathing exercises,] your breath becomes deeper and deeper. Close your eyes. Your body starts relaxing and your anxiety level goes down.”

Sharif also recommends that clients download a meditation app for their smartphones and use a journal to record how they’re feeling when cigarette cravings strike. This helps them log and identify which situations and emotions are triggering their need for nicotine,
she explains.

Get to the root of it. Asking clients about the circumstances that first caused them to start smoking can help in identifying what triggers their nicotine use and the bigger issues that may need to be addressed through counseling, Sharif says. In some cases, a specific traumatic event or stressor caused the person to start smoking. In other instances, it was a learned behavior because everyone in the household smoked as the client was growing up. “Find out when they started smoking and why,” Sharif says. “Gradually, when they become more aware of themselves, they quit.”

Change social patterns. Cigarettes are often used as a coping mechanism when people experience anxiety in social situations, Harms says, so clients may need to focus on social skills as they start the process of quitting smoking.

“[Cigarettes] are their way to socialize and get out and meet people. If you have social anxiety, you can still go up to someone and ask for a cigarette or ask for a light. It’s programmed socialization,” Harms explains. “It gives you an excuse to be close to people, feel more sociable. If you take away their cigarettes, you’ve got to replace that.”

Brooks agrees, noting that clients who smoke likely have friends who are also smokers. For example, he says, it is not uncommon to see people smoking and talking together outside of Alcoholics Anonymous meetings. Counselors can help clients prepare to avoid situations where smoking is expected and practice asking people not to smoke around them, Brooks says. Counselors can also support clients in creating social networks of people who don’t smoke, including support groups for ex-smokers, he adds.

Break behavioral habits. Similarly, Brooks says, counselors can help clients change the behavioral habits they connect to smoking, such as starting the morning by reading the paper, drinking coffee and smoking a cigarette. Counselors can suggest activities and new rituals to replace the old ones, such as taking a daily walk, he says.

Harms encourages clients to replace their former smoke breaks with “clean air breaks.” They can still take their normal time outside, but instead of smoking, he suggests that they walk around the block, sit and read a book, eat an apple or use their smartphones outdoors. If they had a favorite smoking spot outside, he urges them to find a new place to go instead.

Find comforting substitutes. “The whole ritual of lighting up a cigarette — tapping the pack to pull out a cigarette and flicking the lighter — the behaviors that go with [smoking] can be very comforting,” Harms says. “Sometimes that’s what’s so hard to break — the behaviors that go with it.”

Tedeschi recommends that counselors work with clients to have comforting alternatives ready to go even before the clients attempt to quit smoking. It is hard for people to figure out alternatives in the heat of the moment when a craving strikes, he explains. Tedeschi offers several possible substitutes for consideration: sugar-free gum, beef jerky, cinnamon sticks and even drinking straws cut into cigarette-sized lengths through which clients can inhale and exhale.

If clients are comforted by having something in their hands, Brooks suggests keeping a pen, stress ball or prayer beads nearby. Staying hydrated and carrying a water bottle can also help these clients, Tedeschi adds. Most of all, counselors should work toward the idea of replenishment and filling in where clients feel they are losing something, he says.

Don’t dismiss pharmacotherapy. A wide variety of quitting aids are available, from nicotine patches, lozenges and gum, to prescription pills such as Chantix. The counselors interviewed for this article agree that these stop-smoking aids can be helpful when used alongside counseling. However, Tedeschi says, counselors should work with their clients’ physicians when such medications are being used, or make sure that clients are talking with their physicians. Counselors should also be aware of the potential side affects that these medications can have, such as aggressive behavior.

Brooks notes that none of these options is a magic solution to quit smoking. For example, nicotine gum and other medications can be prohibitively expensive, and some clients can continue to smoke even while using nicotine patches or gum. As for electronic cigarettes, Sharif and Harms agree that they are not a recommended alternative. Electronic cigarettes are carcinogenic, addictive and mimic the “puffing” behavior of regular smoking, Harms notes.

Connect clients with other supports. Counselors should equip clients with resources they can turn to outside of counseling sessions, such as local support groups for ex-smokers or the phone number for their state’s tobacco quitline, Brooks suggests. Nicotine Anonymous (nicotine-anonymous.org) is an ideal resource for clients who are trying to stop smoking, Brooks says. The 12-step method at Alcoholics Anonymous (AA) can also be applied to tobacco use for clients who attend AA meetings already or who don’t have a Nicotine Anonymous support group in their local area, he adds.

Sharif suggests that counselors keep brochures and other information about quitting smoking alongside the materials they might have about depression or suicide prevention in their offices or waiting rooms. It is better for counselors to distribute information that they have vetted themselves rather than having clients search the internet for information on their own, she notes.

 

Try and try again

On average, it takes a smoker 10-12 attempts to fully quit cigarettes, according to Tedeschi. For that reason, it is imperative that practitioners not give up on clients after their first, second or even 10th try, he stresses.

Quitting smoking is hard, Tedeschi acknowledges, but possible with perseverance. “Don’t be discouraged as a clinician if your client relapses. [Quitting] is definitely not a one-time event; it’s a process. … Relapse prevention is important, but it’s equally important to be ready for the relapse,” he says. “One of the best things a counselor can give a client is that reassurance. Any attempt to quit for any length of time is a success rather than a failure. That’s just the reality of this addiction. As long as they keep trying, they’ll get there. The only failure is to stop trying. The most important message a counselor can give a client is to never give up.”

 

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Statistics: Smoking and mental health

  • Roughly 50 percent of people with behavioral health disorders smoke, compared with 23 percent of the general population.
  • People with mental illnesses and addictions smoke half of all cigarettes consumed in the U.S. and are only half as likely as other smokers to quit.
  • Smoking-related illnesses cause half of all deaths among people with behavioral health disorders.
  • Approximately 30-35 percent of the behavioral health care workforce smokes (versus 1.7 percent of primary care physicians).

— Source: U.S. Substance Abuse and Mental Health Administration (see bit.ly/1sEx97a)

 

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Resources

 

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

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.

Treating psychogenic nonepileptic seizures

By Jason Wright August 26, 2016

Imagine what it’s like to suffer from seizures that can strike anytime, anywhere. Imagine losing your driver’s license, job and social life because of seizures that seem to be uncontrollable. Imagine the emotional turmoil that ensues as these seizures take over more and more of what you once enjoyed, considered necessary or maybe even took for granted.

Now imagine your neurologist or epileptologist telling you there is no medical reason for your condition. The seizures have a psychological origin and are your brain’s way of coping with Branding-Images_seizuresemotional stress. Unlike what your primary care physician told you, your condition isn’t epilepsy, meaning all those drugs you’re taking to treat epilepsy are absolutely worthless.

Finally, imagine dealing with the skepticism of your family and friends now that they know these seizures are “all in your head — the doctor even said so.” This is a snapshot of what it is like for people who suffer from psychogenic nonepileptic seizures (PNES).

My first case

It was a Tuesday afternoon at my clinic, one of the week’s two “walk-in” days in which both regular and new clients could see a clinician without an appointment. On this particular day, a young woman in her 20s (I’ll call her Charleen) walked in, trembling and barely able to speak. All our clinicians were busy, but the receptionist told her that if she had a seat, someone would be with her shortly. The front office staff said she seemed slightly disoriented and not fully able to explain why she was in our office or who had referred her.

After I finished another client’s session, I walked into the waiting room and introduced myself. Charleen made no eye contact, and about a minute into our conversation, she told me she had to leave and return home to “take her dogs out.” She assured me that she would be back, however. Later that day, she called the office and made an appointment with me for the following week.

During that appointment, Charleen told me she had been suffering from PNES and anxiety, and that a local mental health agency had referred her for those conditions. She had left so abruptly the day she walked in because she was on the verge of having a seizure episode and didn’t want to have it in my office. She then tearfully proceeded to tell me about her life, and losses, with PNES, which included the experiences mentioned at the beginning of this article.

Although I was aware of PNES, I had never worked with anyone diagnosed with the condition. With more than 20 years of experience as a licensed counselor, however, I had extensive experience with clients struggling with anxiety. There were no other places that worked with PNES within a reasonable distance for Charleen, so I agreed to become her counselor. I began reading everything I could get my hands on related to PNES, starting with Psychogenic Non-epileptic Seizures: A Guide, by Lorna Myers, and even attended an online training given by Myers.

My work with Charleen progressed nicely, and I began to contact other referral sources in my area for more PNES cases. The treatments I used were bringing impressive results to a condition that, as I found out later, many clinicians feared. As the successes continued, I contacted Myers, director of the PNES Treatment Program and the Clinical Neuropsychology Program at the Northeast Regional Epilepsy Group in New York, to be placed on the national referral registry for PNES. Given the dearth of providers for PNES, I began getting referrals from other states. My zeal for working with PNES sufferers has continued to grow since that time.

Diagnosis

Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not include the acronym PNES, it does describe the condition as a conversion disorder (functional neurological symptom disorder) “with attacks or seizures” (F44.5). Professionals treating the condition most often use the acronym PNES, but NEAD (nonepileptic attack disorder) is also used on occasion.

The DSM-5 diagnostic criteria for psychogenic seizures include “altered voluntary motor or sensory function” that do not have a medical or neurological origin and are “not better explained by another medical or mental disorder” and that cause “clinically significant distress” in all facets of life. The term pseudo-seizures is often used to describe this condition. This is inaccurate, however, because there is nothing fake (or pseudo) about these seizures. PNES is not the same as malingering (looking for secondary gain) or factitious disorder (an attraction to being ill). Individuals who experience PNES subjectively believe and feel that they do not have control over their condition.

Several tests can help rule out seizures with a medical origin. The gold standard for diagnosing PNES, however, is the video EEG, a test that measures brain waves. During a video EEG, the person is admitted to an inpatient facility and observed for an extended period of time (generally multiple days). Whenever a seizure occurs, the brain’s electrical activity is analyzed. When a seizure has a medical origin, the EEG will display abnormal brain wave activity. In the case of PNES, brain wave activity remains unchanged during the seizure. Currently, this is the only way to reliably diagnose PNES.

In some cases, individuals who suffer from psychogenic seizures may also have epilepsy or experience other medically oriented seizures. In their paper “Defining psychogenic non-epileptic seizures,” Selim Benbadis and Valerie Kelley write that “about 10 percent of patients with PNES also have epilepsy.”

Traumatic experiences and treatment options

In most cases, sufferers of psychogenic seizures have endured at least one significant traumatic experience in their past, often including sexual victimization. Whatever the traumatic experience may be, psychogenic seizures are believed to serve as a psychological shut-off valve of sorts when sufferers become emotionally distressed. The stress may be due to external circumstances (e.g., social anxiety, job stress) or internal stimuli (e.g., flashbacks from traumatic experiences, hallucinations). It is common for PNES to occur comorbidly with other psychiatric conditions such as posttraumatic stress disorder (PTSD), dissociative disorders and anxiety disorders.

What can counselors do to help those suffering from psychogenic seizures? There are several treatment options to consider.

Psychoeducation: Psychoeducation is extremely important for those suffering from PNES because many of the clients who seek counseling do so only after years of unsuccessful treatment for epilepsy or other medically oriented conditions. They are typically referred to counseling after finally being successfully diagnosed by an epileptologist or neurologist but still may not have a proper understanding of how something that seems to have a medical origin is actually psychological in nature. Proper education for clients and their loved ones will help minimize the confusion and stigma that are often associated with this condition.

Journaling and mindful awareness: This phase of treatment involves clients learning two vital exercises: keeping a seizure journal and mindful awareness.

Before individuals become incapacitated by psychogenic seizures, they generally report a variety of prodromal symptoms, including trembling, headaches, dizziness and fatigue. The typical response one feels when a seizure is approaching is to become more anxious. This response is logical, especially considering the havoc and disruption the seizures have caused in the person’s life previously. However, an increase in stress is exactly what makes psychogenic seizures more likely to occur (stress and anxiety typically activate the seizure to begin with). Therefore, learning how to be mindful of prodromal symptoms is vital for the person to do what is necessary to avoid progression to a full-blown seizure — namely, by practicing anxiety and stress reduction.

Keeping a record (a journal) of seizure activity and each seizure’s antecedents will provide the client and counselor alike with vital information regarding when and where seizures are most likely to occur. This also keeps the client and counselor informed on therapeutic progress. Seeing one’s successes on paper can be inherently motivating and help foster the confidence that is so beneficial in combating anxiety and stress.

Anxiety/stress reduction: The next phase of treatment includes a variety of well-established and empirically verified interventions aimed at minimizing stress and reducing anxiety. This can be extremely effective in halting seizure progression.

I have found that a combination of deep breathing, progressive muscle relaxation and positive visualization can help reduce anxiety significantly. This intervention is the first choice for many of my clients suffering with PNES. Cognitive restructuring, including the recognition of stress-inducing schemata, identification of limited thought patterns and utilization of balancing thoughts that directly counter stress-inducing schemata, can also be effective in controlling anxiety and stress. Learning conflict resolution skills and receiving anger management counseling may be helpful for clients whose stress occurs more as anger. In short, by helping clients find the interventions that keep their stress levels low, counselors will give those who suffer with PNES the best chance to gain control over their seizures.

Biological considerations: Despite the psychological and emotional antecedents to psychogenic seizures, it is also important to consider physiological themes during treatment. Dietary factors are an element that deserves strong consideration in the treatment of nonepileptic seizures. When these issues affect seizure activity, they are referred to as physiogenic seizures.

I have found that many clients who suffer from psychogenic seizures also struggle with physiogenic seizures. For example, many PNES clients who regularly consume coffee will acknowledge that caffeine makes their seizures more likely and that reducing or eliminating its use is beneficial. This is most likely because caffeine stimulates the nervous system, increasing the possibility of elevated stress and anxiety levels and, thus, psychogenic seizures. In addition, avoiding foods with a high glycemic index will help to ensure that blood sugar levels remain stable. Unstable blood sugar levels can lead to hypoglycemia (low blood sugar), which, according to the Epilepsy Foundation, can trigger nonepileptic seizures.

Within the biological sphere of consideration, many patients find psychiatric medications to be beneficial. This is likely because the correct medications will help foster an emotional/mental state that reduces the likelihood of seizures occurring. It is important to note, however, that psychiatric medications do not treat the seizures directly. As is the case with other conditions, when a client with PNES is receiving treatment from a psychiatrist or other provider, it is very important for the counselor to keep open lines of communication with all said providers. In some cases, a change in psychiatric medications, or the addition of other medications, may result in an increase in seizure activity. It is necessary for the counselor to know what medication changes may have preceded the client’s seizure surge.

Working through trauma: A final phase to strongly consider when treating PNES is helping clients work through traumatic experiences. This phase of treatment can include a wide range of established interventions such as journaling, the empty chair, autogenic training, systematic desensitization and even family therapy, although many other effective interventions also exist for this stage. Myers suggests that the use of prolonged exposure may be helpful in the treatment of PTSD and may also be used to treat psychogenic seizures. At times, treatment will be more challenging depending on how many comorbid conditions are present.

In my experience, I have found that some clients will gain considerable control over their seizures before this final phase and will even opt out of this phase of treatment. As a client-centered clinician, I must respect a client’s choice to end therapy before this stage, although I always explain the potential benefits (and drawbacks) of engaging in this material.

Conclusion

As a clinician, I have found working with those suffering from PNES to be a very rewarding experience. It is a wonderful thing to watch these clients gain more confidence and hope as they slowly and methodically reduce their seizures and begin to regain what they lost while buried in the throes of their unfettered condition.

In their article “Psychogenic (non-epileptic) seizures: A guide for patients and families,” Selim Benbadis and Leanne Heriaud suggest that the competent treatment of PNES will result in the elimination of seizures in 60 to 70 percent of adults, and the results for children and adolescents may be even more impressive. The treatment of PNES is evolving as research continues. But the numerous empirically validated treatment options currently available to competent counselors can be just what PNES clients need to begin the journey of gaining hope and confidence, reducing seizure activity and taking back their lives from the grip of psychogenic seizures.

 

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Jason Wright is a licensed professional counselor and licensed marriage and family therapist at the HumanKind Counseling Center in Lynchburg, Virginia. He holds a doctorate in counseling. Contact him at dothejcbeat@aol.com.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines, sample articles and tips for getting published in Counseling Today, go to ct.counseling.org/feedback.

 

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