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Living with — and beyond — OCD

By Bethany Bray January 24, 2020

In popular culture, obsessive-compulsive disorder (OCD) is often portrayed through characters who can’t bring themselves to step on cracks in the sidewalk, who are germaphobes, or who are obsessed with cleanliness and organization. These “hang-ups” are often played for comic effect.

“There’s a huge misconception that OCD is cute and quirky,” says Shala Nicely, a licensed professional counselor (LPC) with a practice in Marietta, Georgia, who specializes in treating OCD and related disorders. “There’s nothing further from the truth. That [stereotype] keeps people from seeking help. They think they just need to ‘get it together’ and deal with it.”

In reality, OCD can be debilitating, says Nicely, who has lived with the disorder since she was a child. Individuals with OCD are haunted by unwanted and invasive thoughts that are often self-critical, fear-inducing or disturbing. One of the classic portraits of OCD is the person who won’t touch a doorknob without a sleeve pulled over their hand out of fear of contracting germs. But that is only the tip of the iceberg when it comes to the different types of compulsions — whether external, such as repeated hand-washing, or internal, such as rumination — that individuals with OCD feel subjected to in order to keep themselves safe.

OCD can be “hell on Earth,” Nicely asserts.

“It puts people in absolute misery. It makes people’s lives smaller and smaller and smaller,” she says. “Having OCD is like living with an abuser 24/7. It’s incredibly mean, it’s very critical, and [it] can be violent. It is being yelled at by your own brain and you can’t get away from it.”

The tipping point

Justin Hughes, an LPC who owns a private practice in Dallas, specializes in treating clients with OCD, anxiety and other mental health issues. He says many of his clients seek treatment because they are overwhelmed by intrusive thoughts or because their compulsions and routines are interfering with their daily life — taking up enormous amounts of time and causing them stress or even physical pain. Other clients come to treatment because a parent, spouse or loved one noticed the toll that OCD was taking on the person and expressed concern.

Karina Dach, who specializes in treating OCD and anxiety at her private practice in Denver, says clients sometimes come to counseling knowing that “something doesn’t feel right” but without realizing that they have OCD. “They may say things like, ‘I feel stuck,’ ‘My brain won’t let me move on,’ or ‘I can’t stop thinking about this or imagining this.’ They might feel like something is wrong with them or worry that these thoughts and fears mean something bad about their character or them,” explains Dach, an LPC and licensed mental health counselor.

Clients who come to counseling with OCD may be struggling with self-criticism and intense feelings of shame, guilt, anger, worry and fear, Nicely adds. Intrusive thoughts are common with OCD, and for some people, these thoughts can involve the idea that they might somehow end up killing, injuring or sexually molesting someone, including their loved ones. As these thoughts repeat themselves over and over, the individual may begin to believe the content of these thoughts and feel a deep sense of shame or embarrassment.

In fact, clients struggling with OCD may be hesitant to share the worst of their intrusive thoughts because they can involve things that are criminal or dangerous. “Some [individuals with OCD] really do think they might be a closet murderer. They’re afraid to share that, [thinking that] they might get in trouble,” Nicely says.

Given that insight, Nicely says, counselors should not hesitate to follow up conversations about intrusive thoughts and worries in session by asking clients if there is anything else they have been too scared to share. These clients should be reassured that counseling is a safe and confidential place to share whatever they are going through, Nicely adds.

Obsessions + compulsions

The National Institute of Mental Health reports that an estimated 1.2% of U.S. adults experience OCD each year. This prevalence is higher for females (1.8%) than for males (0.5%). The lifetime prevalence of OCD in the U.S. is 2.3%.

Jeff Szymanski, a clinical psychologist and executive director of the International OCD Foundation, notes that even though the prevalence of OCD is not increasing, mental health practitioners may see more people who struggle with the disorder in their caseloads in the future because of a gradual, general increase in awareness and a reduction of stigma regarding
the disorder.

OCD is characterized by two components: 1) recurring and intrusive thoughts (obsessions) and 2) excessive urges to perform certain actions over and over again (compulsions) to prevent or counteract the recurring thoughts. The types of obsessions and compulsions that individuals with OCD can experience are wide-ranging.

Not all recurring thoughts can be categorized as OCD obsessions, Szymanski stresses. “Obsessions in OCD are also ego-dystonic, meaning that the individual doesn’t like or want them. … Some recurring thoughts people like to have,” he says. “In lay language, people say things like ‘I’m obsessed with baseball.’ This means they like baseball. They may even spend a lot of time ‘compulsively’ following baseball. But this doesn’t interfere with their life, and it is something that is invited, not something they are trying to get away from.”

OCD-related obsessions can include unwanted sexual thoughts, religious obsessions, fear of contamination (by dirt, germs, chemicals or other substances), fear of losing control of yourself, fear of being responsible for harm to oneself or others, fear of illness, and myriad other concerns. Compulsions can involve:

Washing and cleaning tasks (including personal hygiene)
Checking behaviors (such as checking news headlines over and over to ensure that nothing terrible has happened, or checking multiple times that a door is locked)
Repeated actions such as blinking or tapping
Performing certain actions multiple times (e.g., opening and closing doors, going up and down stairs)
Asking questions (possibly to include the same or similar questions over and over) to seek reassurance
Internal actions such as repeated prayers, counting rituals, and repeated mental review or replaying of past scenarios and interactions

(Get an in-depth explanation of OCD from the International OCD Foundation at iocdf.org/about-ocd.)

“If a counselor begins hearing the exact same things [from a client in session], worded or behaved in similar ways, this is a good indicator [of OCD] to watch out for,” Hughes says. “Many of my clients are good at exactly quoting themselves on what they’ve said before. Obsessions are repetitions on a theme; if you get good at catching the theme, you can usually spot an obsession miles away.”

Compulsions can also involve avoidance behaviors. For example, Dach once had a client, a new mother, who was experiencing intense thoughts and fears about harming her baby. She would avoid interacting with her child — particularly being in the bathroom with the child while he was being bathed — because she felt it was safer to be away from him.

OCD-related avoidance can spill over into the life choices that clients make, such as where they work or live, what their hobbies are or even the words they use, Dach says. Individuals with OCD sometimes exercise another form of avoidance — breaking up with a partner because they fear the doubt, uncertainty and risks involved in having a relationship. However, they soon find that ending the relationship doesn’t quell their rumination, Dach notes.

Individuals with OCD “operate on a risk-adverse level,” explains Dach, a member of the American Counseling Association. “You find them checking a lot, asking for reassurance, accommodating their fears and compulsions. … It’s terrifying and it takes over people’s lives. We see OCD as this mental bully. You are a complete prisoner to your fears. People with OCD just want to protect themselves and their loved ones.”

Obsessions are often a reflection of a person’s deeply held values, such as being a good parent, keeping their family safe, or being a good person, Dach notes. Focusing on these values can be a source of leverage when counseling clients with OCD. When working with the new mother who had intrusive thoughts about harming her child, Dach talked with the client about how her fears were based in the values she possessed of wanting to connect with her child, be a good mother and keep him safe.

“If you can find what the client’s values are, that can be very powerful,” Dach says. “Maybe you fear rejection and failure but value excelling in a career. Finding those values can make a really clear [therapeutic] path to work on and find motivation.”

Several of the counselors interviewed for this article recommend that practitioners use the Yale-Brown Obsessive Compulsive Scale to assess clients for OCD and to get a full evaluation of clients’ obsessive thoughts and compulsive behaviors. If clients identify numerous behaviors and thoughts that they experience from the assessment’s detailed checklist, counselors should work with them to “triage,” creating a plan of care to address their most pressing or concerning issues first, Nicely says. Seeing the fearful thoughts and tortuous behaviors that they’ve been experiencing included on the checklist can serve to normalize clients’ experiences and demonstrate that they aren’t alone in their struggles, she adds.

Distinguishing OCD

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders categorizes OCD under a cluster of diagnoses that also includes body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder.

OCD can be complicated to identify because the disorder often co-occurs with other issues such as bipolar disorder, anxiety-related disorders, depression, eating disorders and substance abuse, notes Nicole Hill, an LPC who co-authored an ACA practice brief on OCD. Because clients with OCD often struggle with multiple presenting concerns, the disorder can be hard to pinpoint. In addition to delving into these clients’ distress, counselors should complete full biosocial assessments to get a clearer picture of their life and family history, social landscape, early childhood experiences and other contextual factors, says Hill, a professor and dean of the College of Education and Human Services at Shippensburg University in Pennsylvania.

Although there is no one particular cause of OCD, research indicates that there may be a number of contributing or correlating factors, including genetics and family-based factors, autoimmune issues, and the brain structure involved in transmission of serotonin. Being aware of the client’s full context — especially whether other family members have OCD — can provide counselors a better understanding of the person’s experience and risk factors, says Hill, an ACA member who co-authored a chapter on OCD and related disorders in the 2016 book Diagnosing and Treating Children and Adolescents: A Guide for Mental Health Professionals.

OCD is easier to pinpoint in clients who describe overt compulsive behaviors, such as checking the weather forecast repeatedly. Asking questions to probe the depth and root of clients’ fears can help uncover mental compulsions that aren’t as immediately noticeable, such as mentally reviewing the activities of their day over and over again, repeating a conversation or a word to themselves a certain number of times, or saying a certain prayer repeatedly, Dach says.

To probe clients’ experiences, Dach suggests counselors begin by asking how they deal with stress and anxiety. It is certainly normal for people to experience anxiety from time to time, and it is true that individuals with anxiety disorders may be confronted by intrusive thoughts, ruminate, and perform certain coping behaviors. With OCD, however, the worry, fear and compulsive behaviors become so all-encompassing that they impair the individual’s ability to function. For example, most people wash their hands to keep from getting sick, but individuals with OCD may wash their hands a certain number of times, for a certain length of time, or until it feels “right” to them, Dach says.

“We all have this inner voice that’s telling us what’s safe and not safe. But someone with OCD has a faulty alarm system. They’re more vigilant. A whole battle can be happening internally on what’s safe and what it takes to be safe,” Dach explains.

To uncover compulsions that are internal (and, thus, less apparent to others), Dach suggests asking clients questions along the following lines:

Are there words or statements that make you feel better or that you say to yourself? Do you do something a certain number of times in your mind until it feels right?
When you’re lying in bed, is that when your mind wanders the most? What are you thinking about? Is it about your day and what you could have done differently? What you
did wrong?
When you enter a room, what’s the first thing you do? Do you beeline straight to where you need to go, or do you scan the area first to feel safe?

From there, Dach suggests asking clients what would happen if they weren’t able to complete whatever action they felt compelled to perform. “If there is clear distress in their answer, that may indicate OCD,” she says.

Another indicator that OCD may be present is if the client doesn’t respond to methods that counselors typically use to help individuals with their negative thoughts, says Hughes, the Dallas-Fort Worth advocate for OCD Texas, a regional affiliate of the International OCD Foundation. “If a client isn’t improving from certain methods — especially things like cognitive restructuring in cognitive behavioral therapy — this is ‘Getting Stuck 101’ and needs further assessment,” Hughes says. “Most of my clients have had prior experience with a counselor who had no idea how to treat OCD from an evidence-based way and approached it the same as regular old automatic negative thoughts. This is not typically helpful.”

OCD is disruptive, not only to the individual’s ability to function but also to their family life, says Hill, whose past clinical work included treating juvenile clients with OCD via play therapy. Parents and families often restructure their routines or make accommodations to work around a loved one’s compulsive behaviors, especially if the individual with OCD is a young child. OCD behaviors can be very concerning to parents and, in some cases, embarrassing in public situations. In making accommodations, the family typically feels like they are doing what they can to help the person, but that approach is actually counterproductive, Hill says. In reality, accommodating or yielding to OCD behaviors can exacerbate the issue.

Counselors shouldn’t hesitate to involve a client’s family in OCD treatment (if applicable and with the client’s consent) or to reach out to collaborate with social workers, family counselors or other professionals who may be working with the family, Hill says. Counselors can play a vital role in educating parents and family members about what an OCD diagnosis entails and clarifying the therapy goals for their loved one. They can also offer helpful, nonaccommodating ways to intervene when the person’s OCD spikes. Hill says that in her past work with juvenile clients, she often saw the severity of OCD decrease when she used filial play therapy with children and parents. This approach served to bolster their relationship, problem-solving skills and communication patterns. It also instilled a focus on positive behavior and empowering the child, she says.

Working with other treatment providers

Research has shown that a combination of therapy and psychiatric drugs, especially exposure and response prevention (ERP) therapy and serotonin reuptake inhibitors, can be particularly helpful to people with OCD.

“Attending to clients’ socioemotional and cognitive issues [in counseling] will be helpful, in addition to medicine,” Hill says. “Research consistently shows that the both/and approach is best, with medication and therapy.”

Medicine can “turn down the volume” on clients’ OCD so that therapy can help them manage their rituals and compulsions, says Nicely, who estimates that three-quarters of her clients take medication. Eventually, if clients and their prescribers agree it is the best course of action, their medications can be tapered back as their coping skills are strengthened in counseling.

Although professional counselors cannot prescribe medications, they must always consider their clients’ use of medications — and be proactive in working with clients’ medication prescribers — when looking at the whole picture of treating OCD. With clients’ consent, counselors can check in with these other treatment providers about clients’ symptoms and progress in counseling.

“I always worked on a team with other professionals,” says Szymanski, who was previously the director of psychological services at McLean Hospital’s OCD Institute in Massachusetts. “It is important to ensure that some time is spent coordinating care and that everyone’s work is complementary and not getting in the way of each other. It is equally important to inquire from the client how the team format is working for them and to ask them for specific feedback and encourage them to give direct feedback to each of their team members.”

Coordinating care among multiple treatment providers can be challenging, but it is worth it to work toward the best outcome for the client, Hughes asserts. Even imperfect, one-way communication stands to benefit the client.

“Although seamless communication and record exchange between providers is likely ideal, it just rarely happens in real life,” Hughes says. “In complex cases, it is almost unheard of for me to not [reach out to] another provider that is connected somehow to shared treatment concerns. I think we need to be realistic about other providers’ schedules and to communicate what we can, how we can. This often looks like me leaving a psychiatrist a voicemail after release is given and not hearing back, but at least they have the information.”

In addition to professionals who prescribe them medications, clients may be seeing other practitioners for treatment of issues such as depression and substance abuse that often co-present with OCD. This offers opportunities not only to coordinate care but also to make other health care professionals who do not specialize in OCD treatment aware of the disorder’s nuances. These professionals can also be alerted to the pitfalls of inadvertently undermining the client’s work in counseling by feeding their compulsions through accommodation or reassurance, Hughes says.

Many other comorbidities in clients will often improve by treating their OCD first, Hughes adds.

Exposure and response prevention

Research has identified ERP, a type of cognitive behavior therapy, as the most helpful and effective therapeutic method for treating OCD. All of the counselors interviewed for this article recommend its use with clients who have OCD. The International OCD Foundation refers to ERP as the “gold standard” for treating OCD and more helpful than traditional talk therapy methods.

In ERP, clinicians use gradual exposure to desensitize clients to the OCD-related thoughts, compulsions, situations or objects that are invoking fear and worry in them. With each exercise, the client works to overcome a triggering thought or scenario without responding with a compulsive action. This is the “response prevention” part of ERP. Exposure work is done both in session with a counselor and outside of session as homework for clients to complete on their own.

Counselors should be aware that clients’ OCD is likely to spike as they begin ERP treatment, Nicely says, because it removes the compulsions that have given them reassurance in
the past.

Over time, ERP empowers clients to confront thoughts and situations that they often would have tried to avoid previously, Dach says. “When someone has intrusive thoughts, they tend to [try and] push them away, and it effectively boomerangs. Pushing things away and trying to avoid them only empowers [the OCD] and gives it too much value,” she explains. “This [ERP]
puts them in the driver’s seat. They are the driver, instead of the fear deciding their choices.”

With the new mother mentioned earlier in this article, Dach used incremental exposure exercises to help her overcome her fear of harming her baby. At first, the baby was left outside of the counseling room with a caretaker while the client met with Dach. They started small, exposing the client to words that were triggering, such as “baby” or “bathing.” As the client progressed, Dach asked her to bring the baby into sessions. Even taking the baby out of his car seat and putting him on her knee was triggering to the client at first, Dach recalls. Dach would talk the client through each exercise, asking her throughout to monitor her level of distress on a scale of 1 to 10.

Eventually, the client graduated to exercises that included changing the baby’s diaper in session. In time, the client was able to work toward bathing her child at home, which had been one of her most fear-inducing obsessions.

Giving clients exposure assignments to work on between sessions is a critical part of ERP, Dach says. This can include creating a “worry script” in which clients write out imagined worst-case scenarios for themselves. For example, for one client, the scenario might involve going to the mall or another public place and losing control of themselves so that they vomit or yell and cause a scene, Dach says. The client imagines everyone staring at them, the client dying of embarrassment and then being banned from the mall. The client writes out all of the details of what they are feeling, seeing and experiencing in this imagined scenario. Next, the client reads or rewrites the story script repeatedly or records themselves reading it and listens to the recording over and over, Dach explains.

“It’s like watching a scary movie 1,000 times. It might be scary when you watch it the 1,000th time, but [it’s] not as terrorizing as the first time,” she says.

Dach uses the metaphor of working at a garbage facility to explain the effectiveness of ERP: On your first day, you notice the smell of the garbage and it’s so disgusting to you that you can’t even eat your lunch. But the smell bothers you less and less as you return to work each day and, eventually, you barely notice the smell at all.

ERP is granting permission “to open the doors to your dungeon and hang out with all these skeletons that you’ve got hiding in there,” Dach says. “If you grab your sleeping bag and pillow and hang out in there, eventually you’ll be more comfortable being around them.”

Hughes recalls one client with OCD who was struggling with severely distressing thoughts about harming her children. The client had no history of harm or abuse. Over time, the client found it difficult to differentiate between reality — that she would never intentionally hurt her children — and her intrusive thoughts about having impulses to stab her children, Hughes says.

“She knew [these fears] were irrational, yet it felt so real to her,” Hughes says. “As can be very typical, the stress also took a toll on most every area of her life, [including] making work difficult.”

ERP work began with small exercises the client learned to conquer while staying present with her distress and without turning to compulsions, Hughes says. The client was able to integrate ERP assignments into her daily life with the support of her loved ones, church community and her own desire to be able to engage with her family without fear of harming them.

She soon graduated to script writing and larger exposures that involved holding knives and stating her feared thoughts aloud (appropriately and not in front of her young children), Hughes says. For example, the client would work outside in the family garden and repeat to herself the worst-case scenario she had written in her scripts: “I’m wanting to use these yard tools to kill my daughters.” Later, she added more distressing content: “I want to stab them, and I’ll get arrested and divorced and be hated by my kids.”

Other exposures involved holding a butcher knife firmly for 15 seconds at a time (and eventually longer) while repeating her scripts. Over time, the client worked toward being home alone with her children, bathing her children, and ultimately cooking for her children (including using knives) while her husband was out of town.

Now the client’s OCD symptoms score so low on the Yale-Brown Obsessive Compulsive Scale that she would be considered subclinical, Hughes says. “In relapse prevention planning, [this client] understands the chronic nature of OCD and the necessity of staying on top of her good progress, with the plan to follow up at occasional intervals for ‘booster sessions,’” Hughes says. “I gain so much joy from stories like these.”

Tolerating uncertainty

ERP is effective because it empowers clients to tolerate the uncertainty that is at the core of their fear and worry, Nicely explains. The crux of the problem is not a client’s worry over contracting HIV or stabbing their husband, she says, but tolerating the uncertainty of whether or not those fears might happen.

“The hallmark question of OCD is ‘what if’ and having doubts,” says Nicely, the author of the 2018 book Is Fred in the Refrigerator? Taming OCD and Reclaiming My Life. Treating only the content of a client’s worries without teaching the client to tolerate uncertainty will simply lead the OCD to surge (or resurge) in another area of the client’s life, Nicely notes.

For ERP to be effective, it requires commitment and trust between the client and practitioner. Nicely explains to each client that the work requires a cognitive shift — that trying to avoid anxiety and OCD triggers actually makes them worse.

In working with clients with OCD, Nicely uses the acronym JOY: Jump into anxiety, opt for greater good, and yield to the anxiety. Nicely goes into detail about this method in the 2017 book she co-authored with Jon Hershfield, Everyday Mindfulness for OCD.

She asks clients, “What if we didn’t push the anxiety away? What if we brought it toward us? Can you handle it?” Then she points out an example of how the clients are already handling uncertainty by taking the first step of coming to counseling. Bringing anxiety toward them is equal to taking away OCD’s power, she explains.

Nicely books a double session with clients for their first exposure treatment. After the exposure work, they process what happened together. Nicely asks questions such as: Was it as hard as you thought? What did you learn? Did you learn that this is something that you can do to get your life back?

“If you do [triggering things] over and over again, then the brain begins to learn that these things aren’t the problem,” Nicely says. “The reason that our brain is putting these thoughts up front is because we’re reacting to them. The brain is learning when you’re allowing it to stay at a high level of anxiety.”

“OCD is a biological issue,” she says. “Our brains [in those with OCD] are structurally and functionally different than those without OCD. You can’t think your way out of this. It’s a brain disorder, and ERP changes the way our brain functions.”

Nicely uses a concept she calls “shoulders back” with both herself and her clients. She says that squaring one’s shoulders can serve as a physical reminder that whatever a person’s OCD is telling them, it doesn’t matter, and they can act as if it’s irrelevant.

“Ultimately, we want people to hear all of this [OCD triggers] in their heads and go on and have it bother them less and less,” Nicely says. “We want them to live in a world of uncertainty and not have it bother them and act as if their intrusive thoughts don’t matter.”

It can also be helpful for clients to imagine what their OCD “monster” looks like or even to give it a name. Nicely does that herself, even speaking to her OCD when it begins to surge. Nicely thinks of her OCD as something that will always be a part of her. It’s something that, at its core, wants her to feel safe.

“It’s exceptionally important [for clients] to realize that OCD is part of them, but it is not them,” she says. “That will help them to conceptualize the process. Think of it as something that has been torturing you. Talk back to it and tell it where you want it to go.”

Reassurance

The compulsions associated with OCD often arise out of a person’s urge to find reassurance and feelings of safety, Dach says. As helping professionals, counselors’ natural reaction may be to try to comfort these clients by telling them that their worst fears will not come true. But in the case of clients with OCD, offering reassurance is actually doing harm and reinforcing behavior, Dach stresses.

“No one knows whether or not the fear will happen — not the therapist [and not] the client. But the client will search and search and search for reassurance, an illusion of security and control,” Dach says. “If a practitioner gives them reassurance, they’re making the condition worse.”

When Dach finds clients asking questions as a means of seeking reassurance in sessions, she explains that she will answer questions to provide education or information but not for the purposes of offering reassurance. “It may be a hard pill to swallow, but we [counselors] need to sit with their uncertainty together and model what it looks like to sit with distress,” Dach says.

When clients express anxiety over the possibility of vomiting in a public place or some other OCD-related fear coming true, counselors shouldn’t reassure them that it won’t happen, Dach says, because there is no way to ensure that it won’t. Instead, she says, counselors can respond with questions such as, “If you did vomit, what’s the worst thing that could happen? What would it feel like? How do you know it’s going to happen?”

“The possibility is there, but the probability is low,” Dach says. “I can’t tell [the client] whether or not something is going to happen. The best we can do is put ourselves in a situation [via exposure] to learn what’s going to happen. Then I offer to lean into that discomfort [with the client].”

On the same team

There is sometimes a misconception among mental health professionals that exposure work can traumatize clients, but that simply isn’t true, Dach stresses. Therapy with a practitioner specially trained in ERP is hard work — it’s asking a client “to walk into their worst nightmare and have a party” — but it’s also incredibly effective and rewarding, she says.

“This is an extremely collaborative intervention. We’re on the same team. It’s not forcing [clients] to do things. It is asking them to get close to the thing they’re afraid of the most. You [the counselor] are there to offer gentle pushing, but it’s all choice-based,” Dach says.

Nicely and Hughes say that clients with OCD tend to be incredibly brave and also deeply caring. It is inspiring, Nicely says, to watch clients tackle such hard things in therapy and become more resilient.

“For many reasons, I love work with clients who have OCD,” Hughes adds. “I have found that they are some of the kindest, hardest-working and most conscientious individuals on this planet. This is where I believe many of their personality strengths arise once [they move] through pathology. It is a joy every day to see recovery, growth and maturity bloom out of suffering.”

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The International OCD Foundation offers a wealth of resources and information on its website, iocdf.org, as well as training programs, an annual conference, and local affiliates around the country.

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Contact the counselors interviewed for this article:

Karina Dach: anxietyocdcounseling.com
Nicole Hill: NRHill@ship.edu
Justin Hughes: justinkhughes.com
Shala Nicely: shalanicely.com

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OCD is not an adjective

It’s not uncommon for people to describe themselves in casual conversation as “obsessed” with a television series or “OCD” about the way they organize their closet.

Professional counselors can be agents of change when it comes to casual use of the language related to obsessive-compulsive disorder (OCD), says Shala Nicely, a licensed professional counselor in Georgia who specializes in treating the disorder. She encourages counselors to be mindful of their own language and to gently correct those who misuse OCD-related terms.

One place to begin: Stop using OCD as an adjective, she says. Someone might be meticulous or detail-oriented or neat, but he or she is not “OCD.” To say “I’m so OCD” about something can discourage people who really do have OCD from seeking treatment, especially if that offhand pronouncement comes from a mental health professional, Nicely says.

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Bethany Bray is a senior 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.

Parent-child interaction therapy for ADHD and anxiety disorders

By Donna Mac March 6, 2019

When one hears the term “parent-child interaction therapy” (PCIT), it might be assumed the therapy’s purpose is solely for that specific use — i.e., for parents to use with their children. However, this couldn’t be further from the truth. In fact, PCIT can be used in therapy sessions, then the therapist can teach the child’s teacher how to use PCIT in the school environment and, of course, the therapist can teach parents how to use these skills at home and in community settings, all in an effort to coordinate and synchronize treatment across settings.

Sheila M. Eyberg developed PCIT in the 1970s out of the University of Florida. It was built from multiple theories of child development, including attachment, parenting styles and social learning. In the past, PCIT was intended mostly for children 2 to 7 years old with disruptive emotional disorders and behavior disorders such as attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder. The purpose of PCIT was to work on rapport building and to enhance the relationship between the child and parent, for the child to develop more intrinsic motivation to comply and for the parent to develop more positive feelings toward the child — a cycle that can then be positively repetitive.

In addition to disruptive disorders, PCIT also seems to help children with anxiety disorders. In particular, there is research demonstrating its efficacy with the anxiety disorder of selective mutism. Therefore, clinicians have also begun using it for social anxiety disorder, social phobia, school phobia and agoraphobia. In school and community settings, PCIT is used as an antecedent intervention that helps shape the environment to create an emotionally safe space for these types of anxiety disorders to be more effectively managed. (It should also be noted that PCIT can be used to treat ADHD and anxiety beyond age 7 with simple modifications.)

The goal of this therapy is to produce more prosocial behaviors, regardless of the diagnosis. For example, with anxiety disorders that specifically manifest as a fear of being around people or communicating with others, the goal is for the child to be less inhibited and avoidant. The child’s symptoms might include struggling to leave the home, averting eye contact, displaying a shrinking body posture and having frozen reactions, both in terms of a lack of verbal response and a lack of body movement (think of a “deer in the headlights” appearance). The goal in such cases is to help these children manage their symptoms so they can present in a socially expected manner.

On the other hand, children with ADHD can present as too disinhibited, demonstrating hyperactive, impulsive, incessant and intrusive behaviors, so the goal is to adjust those behaviors to be more inhibited.

Subsequently, the PCIT goal for both of these populations is to produce more desired social behaviors, which will lead to better social outcomes, thus perpetuating the cycle in a positive manner. When children receive positive social feedback, they are likely to keep using these skills in an effort to continue engaging in positive interactions.

Addressing self-esteem

PCIT is a relationship-enhancing therapeutic technique. The concepts from this therapy that I use with children who have either ADHD or avoidant anxiety disorders revolve around Eyberg’s child-directed interaction (CDI) and PRIDE skills. CDI and PRIDE go hand in hand and, when combined, have been shown to build rapport with the other person and build confidence and self-esteem within the child (in an effort to manage both disruptive and anxious-avoidant behaviors). If a child feels comfortable with a certain relationship, that child may feel more valued, worthy and confident and have stronger self-esteem. As a result, the child will be less anxious, better able to manage disruptive impulses and more likely to use expected social skills.

Children with ADHD often struggle with their self-esteem because of the amount of negative feedback they tend to receive on a daily (or more frequent) basis: “Don’t touch everything in this store.” “Stop asking me if we can go to the pool.” “Leave your sister alone.” “Why can’t you just behave?” Yet if a child receives positive feedback versus corrective feedback in an approximate ratio of 4-to-1, the child will be more likely to comply with the directive to “stop asking that question,” to “leave your sister alone,” etc.

Children with the avoidant types of anxiety disorders also struggle with self-esteem because of the negative judgments they assume and perceive that others are making about them. When these children receive praise, it helps them feel less anxious. In turn, when their brains are stabilized, they are more able to use their actual abstract counseling strategies (such as cognitive behavior therapy, or CBT) on themselves to manage their anxiety and actually “leave the house,” “maintain eye contact,” “use complete sentences” (rather than one-word answers), etc.

In therapy, PCIT can be used as a stand-alone treatment, but I recommend combining it with other therapeutic treatments such as operant conditioning, exposure therapy and CBT. Of course, the use of CBT will depend on the age of the child and whether his or her brain is developed enough to process abstract counseling strategies. Children don’t usually possess this ability until age 7 or 8. It should be noted that use of these treatment techniques (alone or in combination) does not guarantee success or an absence of symptoms.

Implementing PCIT with CDI and PRIDE

Some professionals refer to CDI as “child chooses.” Regardless of the terminology, during this portion of PCIT, no directives are to be given to the child and no questions are to be asked until CDI has been used for at least three minutes. This allows the child to feel positive about himself or herself because nobody is giving directions to correct something that the child was “doing wrong” upon entering a room or during a new transition.

When children feel positively about themselves, they are more likely to comply later down the line. Therefore, it should be noted that CDI is not a time to criticize. CDI means that the child will choose something to do without any adult direction. The adult (whether that is the counselor, the parent or the teacher) is to observe what the child does and give the child physical space if the adult’s presence seems to agitate or increase anxiety in the child. After at least three minutes of CDI, the adult uses PRIDE skills (verbal interaction from the adult) when the child seems more emotionally regulated. PRIDE is an acronym that directs the adult to offer the child labeled praise, reflection, imitation, description and excitement/enjoyment (in the adult’s voice).

As a real-life example, let’s say that “Alison” is in homeroom at school first thing in the morning. At the therapeutic school in which I work, this is where the students meet in the mornings to get any homework lists, eat healthy food, use coping skills, check in with their teachers and therapists, and practice socializing with peers appropriately. CDI is used immediately upon students’ arrival.

In this case, Alison puts her backpack on the floor upon entering the room, then goes to sit at her desk (her backpack is not where it is supposed to be, plus it is open, with its contents falling out). When Alison enters the classroom for the first time, it is time for CDI, so the teacher is not to direct her to move the backpack, at least for a few more minutes. (If your first interaction involved someone telling you to correct something, think about how you would feel.)

At her desk, Alison eats an apple, and then a peer asks Alison for a piece of paper. Alison silently gives her peer the paper, without offering any eye contact, and then gets up to throw away the apple she just finished eating. She then remembers to get her assignment notebook out of her desk. Even though Alison’s backpack is open on the floor with papers, food and more disorganized contents spilling out, the teacher doesn’t direct her to do anything until after offering Alison the full array of PRIDE skills:

Praise: Praise appropriate behavior. This should be specific labeled praise about what is positive. In this case, it could be any number of things: “Alison, thanks for sharing your paper with Sarah. You are so helpful” or “Thanks for throwing away that apple in the garbage. You are very responsible” or “You remembered to get out your assignment notebook. You have a great memory!” This labeled praise includes helpers to build confidence in Alison related to both her IQ and her EQ (emotional intelligence), therefore lessening her anxiety and helping her manage her impulsivity.
Reflect: Reflect appropriate talk. This means the adult reflects back what the child says to them. For example, when Alison is done with her assignment notebook, she asks the teacher, “When is the fire drill?” The teacher is to reflect the main concept of the question. In this case, the teacher might say, “I am glad you want to know when the fire drill is so you can be prepared. That is very responsible of you. It is at 9.” Reflection is key to letting children know you are really listening to them. And if someone is listening to them, then they feel valued, understood, worthy and accepted, lessening their anxiety and raising their self-esteem. In this case, the teacher also offered more labeled praise about Alison being prepared and responsible.
Imitate: Imitate appropriate social behaviors. If Alison takes out paper and colored pencils to draw as a “quiet coping” skill during the appropriate time, the teacher takes note of how to imitate this same concept down the line. “Your drawing just reminded me of something, Alison. When all of the homeroom students have arrived, we can all play that drawing game we played a few weeks ago. Would you be willing to lead the game since you really understood it last time and are such a talented artist?” This lets Alison perceive that she is worthy because she was doing something that the teacher also wants to do (artwork). This serves to lessen Alison’s anxiety. It also helps her realize that she can in fact be a leader herself, increasing her self-confidence.
Describe: This is the time to give behavioral descriptions. Simply describe what the child is doing, which shows the child that someone is both attending to them and giving approval of their actions. This serves to increase the child’s confidence and decrease anxiety. For example, the teacher might tell Alison, “You’re drawing a sports car with a mountain in the distance. That looks fast and powerful yet peaceful at the same time. That’s pretty impressive and creative that you’re able to capture all of that in one picture.” This description also includes more labeled praise pointing out that Alison is creative.
Excitement/enjoyment: Demonstrate excitement in your voice, which is key to attending skills. This strengthens the relationship with the child and allows the child to experience many positive feelings. This also increases the chances the child will comply when you give a corrective direction.

It should be noted that some people with anxiety fear receiving positive praise in front of other people. If this is the case, adjustments can be made to the treatment technique.

In Alison’s case, all of the PRIDE letters were used, and she received even more than the allotted three minutes of CDI time. Alison’s CDI time included getting to choose to eat her apple, asking her fire drill question and taking out paper to draw a picture. Once CDI and PRIDE have been used, the teacher can move to adult-directed interaction, in which the teacher can finally:

Ask questions: “Alison, do you have your math assignment from last night?”
Direct some peer interaction (such as getting the students together for the drawing game referenced earlier).
Give instructions (such as addressing that backpack issue): “Alison, it would help us out if you could close your backpack and put it in your locker. I would hate for anything of yours to get lost or for someone to get hurt tripping on it.” When Alison complies with that direction, the teacher can follow up with more labeled praise: “Thanks for following directions.” One caveat: Never say, “Thanks for listening.” There is a big difference between someone “listening” and someone “following directions.”

Other considerations

The CDI/PRIDE skills/adult-directed interaction combination should be used in the child’s home continuously, at play dates in others’ homes, at school and community activities and, of course, in the therapy office. PRIDE continues to be a way of communication, so it doesn’t stop when the conversation gets going.

In the therapy office, once emotional regulation has been established with the combination of CDI/PRIDE/adult-directed interaction, the counselor can move to reminding the child of the operant conditioning plan, then work on CBT skills or exposure skills to continue building strategies to manage impulsivity or anxiety.

If children’s ADHD symptoms are impairing their social and educational functioning with significant intensity, frequency and chronicity, it is also likely that a psychiatrist will prescribe a stimulant medication. ADHD is a genetically based, neurobiological disorder that affects many parts of the brain. Medication can touch parts of this, especially when it comes to dopamine and norepinephrine disruptions, but it can’t adjust everything. Even for the parts of the brain that can be medicated, medication doesn’t guarantee an absence of symptoms. That is why it is crucial to continue using therapeutic techniques as antecedent management and counseling strategies to help children function in their different environments.

In terms of anxiety, for those suffering impairment in their social and educational settings on an intense, frequent and chronic level, the first line of medication will likely be a selective serotonin reuptake inhibitor (SSRI). This is because the main area of the brain affected is serotonin (in addition to anxiety affecting norepinephrine, glutamate and the limbic system structures of the hippocampus, hypothalamus and amygdala). Again, however, an SSRI will not guarantee an absence of symptoms, which is why therapeutic techniques, exposures and counseling strategies remain key.

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For more examples of how the attending skills of CDI, PRIDE and others related to PCIT can be used in school settings, home situations and community/recreation settings, please reference my two books: Toddlers & ADHD and Suffering in Silence: Breaking Through Selective Mutism.

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Donna Mac is a licensed clinical professional counselor in her 12th year working for AMITA Health in one of its therapeutic day school locations. Previously, she was a teacher in both regular and special education settings. She has three daughters, including identical 9-year-old twins diagnosed with ADHD hyperactive/impulsive presentation and selective mutism anxiety. Contact her at donnamac0211@gmail.com or through her websites: toddlersandadhd.com and breakingthroughselectivemutism.com.

Letters to the editor: ct@counseling.org

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

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

Counseling Connoisseur: Cannabidiol and mental health therapy

By Cheryl Fisher February 4, 2019

Carol presented with concerns related to continuous panic attacks that were jeopardizing her work as a medical professional. “I can’t think straight when they happen and I cannot be this debilitated when I see patients,” she explained. Carol had also been self-medicating with alcohol on the weekends to “ease the stress.” Throughout a year and half of intensive therapy, Carol’s panic disorder began to subside, but her general anxiety continued. One day during therapy Carol announced, “I have not been anxious for two weeks!” Thrilled for her, I asked what had caused such a significant change. She looked sheepishly at me and whispered, “cannabis.” I inquired whether she had shifted to smoking marijuana versus drinking alcohol (which she had recently begun cutting back on). She quickly responded, “Oh no! That would get me fired from my job. I am taking a cannabidiol tincture.”

Geraldine came to therapy having returned from a year deployment to a country that is without sunlight for months at a time and has very limited pharmaceutical access. She had been without her medication for anxiety and depression and was feeling overwhelmed. “I can’t function,” she lamented. She had contacted a psychiatrist, but the only available appointment was a month away. We identified some tools she could use to help ease her symptoms while she waited, but they only worked for short periods of time. As a result, she was constantly anxious and depressed. Three weeks into our work together, Geraldine announced that she was feeling much better and attributed it to the cannabidiol-infused honey that she was using in her morning oatmeal.

Tim presented with depression and insomnia related to chronic pain caused by lupus. He had been taking psychotropic medication for years, but it no longer brought him any relief. Despite taking sleep aids, he was unable to get a good night’s sleep. Tim worked hard in therapy and was able to ease some, but not all, of his symptoms through regular mindfulness meditation. To my surprise, Tim appeared one afternoon smiling in delight. “I slept all night this week!” he exclaimed. Again, the answer to his dilemma was cannabidiol, which he consumed in capsules.

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As a counselor, I strive to create the best evidence-based, holistic and individualized treatment plans through collaboration with my clients. In addition to traditional talk therapy, I use a variety of therapeutic approaches, including a wide range of expressive arts and animal and nature-assisted therapies. Recently multiple clients have reported symptom improvement through the use of an over-the-counter supplement that works with the body’s endocannabinoid system (ECS). Approved in the form of an oral solution (Epidiolex) in June 2018 by the U.S Food and Drug Administration (FDA) for the treatment of Lennox-Gastaut syndrome and Dravet syndrome — rare and severe forms of epilepsy — cannabidiol (CBD) has also drawn interest as a therapeutic agent for use on a variety of neuropsychiatric disorders.

What is cannabidiol?

CBD is a naturally derived, non-psychoactive hemp derivative. Proponents describe CBD as a food supplement that provides the therapeutic element of cannabis without tetrahydrocannabinol (THC), which is the component that produces a high. It can be found as a tincture, vapor, infused in honey or creams and is used in food products such as smoothies. Reported side effects include possible positive drug screening results, appetite changes and sleepiness.

How does it work?

CBD affects the ECS, which consists of endogenous cannabinoids, cannabinoid receptors and the enzymes that synthesize and degrade endocannabinoids. As noted in a 2018 article in the journal Frontiers in Molecular Neuroscience, research has found that the ECS plays a significant role modulating physiological functions such as mood, cognition, pain perception and “feeding behavior.” The ECS also interacts with the immune system and moderates inflammatory processes. Animal studies and anecdotal observations have shown that modulating the ECS can have beneficial effects on mood, but the authors note that numerous additional factors, such as the placebo effect, could be influencing these findings.

Research that focuses specifically on targeting the ECS with CBD has also been intriguing. In a 2015 article appearing in the journal Neurotherapeutics, a review of studies on animal and limited human populations concluded that acute doses of CBD can reduce anxiety. The authors call for research on chronic doses and note that because past human studies of CBD were conducted with healthy volunteers, future work should focus on clinical populations.

Overall, current research indicates that CBD has significant potential as a treatment for a number of mood disorders.

What does this mean for counselors?

As counselors, it is important to be informed about supplements clients are using to manage mental and physical disease. While we cannot prescribe medications and should refer clients to their doctors for medical advice around pharmacology and supplements, we do have a duty to provide our clients with psychoeducation and research.

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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.

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EDITOR’S NOTE: Counselors should be aware that according to a U.S. Food and Drug Administration (FDA) statement issued in December 2018, although hemp has been removed from the Controlled Substances Act, it is still illegal to add CBD to consumer food products or to market it as a dietary supplement.

Some jurisdictions, such as the cities of New York and Los Angeles, have begun ordering restaurants to stop selling food containing CBD. The FDA is not currently preventing the manufacture of CBD as a dietary supplement. However, counselors and clients should be aware that like all dietary supplements, those containing CBD are not subject to set standards regarding dose or strength.

Learn more about risk management issues related to client marijuana use (ACA members only): counseling.org/docs/default-source/risk-management/ct-risk-management-july-2018.pdf

FDA statement on CBD cannabis regulation: fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm628988.htm

FDA and marijuana Q+A: fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm#enforcement_action

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Cheryl Fisher

Cheryl Fisher is a licensed clinical professional counselor in private practice in Annapolis, Maryland. She is director and assistant professor for Alliant International University California School of Professional Psychology’s online MA in Clinical Counseling. Her research interests include examining sexuality and spirituality in young women with advanced breast cancer; nature-informed therapy; and geek therapy. She may be contacted at cyfisherphd@gmail.com.

Group counseling with clients receiving medication-assisted treatment for substance use disorders

By Stephanie Maccombs September 6, 2018

Holistic care, or the integration of primary and behavioral health care along with other health care services, is becoming more common. In my experience as a mental health and chemical dependency counselor in an integrated care site, I have come to value the benefits that such wraparound services offer.

I now have the opportunity to consult with primary care providers, medication-assisted treatment providers, dentists, early childhood behavioral health providers and our county’s Women, Infants and Children team about their perspectives and hopes for clients. Every client has a treatment team, and each team member is only a few feet from my office door. I quickly realized the significant positive impact that close-quarters interdisciplinary collaboration has for many clients, and particularly those receiving medication-assisted treatment (MAT) and counseling services for substance use disorders.

MAT is a treatment model that lends itself to the integrated care setting. As described by the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT is the use of prescribed medications with concurrent counseling and behavioral therapies to treat substance use disorders. MAT is used in the treatment of opioid, alcohol and tobacco use disorders. The medications, which are approved by the Food and Drug Administration, normalize brain chemistry to relieve withdrawal symptoms and reduce cravings. MAT is not the substitution of one drug for another. When medications in MAT are used appropriately, they have no adverse effects on a person’s mental or physical functioning.

Medications used in MAT for alcohol use disorder include disulfiram, acamprosate and naltrexone. Those used for tobacco use disorders include bupropion, varenicline and over-the-counter nicotine replacement therapies. Medications used in MAT for opioid use disorders include methadone, buprenorphine and naltrexone — each of which must be dispensed through a SAMHSA-certified provider. Naltrexone is the only medication of the three that does not have the potential to be abused. Federal law mandates that those receiving MAT for opioid use disorder also receive concurrent counseling.

Embracing the advantages of integrated care

The combination of medication and therapy offers a holistic approach to treatment that is easily implemented in integrated care settings. The hope offered by the integration of services is embodied in an extraordinary case involving one of my clients who relapsed and arrived to counseling intoxicated, holding their chest. I was able to immediately consult with the client’s MAT provider, who ruled out the physical causes of chest pain after performing an electrocardiogram. Within 30 minutes, I was able to proceed with de-escalation of the client’s panic attack. The MAT provider educated the client on the next steps for care and on the dangers of using substances while taking MAT medications.

In a nonintegrated site, my only recourse would have been calling an ambulance for the client and a long wait at the hospital emergency room — and possibly a client who discontinued services. It is heartening when I can instead walk a client with symptoms of withdrawal across the hallway to the MAT provider or primary care provider, who can in turn offer targeted expert medical advice and medications to alleviate the symptoms.

Despite the substantial advantages that integrated care offers, however, most mental health and chemical dependency counselors are not adequately trained to provide effective counseling in integrated care settings for substance use disorders. In my experience, clients have better outcomes when receiving counseling services in conjunction with MAT. MAT alone can be effective, but the underlying thoughts and emotions that perpetuate use are not addressed unless concurrent counseling services are offered.

According to SAMHSA’s Treatment Improvement Protocol (TIP) No. 43, counseling for clients in MAT programs:

Provides support and guidance
Assists with compliance in using medications in MAT appropriately
Offers the opportunity to identify additional areas of need
May assist with retention in MAT programs
Offers motivation to clients

Although individual counseling is valuable, I am focusing on group counseling in this article because it offers similar benefits to individual counseling and is typically more cost-effective. In addition, TIP No. 43 notes that group counseling in MAT programs reduces feelings of isolation, involves feedback and accountability from peers, and enhances social skills training.

Resources for group counseling with MAT clients, or group counseling in integrated care settings, may not be easily accessible to many counselors-in-training or to practicing counselors. My goal is to share tips and resources with mental health and chemical dependency counselors that may be helpful in enhancing group counseling services for clients receiving MAT in integrated care settings. These tips and resources may also be useful to those providing group counseling services to MAT clients in settings that do not offer integrated care.

Tips and resources

1) Holistic education: MAT and integrated care are relatively new concepts for counselors, and we are still adapting. If it is new for us, it is new for our clients too. In the initial sessions of psychoeducational or process groups, the inclusion of education about MAT, the benefits of counseling in conjunction with MAT, and treatment in integrated care settings is essential.

Having access to a range of service providers is a benefit that clients should understand and utilize. Treatment team members can speak to the group about their role in client care and how their role may relate to the counseling group. For example, a dentist might help with appearance and self-esteem issues; an early childhood care provider might help the children of clients process situations arising from parental drug use; a primary care or MAT provider might link the client with hepatitis C treatment in addition to MAT. Such education can answer many questions that the group may have and help clients benefit from quality holistic care.

2) Dual licensure and continuing education: Many chemical dependency counselors refer out to mental health counselors and vice versa. In integrated care, it is ideal for counselors to be dually licensed. Dual licensure and training can assist counselors in identifying and addressing a variety of dynamics that may arise in group counseling with MAT clients.

For example, one client might have major depressive disorder and be using MAT for alcohol recovery, whereas another client might have symptoms of mania and be receiving MAT for opioid recovery. The way that counselors assist these clients may differ based on their knowledge of mental health diagnoses and the substance being used. Furthermore, counselors who are knowledgeable about these differing yet comorbid disorders will be better equipped to provide education to the group about the individualized and shared experiences of each member in recovery.

Some states have a combined mental health and chemical dependency counseling licensure board, whereas others have separate licensing boards. For more information about licensure, contact your state boards. If dual licensure is not plausible or desirable, I strongly recommended seeking continuing education in both mental health and chemical dependency counseling, as well as their relation to MAT.

3) Cognitive behavior therapy (CBT) and solution-focused brief therapy (SFBT) techniques: According to SAMHSA’s webpage about medication and counseling treatment, by definition, MAT includes counseling and behavioral strategies. The combination of MAT with these strategies can successfully treat substance use disorders.

One of SAMHSA’s recommended therapies is CBT, an evidence-based practice that has been shown time and time again to be effective in the treatment of substance use disorders. In an extensive review of the literature about the efficacy of using CBT for substance use disorders, R. Kathryn McHugh, Bridget A. Hearon and Michael W. Otto (2010) outlined a variety of interventions shown to be effective in addressing substance use disorders in both individual and group counseling. Those interventions included motivational interviewing, contingency management, relapse prevention interventions and combined treatment strategies.

Combined treatment refers to the use of CBT alongside pharmacotherapy, which includes MAT. Although some studies the authors reviewed indicated that MAT alone could be effective in treating substance use disorders, others demonstrated that combined treatment was most effective. Given SAMHSA’s recommendation, the literature review and my own personal experience, I believe that CBT may best benefit a group of MAT clients with substance use disorders in an integrated care setting.

Although CBT is suitable, I have learned that integrated care sites are much more fast-paced than the typical behavioral health counseling agency. Primary care and MAT appointments are as short as 15 minutes. In my work with our on-site behavioral health consultant, I noticed her quick and effective use of SFBT with individual clients. Although there is some research discussing the use and efficacy of SFBT in the treatment of substance use disorders, there is little information about using SFBT in groups with MAT clients in integrated care. This is a much-needed area for future research.

4) SAMHSA: SAMHSA has been mentioned various times throughout this article. That is a tribute to the value I place on the agency’s importance and usefulness. SAMHSA, in my opinion, is the best resource for exploring ways to enhance groups for clients receiving MAT. SAMHSA offers educational resources about a variety of substance use disorders; forms of MAT for different substances; comorbidities; and evidence-based behavioral health practices. SAMHSA is up to date, provides a variety of free resources for counselors and other professionals, and also has information about integrated care for professionals and clients.

According to SAMHSA’s TIP No. 43, groups commonly used with MAT clients include psychoeducational, skill development, cognitive behavioral and support groups. Suggested topics for individual counseling with MAT clients, which easily can be translated to group format, include feelings about coping with cravings and a changing lifestyle; how to identify and manage emergencies; creating reasonable goals; reviewing goal progress; processing legal concerns and how to report a problem; and exploring family concerns. Visit SAMHSA’s website (samhsa.gov) to enter a world of helpful information and resources for both personal professional development and client development.

5) Professional counseling organizations: Whereas SAMHSA offers information about substance use disorders, comorbidities, MAT, and individual and group counseling, the counseling profession’s codes of ethics and practice documents are crucial to the ethical provision of group counseling in this challenging field. Among the resources to consider are the 2014 ACA Code of Ethics, the Association for Specialists in Group Work (ASGW) Best Practice Guidelines (which clarify application of the ACA Code of Ethics to the field of group work) and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling’s (ALGBTIC’s) competencies for providing group counseling to LGBT clients. ASGW also has practical resources to augment your group counseling skills through its Group Work Experts Share Their Favorite Activities series. Combining these resources with information acquired from SAMHSA and the tips in this article should prove helpful in designing and running effective groups for clients in MAT in integrated care settings.

Conclusion

As integrated care becomes more widespread, counselors must adapt their practice of counseling to the environment and to the full range of client needs. It is a counselor’s duty to utilize the benefits that integrated care has to offer, such as immediate and continual collaboration with treatment team members.

For clients in MAT, group counseling in integrated care can provide a multitude of benefits, including the opportunity to learn from each treatment team member, the opportunity to build community in the journey to recovery and accountability. To enhance group counseling in these settings, counselors might consider:

Including education from each service provider in the early stages of the group
Seeking dual licensure or relevant continuing education opportunities
Implementing theories that are suitable for the client issue and the setting
Using resources made available by SAMHSA and professional counseling organization such as ACA, ASGW and ALGBTIC

Implementing these tips and resources will result in a fresh and efficient group counseling experience for clients in MAT in integrated care settings.

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Stephanie Maccombs is a second-year doctoral student in the counselor education and supervision program at Ohio University. She is a licensed professional counselor and chemical dependency counselor assistant in Ohio. She has worked as a home-based addiction counselor and currently works in a federally qualified health center providing mental health and chemical dependency counseling services to adults participating in medication-assisted treatment. Contact her at sm846811@ohio.edu.

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.

Is depression lurking in your medicine cabinet?

By Bethany Bray July 16, 2018

An estimated one in three American adults are taking one or more medications that can – and often do – cause depression.

A recent Journal of the American Medical Association (JAMA) study found that many common medications that Americans take regularly, such as drugs for acid reflux or high blood pressure, have the potential to cause depression as a side effect.

The study, published in JAMA‘s June 12 issue, analyzed federal health survey data collected from U.S. adults between 2005 and 2014. Of the more than 26,000 participants, 7.6 percent who were regularly taking one medication reported having depression — and this doubled in those who were taking three or more medications.

“The estimated prevalence of depression was 15 percent for those reporting use of three or more medications with depression as an adverse effect, vs 4.7 percent for those not using such medications,” wrote the article’s co-authors.

The study also found that the number of Americans who regularly take medications that carry depression as a side effect has increased from 35 percent to 38.4 percent between 2005 and 2014. The percentage of people taking three or more these medications concurrently increased from 6.9 to 9.5 percent over the same timeframe.

American Counseling Association member Dixie Meyer says these findings only affirm the importance for counselors to familiarize themselves with medical diagnoses and commonly prescribed medicines. Also, counselors should routinely screen for depression in clients who take medications with depressive side effects, as well as those in at-risk groups, such as minorities, clients with low socio-economic status or who identify as LGBTQ.

As the evidence for the intertwined nature of the medical and mental health fields continues to accumulate, it becomes increasingly important for counselors to bring themselves up to speed on medical research that may inform clinical practice, says Meyer, an associate professor in the medical family therapy program in the department of family and community medicine at the St. Louis University School of Medicine. This can happen both through individual professional development and a profession-wide focus.

“We know that for professions to succeed, there needs to be a continual adaption. For the counseling field, counselor training programs need to include not only counseling but medical research evaluation,” Meyer says. “Counselors need to be trained in understanding the relationship between physical and mental health disorders. For example, trauma increases the likelihood for chronic health conditions.”

Meyer is also the director of the Relationships and Brain Science Research Laboratory at the St. Louis University School of Medicine. She frequently gives presentations to counselors on the importance of understanding their clients’ medications, including at ACA’s 2016 conference in Montreal. She recommends that all counselors have a copy of the Physicians’ Desk Reference on hand so that they can quickly look up any medication. Counselors can also refer to resources like Medscape.com for updates on the latest medical research that may inform clinical practice.

“Because this [JAMA] research is not a clinical trial or a prospective study that can inform the reader of temporal implications, we should interpret the results with caution as they are correlational in nature,” says Meyer. “It is not uncommon for physicians to prescribe, at the onset of treatment or later concurrently with treatment, a medication intended to manage side effects. While the sample with the 15 percent increased risk were taking three or more medications with the depression side effect, we can still expect the majority of individuals using these medications will not experience an increase in depression. Thus, any preventative care could be needless without symptoms present.”

When it comes to counselors, clients and medication, Meyer suggests the following:

Intake forms should include use of both prescription and over-the-counter medications. The form should specify that he or she should include medications taken periodically or on an as-needed basis.
Counselors should implement regular, monthly checks to assess if medication usage has changed.
In addition to counselors systematically assessing how clients perceive the effectiveness of their psychotropic medication and side effect evaluation, the medication management component of counseling should include an assessment of those medications associated with depression risk, like anti-hypertensives, hormonal contraceptives and other hormone replacement therapy and proton pump inhibitors (commonly used to treat acid reflux).
Clients being treated for depression, those in at-risk groups (LGBTQ, racial minorities, women, low-income) and those taking medications with depressive side effects need to be routinely screened for depression. A monthly screen for depression using widely available tools like the PhQ-2 or PHQ-9 can easily be incorporated into clinical practice without being too cumbersome for clients.
Counselors need to monitor both the mood and somatic symptoms of depression in high-risk groups. Many of the symptoms of depression are somatic; thus, clients may be experiencing depressive symptoms that go unnoticed because they are unrelated to mood changes.
Counselors need to be well-versed in who is at risk for depression. The [JAMA] research reported that the medications with potential depressive side effects were more likely to be given to those individuals already at an increased risk for depression (e.g., female, widowed, older populations and those with more chronic health conditions). Not only does this make it difficult to determine if the research is uncovering depression prevalence already present or if vulnerable populations are being placed in a position that increases their depression risk. Thus, counselors need to understand what the research tells us about who is at risk for depression — and counselors need to identify if these individuals are also taking medications with this potential side effect.
Counselors need to encourage self-monitoring of mood symptoms and discuss with clients taking medications with depressive side effects how to intentionally monitor their mood at home. For example, smart phone apps designed to track mood are widely available.

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Find out more

Read the full JAMA article: jamanetwork.com/journals/jama/article-abstract/2684607

From NPR, “1 In 3 Adults In The U.S. Takes Medications Linked To Depression”

From the Counseling Today archives:

“The counselor’s role in assessing and treating medical symptoms and diagnoses”

“Healthy conversations to have” (on discussing psychiatric medication usage with clients)

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

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

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