Tag Archives: Mental Health

Turning your emotions into positive actions: A psychological approach to COVID-19 challenges

By Esther Scott December 8, 2020

It has been almost a year since it started. These past few months have been challenging times for everyone. We are witnessing frustration on many different levels, and we have all experienced a number of emotions: anger, fear, isolation, anguish, love, anxiety, solidarity, grief — with anger and anxiety being the most powerful ones over the summer.

Now, as we begin the transition from autumn to winter, depression is positioning itself to become the frontline emotion. With dissatisfaction from a lack of activities and face-to-face encounters, negative current events and a generalized sense of loss, we may face an increased risk for situational depression. The opportunity for situational depression to creep in becomes even greater as the days get shorter and we spend more time inside and in the dark as winter approaches.

In light of our current situation and these potential threats, understanding our emotions and recognizing the symptomatic behaviors of depression will be key to avoiding the creation of habits that could have long-term negative consequences. Instead, let’s focus on turning our emotions into positive actions that can build our resiliency skills.

Understanding your emotions

Everyone reacts in their own way to the events we are experiencing, but the emotions of anger and anxiety are common to almost everyone. We may be angry because progress in the area of race relations seems painfully slow, because of the rioting and looting we have witnessed, or because the government response to all of these things was not what we wanted or expected. Many people are experiencing anxiety and emotional fatigue due to all of the restrictions that COVID-19 brought to us this past summer, which limited our ability for recreation and recharging. Many are also experiencing exhaustion from all of the cultural changes that have taken place in just a few months but that have seemed to drag on for decades. Let’s take a closer look at these emotions.

Anger

Anger is often called a secondary emotion because we tend to resort to it to protect ourselves from or to cover up other vulnerable feelings. We almost always feel something else first before we get angry. We might first feel afraid, attacked, trapped, offended or disrespected. If any of these feelings are intense enough, we think of the emotion as anger.

What to Do

First, answer the following questions: What types of situations set you off? Are there people, situations or events that you simply need to avoid?

Second, check your thoughts. Be sure to take a step back and identify how you might need to change in your prejudices and in your interactions with others. Anger is a feeling, and it tells us there has been an injustice; that we are being denied something we should have. It provides its own justification. But it is an emotion that impairs critical thinking. There may be other elements that need to be considered before we act in anger.

Finally, focus on what matters most: love. After witnessing so many recent and ongoing tragic events, it is important to identify how we can respond to what is happening in our world in a positive way. It is most effective to connect through empathy and positive actions.

Fear and anxiety

Fear has a purpose: to keep us alive. When being chased by a lion, it is a natural and healthy reaction to feel afraid. Fear triggers the release of adrenaline and gives us the push to keep running. However, when we fear irrationally, we unnecessarily trigger cortisol, and this can have a negative effect on our physical health.

Almost everything about the coronavirus pandemic is uncertain: how many more people will become infected and possibly die, how much more the economy and job market will be impacted, how soon things will return to “normal.” Uncertainty can cause feelings of extreme discomfort and activate irrational fears that hold us back from fully experiencing life. It might also interfere with our ability to solve problems or prevent us from being objective in finding solutions. Even worse, elevated levels of anxiety can actually compromise our immune system, making us even more vulnerable to the virus.

 What to do

First, replace fear with strength. The presence of the coronavirus does not have to become a traumatic and overwhelming experience that marks us for life. On the contrary, it can be an excellent opportunity to exercise our resilience. The ability to handle adversity will be a critical component to our success moving beyond COVID-19. Maintaining an optimistic attitude is essential to supporting recovery. Being optimistic helps make your thoughts and emotions much more positive, which in turn gives your immune system a boost.

Second, have an action plan. Having a plan of action allows your brain to feel in charge. The next time you experience an attack of anxiety, write down your worries and identify your options. Examine your worries, aiming to be realistic in your assessment of the actual concerns and your ability to cope. Identifying what worries you and then focusing on what you can control will calm the nervous system and provide a feeling of inner strength.

Third, focus on the future. This will move you from paralyzing anxiety to action. Remember, anxiety comes from not knowing what will happen, and depression comes from believing that there is nothing we can do to change it.

Imagine yourself coping and adapting. Studies have shown that religious individuals involved in tragic circumstances often reported finding hope, peace and even increased joy in the midst of the experience. This consequently led them to report high satisfaction in their lives. “We are hard pressed on every side, but not crushed … struck down, but not destroyed” (2 Corinthians 4:8-9). We can all benefit from this kind of optimism.

 

What’s next? Grief and situational depression

The coronavirus pandemic is causing people to struggle with multiple types of mental health issues, including grief and situational depression. It is important to recognize the signs of grief and situational depression so that you can get the help you need.

Grief

Our new reality since the onset of the global pandemic has been marked by increased grief and a sense of loss. School, vacations, weddings, concerts, meetings, travels plans, social events and many other things have been canceled this year in the wake of the virus. It has forced on us an uncertain future and a collective grief.

We are mourning the loss of thousands of lives, and we are also mourning the loss of our “normalcy.” From going to work, to participating in community and religious gatherings, to engaging in the everyday routines that we previously took for granted, such as shopping or visiting with friends — everything has been impacted.

What to do

First, remember that your feelings are valid. There is no right or wrong way to feel after a loss. The shock and disbelief that have followed after all we have lost can trigger feelings of anger, regret, sadness and depression. All are common reactions. You may even be struggling with anticipatory grief, or the feeling that greater loss is still to come, because you may fear losing another family member or loved one.

Second, reach out. Although you might be tempted to shut everyone out in the midst of your grief, it is important to reach out. Talking about your feelings with someone when you are stressed or upset may not bring back what you have lost, but it can help you to feel better and less alone. Find ways to memorialize what you have lost. If you have lost someone, write a letter about your loved one’s life and their impact on you. If you lost a job that was important to you, write about all you learned during your tenure in that position. 

Depression

For many, the rapid changes brought about by the pandemic have been as scary as the virus itself. Business closures, income reduction and the uncertainty of what might be ahead have increased symptoms of situational depression in a large number of people.

According to the World Health Organization, more than 264 million people worldwide experience different types depression: major depressive disorder, bipolar depression, perinatal and postpartum depression, and situational depression. Situational depression differs from other types of depression in that it is a short-term, stress-related type of depression. It is also known as reactive depression. It can develop after experiencing a traumatic event or series of events.

Symptoms of situational depression vary from person to person, but in most cases, they include sadness, hopelessness, constant worrying, feelings of anxiety or stress, difficulties sleeping, trouble carrying out daily activities, feelings of being overwhelmed, thoughts of or attempts at suicide, lack of enjoyment in normal activities, and regular crying.

What to do

First, accept the new reality. There is something “unreal” in the world of masks and physical distancing in which we now live. It is a world that sometimes keeps us from recognizing a friend who passes by or that makes greeting your relatives with kisses and hugs seem like an outdated custom from another era. However, it is important to remember that every storm passes. “This too shall pass.”

Looking at crises as opportunities to rethink and reorganize our priorities can prove beneficial. The analogy of a diamond may be helpful here. The beauty of the diamond comes about from the extreme experience of pressure and heat. The same can be true for you. By accepting your new reality and recognizing the opportunities it has brought you, you can emerge stronger from your situation and the complex challenges you have faced.

Second, focus on progress. In the mental health community, we have observed that when it comes to overcoming depression, even small changes in our clients’ daily lives can produce positive results. When people who were extremely depressed were asked to simply write down three good things that happened to them each day, 94% of the people in the study reported that they experienced some relief from their depression symptoms. Focusing on progress increases positive feelings. If you are suffering from depression, keep a gratitude journal with three good things that happen each day. This exercise will likely help you too.

Third, be kind to yourself; you are doing the best you can. The COVID-19 crisis has generated enormous distress for us as a society. It has served as a reminder that our emotions affect our physical and mental health — a reminder that our emotions are an expression of what happens to us and what matters to us. However, it is also important to remember that the feelings of hopelessness we may be experiencing are symptoms of depression, not the reality of our situation. You are not hopeless. There is hope.

 

Conclusion

Our current global crisis has brought an opportunity for us to influence one another for positive change. The solution for change starts with us, through our words and actions. So, as you think about the realities and uncertainties of our world during the crisis we are all facing, be mindful of the different ways that you can change your emotions into positive actions, starting with being kind to others and being kind to yourself.

 

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Esther Scott is a licensed professional counselor in Arlington, Texas. She is a solution-focused therapist. Her specialties include grief, depression, teaching coping skills and couples counseling. Contact her through her website at positiveactionsinternational.com.

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

A climbable mountain: Quitting smoking and managing mental health

By Bethany Bray August 10, 2020

For people with a preexisting mental health condition, quitting smoking can seem like climbing two mountains at once.

Managing a mental health condition is a daily — sometimes moment-by-moment — challenge, and smoking is often used as a coping mechanism. Understandably, people with mental health conditions who smoke often fear that taking away that source of comfort could send them into a tailspin.

“That was the way I always seemed to manage my stress: Sit down, light a cigarette, and it would make my brain think, ‘It’s going to be OK.’ But in reality, it’s not,” says Rebecca M.* a Florida resident and participant in the Centers for Disease Control and Prevention (CDC)’s Tips from Former Smokers campaign who lives with depression.

Rebecca smoked her last cigarette in 2010. She quit smoking for good — and found balance in her life — with the support of a professional counselor. In hindsight, smoking only made her depression worse, Rebecca acknowledges.

For many people, mental health and smoking go hand-in-hand — you can’t fix one without addressing the other, she asserts.

“Wanting to be healthy, mentally, while smoking is impossible. After I quit, I was able to look at the world with a completely different mindset,” Rebecca says. “Smoking affects every aspect of your life — family relationships, work life, home life. It’s just a cloud. … When I see people who are struggling with mental health [while smoking], I have deep compassion for them. You want so desperately to get better, but with smoking, it’s like taking two steps forward and two steps back.”

In the family

Rebecca says she was “born into a family of smokers.” Growing up, all of her friends and family smoked, so it seemed natural for her to start smoking as a teenager.

She quit smoking for the first time in 2002. However, she started smoking again seven months later as she was going through a divorce and struggling with intense emotions and stress, she recalls.

Throughout this period, she met with several different counselors to help her manage her depression. She had an “aha!” moment in 2009 when her first grandchild was born; she knew then she wanted to quit smoking for good.

“When my oldest grandson was born, it made me stop and think about life in a different perspective. At that time, I reached out to find another counselor, to learn from past mistakes and learn a new way of life,” says Rebecca.

After smoking for more than three decades, she quit fully in 2010, roughly one year after setting the intention, seeking counseling, and going through “some intense self-reflection,” she says. “I was thinking about how I’m a grandmother now, and where do I want to be [in life]? I had a desperate desire to live a healthy lifestyle, and what can I do to get there?”

“Counseling gave me a sounding board, someone I could trust who could give me trusted answers,” Rebecca says.

Since quitting, she says, she has had to examine some friendships with close friends and even family members who continue to smoke. “If they’re not healthy for you, supportive of your healthy lifestyle, it’s important to make those changes as well,” she says. “It was a perspective shift: It’s the difference between being born into a life that you don’t get to choose and choosing the life that you want to live.”

The climb

Professional counselors can help clients meet life’s challenges with an approach based on leveraging the client’s existing strengths. For Rebecca, this included her intention to be a healthy example to her grandson. Practitioners have an arsenal of tools that can help clients make life changes and reach their goals, including smoking cessation.

Rebecca’s counselor helped her establish a self-care routine that includes exercise (she now runs regularly) and meditation. She has come to realize that she needed to exchange one unhealthy behavior, smoking, with a healthy behavior, exercise.

“Nothing will go well unless you take care of yourself first. Counseling taught me how to take care of myself first,” she says.

“[Quitting successfully] is about teaching people about the tools they need. When they are faced with a situation that may make them uncomfortable, or trigger a panic attack or need for a cigarette, they have to have [coping] tools ready and available. For me, it’s been exercise, staying grounded, and focusing on what I can control. I’m [continuing to] educate myself and learn as much as I can so that I can give myself the best self-care I can,” she says.

Most importantly, Rebecca’s counselor helped her accept that her depression, her tobacco dependency, and “all of this was not my fault,” she says.

“I don’t think I could have quit without counseling. I didn’t have the knowledge to do it on my own,” says Rebecca, who turned 63 this summer. “It’s essential to get someone [a mental health professional] who can help you walk this path to healthy living. It’s a path, a journey. It’s one step at a time, one day at a time, sometimes one moment at a time, but it’s empowering. It’s doable, and it feels amazing.”

Rebecca M. has exchanged one unhealthy behavior, smoking, with a healthy behavior, exercise. After smoking for more than three decades, she quit fully in 2010. Photo courtesy of the CDC’s Tips from Former Smokers campaign.

Ten years after quitting smoking, Rebecca’s mental health is good, but she acknowledges that she has to work at it every day. In addition to exercising regularly, she meditates often and tries to approach each day with an attitude of gratefulness, especially for things like a walk on the beach or video chats with her grandsons.

“I’m grateful for every one of those little moments I get,” she says. “It feels wonderful to climb that mountain. … It’s so empowering to be able to overcome tobacco use. There is a lot of life left [after cigarettes], even if you think there’s not.”

Counselors as allies

Professional counselors are particularly suited to help clients quit smoking because the profession has an array of tools focused on behavior modification. Instead of focusing on the health consequences of smoking — as a medical professional might — counselors can instead help clients focus on why they want to quit and how they can leverage their own strength to achieve that goal.

Practitioners also use a holistic perspective to help clients. For example, if a client turns to smoking in social situations because of anxiety, a counselor would help the client address the root cause, finding ways to cope with social anxiety. Similarly, if a client smokes to escape the negative thoughts that can be a constant companion of anxiety, depression, obsessive-compulsive disorder or other mental health conditions, a counselor can equip the individual with techniques to quiet their inner critic.

Read more about the many ways that professional counselor clinicians can support clients on their journeys in the Counseling Today article “What counselors can do to help clients stop smoking.”

In addition to counseling, Rebecca encourages people to use the plethora of tobacco cessation resources offered by the CDC.

“It’s OK to seek help,” she urges. “[Counselors and other professionals] want to see you succeed. You have it in you to succeed. That success is within you; you just have to learn to be kind to yourself and be loving to yourself. That, more than anything, was what I had to learn: to give myself the love that I give others.”

 

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For support to quit smoking, including free coaching, a free quit plan, educational materials and referrals to local resources, call 1-800-QUIT-NOW (1-800-784-8669).

 

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*Rebecca M.’s last name has been omitted for privacy reasons.

 

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Resources

From Counseling Today: “What counselors can do to help clients stop smoking

Find a professional counselor in your local area through the link here: counseling.org/aca-community/learn-about-counseling/what-is-counseling/find-a-counselor

CDC’s Tips from Former Smokers campaign: cdc.gov/ tips

Rebecca M’s page: cdc.gov/tobacco/campaign/tips/stories/rebecca.html

CDC page on quitting smoking: cdc.gov/quit

Additional CDC resources on addressing tobacco use in individuals with behavioral health conditions:

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

Overcoming free-time boredom during COVID-19: Combining a home-based optimal leisure lifestyle with behavioral activation

By Rodney B. Dieser July 7, 2020

As a licensed mental health counselor, I am hearing many of my clients tell me that they are ready to go stir-crazy because of an abundance of free time combined with greater stress during the COVID-19 pandemic. Although many states are reopening their leisure industries, many of my clients feel the safer route — and more thoughtful route toward health care workers and preventing the spread of COVID-19 — is to follow epidemiological and scientific advice by staying home.

Some of my clients are experiencing depression because they have lost their jobs, spend most of their days bored and ruminate on fear-based thoughts. The purpose of this short article is to suggest two interrelated ideas about how to create a psychological breather of positive emotion during your day that can also distract you from worry and stress.

First, develop a home-based optimal leisure lifestyle (OLL), which consists of one serious leisure activity, supplemented by casual and project-based leisure. Serious leisure is centered on acquiring and expressing special skills, knowledge and experience that take months, and sometimes years, to develop. Often, in everyday life, this is known as developing a hobby and is based on mastery gained through hard work and much effort.

My youngest son has taken the extra free time he now has and developed a serious skill-based hobby: He has purchased a watch repair kit and is tinkering away at repairing old watches. I am learning how to play the harmonica to Bruce Springsteen songs.

The Wikipedia page on hobbies identifies hundreds of skill-based hobbies to pursue, many of which are home-based. The internet can help with education and skill development. Often, there are online communities full of people who will welcome and mentor you toward your new serious leisure pursuits.

Casual leisure involves short-lived activities that require little or no specialized training. This type of leisure is based in hedonistic pleasure that requires little effort. For instance, my wife and I are currently watching comedies and documentaries on Netflix and enjoying it.

Project-based leisure is a short-term, one-shot or occasional creative undertaking. My wife is serving her community through her sewing projects and is serving a local nonprofit agency. When our kids were young, they picked a project of leisure learning each week (often it was insects), and we all had fun as we learned together. Just like with serious leisure, you can use the internet to find projects in your community. Often, nonprofit organizations are more than ready to link your personal strengths, passions and skills to a project they are working on.

Developing an OLL will provide transient moments in your day for positive emotion — a psychological breather from going stir-crazy and experiencing brain-numbing boredom. To learn more about OLL and the three forms of leisure I have just described, visit the Serious Leisure Perspective website. There you can learn about Robert Stebbins, who pioneered the academic work over a span of 40-plus years that led to development of the serious leisure perspective and the OLL framework. In addition, this website lists hundreds of studies that provide evidence of how individuals’ positive emotion is increased when involved in serious, casual and project-based leisure.

Research demonstrates that people can remedy stress if they laugh more (casual leisure), find a hobby (serious leisure) and engage in meaning-making activities such as volunteering in their communities or toward social causes (project-based leisure).

Behavioral activation involves having people/clients become more active and involved in life by scheduling activities with the potential to improve their mood. Counselors can help those clients who have an abundance of free time on their hands, whether due to unemployment or wanting to continue self-quarantining, by working with them to create a daily schedule based on developing an OLL. This involves using free time to engage in one serious leisure activity (e.g., starting a new hobby such as digital art, nail painting, cartoon drawing or bird watching), one casual leisure activity (e.g., reading, exploring new musical genres, watching comedies, hanging out with friends virtually) and one project-based leisure activity (e.g., sewing high-grade face masks for health care workers, volunteering at the Humane Society or with a political party, helping a nonprofit with fundraising efforts, creating a family history book by interviewing uncles, aunts and cousins) every day.

Behavioral activation is an evidence-based treatment for depression that has been found to be very effective. In everyday language, it is simply getting people more active and involved in life by scheduling activities that can improve mood. Cultivating an OLL and getting involved in serious, casual and project-based leisure when homebound is one way to create a psychological breather of positive emotion during your day that can also distract you from worry and stress.

 

Self-disclosure of my OLL

The following is a self-disclosure of my OLL during a three-month-plus self-imposed lockdown at home during the COVID-19 pandemic. It is provided so that readers can gain a gestalt of how an OLL can be inserted into everyday life that now may feature much more free time.

Serious leisure: Developing and expressing special skills, knowledge and experience; acquires much effort and is linked to enjoyment.

My daily activities

  • Learning to play harmonica to Bruce Springsteen songs
  • Studying creative writing and attempting to write short stories

Casual leisure: Low skills set focused on distracting; linked to pleasure.

My daily activities

  • Watching more documentaries and comedies on Netflix
  • Reconnecting with “forgotten musicians” of my past (what I used to listen to as a young man). Includes learning about and appreciating musical narrations and sonic arrangements of different genres of music. Examples: Chris de Burgh, James Taylor, Al Stewart, April Wine, Bachman-Turner Overdrive, Thin Lizzy, Supertramp, Triumph and Neil Young. I extended this to the music that my father and mother (both deceased) liked. This included Hank Williams, Waylon Jennings, Stompin’ Tom Connors, Hank Snow and Freddy Fender.
  • Reading the “classics” in literature, such as Mary Shelley’s Frankenstein, Cervantes’ Don Quixote and Arthur Miller’s Death of a Salesman

Project leisure: Short-term activity focused on completing a project

My daily activities

  • Cleaning out parts of the house that have not been cleaned out for years and donating much to Goodwill Industries
  • Gardening
  • Weekly project of exercise for health: Taking a 5- to 15-mile bike ride three days a week; running sprints at an outdoor track one day a week; working out on a Bowflex twice a week

Note: I used my stimulus check to purchase a Bowflex online and set it up in the garage. That piece of exercise equipment, gardening plants/seeds and used books (also bought online) are the only leisure resources I have purchased during the pandemic. Many of my leisure activities, such as playing the harmonica, engaging in creative writing and developing my appreciation of past musicians, have been learned or enhanced through resources on the internet.

 

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Related reading, from the Counseling Today archives (co-written by Rodney B. Dieser): “The serious leisure perspective in mental health counseling

A USA Today opinion piece written by Dieser: “Coronavirus pause: People need people, but it’s risky to resume social activities so soon

 

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Rodney B. Dieser is the author of five textbooks and more than 100 articles on the topic of leisure. His writing about leisure has appeared in USA Today and the Mayo Clinic Proceedings journal. He is a professor of recreation, tourism and nonprofit leadership and an affiliate faculty member in professional counseling at the University of Northern Iowa. He works 10 hours a week as a licensed mental health counselor for Covenant Family Solutions in Cedar Falls, Iowa. Contact him at rodney.dieser@uni.edu.

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

Hearing voices: A human rights movement and developmental approach to voice hearing

By Laren Corrin March 12, 2020

In 2016, shortly after I entered a CACREP-accredited graduate program for clinical mental health counseling, I began hearing, outside of the class setting, about an international human rights movement centered around the “voice hearing” experience — what would be called auditory-verbal hallucinations in clinical mental health settings. The movement includes people with unusual perceptions that often get labeled as psychosis.

I slowly came to learn about the movement through an introductory workshop, a three-day group facilitator training, attendance in online and in-person groups for a year, and the reading of the literature on the topic. Most recently, I traveled to Montreal for the 11th World Hearing Voices Congress, where I was able to shake hands with and hear one of the movement founders, Dutch psychiatrist Marius Romme, speak.

With this article, I hope to familiarize counselors with the Hearing Voices Movement and related international networks of recovery groups. I believe the Hearing Voices Movement is in alignment with the values and ethical principles of the American Counseling Association.

History and current development of the movement

The Hearing Voices Movement started in the 1980s in Europe when a patient confronted Romme about the limitations of the psychiatric care being provided. Why, the patient asked, was it OK for Romme to believe in a God whom he could not see or hear but not OK for her, the patient, to believe in voices that she really did hear? To learn more about the voice-hearing experience and to try to help his patient, Romme had the woman’s story told on TV and asked for other voice hearers to contact him. Approximately 550 reached out.

Remarkably, many of the people who heard voices did not need clinical help. Writing in the Journal of Mental Health in 2011 after conducting a literature review, Vanessa Beavan, John Read and Claire Cartwright asserted that it was safe to say that 1 in 10 people in the general population will hear voices. Romme eventually compared psychiatric treatment to eliminate voice hearing to conversion therapy for sexual orientation.

How did he come to that conclusion? By accepting the reality of the voices rather than just checking them off as a symptom to be treated, Romme said, he could learn much more about their origin and meaning and identify ways to help his patients. He discovered that voices were often a reaction to problems in life, such as bullying or abuse, with which the person could not cope. In other words, there was a relationship between the voices and the person’s life story.

The Hearing Voices Networks (HVN) are the network of community groups that emerged from the Hearing Voices Movement. As of early March, the Hearing Voices Network USA had 119 groups listed on its national website. At the World Hearing Voices Congress that I attended, it was reported that Brazil has quickly grown over the past few years to have 35 groups, whereas the province of Quebec in Canada started with one group in 2007 and now also has 35 groups. The majority of groups are in Europe, where the Hearing Voices Movement started.

The groups developed when people with experiences of voice hearing got tired of not being listened to and of being labeled as having mental disorders. They were also frustrated by the coercive nature of the often ineffective treatments. Individuals with experiences that might be labeled as psychosis in clinical settings can meet in these groups and explore their experiences in spaces that are free of clinical judgment. If a clinician brings a person to attend a Hearing Voices group, the clinician will often be asked to wait outside or in another room while the voice hearer attends. Members of these networks believe in the freedom of voice hearers to interpret their experiences in any way they see fit. The key to this approach is for individuals to be listened to in a curious, nonjudgmental way as they describe their experiences.

People are discovering that when listened to in this way, profound healing can occur. Eleanor Longden’s TED Talk, titled “The voices in my head,” is a great introduction to this approach. Longden describes how changing her perspective on hearing voices — from a disorder to be treated to experiences with meaning if one could just open up their metaphorical wrapping — led to a huge developmental shift that allowed her to make peace with her experience.

Treatment alternatives

I firmly believe the Hearing Voices Movement is in alignment with ACA values. ACA has a rich tradition of promoting social justice, honoring diversity, and supporting the worth, dignity, potential and uniqueness of people. In clinical practice, counselors work to promote the ethical principle of client autonomy, fostering the right of clients to control the direction of their treatment and lives. This aspiration is realized with all range of mental health concerns, but experiences that could be labeled psychosis are generally approached differently in the U.S. mental health system, potentially indicating a blind spot in the field of mental health.

In contrast to the ACA values I learned in my first semester of graduate school, I began to have a growing concern when learning about counselor roles that stood in opposition to those values. Specifically related to psychosis were the two roles of providing psychoeducation and monitoring adherence to medications. This involves instructing the client in the medical model, explaining that hearing voices and other unusual experiences are symptoms of a brain disease process, asserting that symptoms have no personal value or meaning to be explored, and teaching that treatment should consist of attempting to arrest that disease process. In taking that approach, psychoeducation essentially serves to impose a particular value or framework on the client’s experience of hearing voices.

The American Psychiatric Association established the medical model upon its founding in 1844, writing in its journal at the time that “we consider insanity a chronic disease of the brain …” That is the lens and approach that the organization has taken and buttressed with evidence. Of course, the medical model framework is useful for some people, and many useful treatments have been derived from it. However, there are other people who prefer alternative social or developmental models and lenses that are more in alignment with ACA values.

A 2017 United Nations Human Rights Council report concluded that one of the barriers to mental health and wellness was a lack of free and informed consent. Specifically, “In order for consent to be valid, it should be given voluntarily and on the basis of complete information on the nature, consequences, benefits and risks of the treatment, on any harm associated with it, and on the availability of alternatives.”

The availability and awareness of alternatives and complementary approaches may be a key piece that needs some work. It is important for counselors to identify innovative approaches in line with the ACA ethical principles of client autonomy and nonmaleficence, or avoiding actions that cause harm. I believe the Hearing Voices Movement is one such promising innovative approach, with evidence building in academic journals and books, including Living With Voices: 50 Stories of Recovery, by Romme and colleagues (2009).

A developmental model

In contrast to the medical model, counselors rely heavily on a developmental model of client concerns. The Hearing Voices Movement comes very much from a developmental perspective and fully acknowledges that voices are often a reaction to problems in life. Having learned that with 70% of adults the onset of voices was related to trauma or conflicts, Romme and colleagues studied 80 children who heard voices and published the results in 2004 in the International Journal of Social Welfare. They found that 75% of children had an onset of voices in relation to circumstances they felt powerless over.

Although the Hearing Voices Movement acknowledges a trauma connection to the onset of hearing voices for the majority of people, a blanket causal explanation for all voice hearing is not declared. All explanations are given space to be heard in the Hearing Voices Networks groups, including the medical model, psychological models such as voices being subpersonalities of the voice hearer, spiritual beliefs that the voices are spirits, and other possibilities.

As a side note to the developmental perspective of hearing voices, there is a new culture emerging of tulpamancers — people who intentionally work to develop voices they call “tulpas” to interact with as friends, based on an ancient Buddhist practice. A researcher at McGill University, Samuel Veissière, has done phenomenological research on tulpamancers, and Tanya Luhrmann of Stanford University is working on a neuroimaging study of these individuals.

The book Living With Voices outlines a three-phase developmental recovery framework identified from people who recovered from the distress of hearing voices:

1) Startled phase: Anxiety and a feeling of being overwhelmed dominate. Sigmund Freud wrote about his experience of being a voice hearer while living alone in a strange city in The Psychopathology of Everyday Life. His description of his experience was translated into English as the voice suddenly pronouncing his name.

2) Organization phase: Interest in the experience is developed, and the voice hearer looks for more information.

3) Stabilization phase: Person recovers their own potential and capacity to live the life they choose.

Although this may appear to be a linear process, in actuality the process may be repeated each time that a new voice makes itself know to the voice hearer.

To clarify, in the Hearing Voices Movement, to “recover” does not mean that symptoms have been eliminated but rather that the person has recovered from the distress of hearing voices. As was the case in the not-too-distant past when homosexuality was termed a mental disorder, the solution is not to force people to be different than they are but rather to change society to allow people to accept themselves as they experience life and love. 

A role for the counselor

In the U.S. mental health system, clients who hear voices are most commonly acculturated into the perspective that their voices reflect a disease process with no inherent meaning. Frequently, once a mental health professional identifies voice hearing as a symptom, the voice hearer’s underlying traumas are systematically ignored and invalidated. The only history then asked about is family history of mental illness to confirm the diagnosis, even though the person’s trauma history could be addressed in counseling.

The Hearing Voices Movement allows many voice hearers to discover relationships between their voices and their life experiences. Some voices have the tone or use the language of a childhood bully or an abuser. Often, voices express difficult emotions that the voice hearers are not able to express themselves.

The Maastricht interview, named for the Netherlands university city in which it was created, was originally a research tool designed in collaboration with voice hearers to learn more about their experiences, but it was found to have clinical value in the beginning process for clients to explore their experiences. The Maastricht interview can be considered a voice-mapping process in which the interviewer asks the voice hearer questions about the voices. Through this process, voices are discovered to serve different purposes, such as representing unfelt emotion, protecting the voice hearer, or attempting to solve loneliness or social isolation.

Among the questions the Maastricht interview uses to accomplish this are:

  • Have you noticed whether the voices are present when you feel certain emotions?
  • Are you able to carry on a dialogue with the voices or communicate with them in any way?
  • Does the manner or tone of the voices remind you of someone you know or used to know?
  • Can you describe the circumstances when you first heard them (each voice)?
  • Please describe your own interpretation of what causes your experience and what your theory is for why you have this experience.

The Maastricht interview can be found on Intervoice, the International Hearing Voices Network website.

The Maastricht interview features eight specific questions that explore potential trauma experienced in childhood at home, in school or in the neighborhood. In addition to the counselor facilitating the organization phase of recovery for the client, these questions provide validation of the client’s life experience and raise awareness of unprocessed trauma that may be worked through more effectively with counseling than in the Hearing Voices groups.

Similarities with internal family systems

In Richard Schwartz’s internal family systems (IFS) model, a person is conceived as being born with several distinct parts (like subpersonalities), each of which can pick up burdens or traumas in life, and a core self that is not affected by traumas. The parts interact within the person, much in the way that different members of a family interact as a system.

I asked Schwartz if the IFS model could work with people who hear voices. He told me that it could. The voices can be worked with as parts in the IFS model, and Schwartz has done work with people with schizophrenia diagnoses.

In the Hearing Voices Movement, voices are seen as being very interactive within the individual who hears them. Likewise, in the IFS model, voices can be looked at as parts that interact as a family system. Additionally, in the Hearing Voices Movement, the goal is not to eliminate the voices (although that sometimes happens). Similarly, in IFS, the goal is not to eliminate the person’s distinct parts but rather to help the person discover and release unprocessed trauma burdens so that the system can live in a harmonized way. Much like in the Hearing Voices Movement, in which voices are acknowledged as real, IFS is best carried out from the understanding that a person’s distinct parts are real and can act within the internal family system.

In one last similarity of note, at the World Hearing Voices Congress, Romme said that most voice hearers know the age of their voices. At his workshop, Schwartz had some participants check in with their parts and find out what their ages were. 

Conclusion

Romme has drawn comparisons between using treatment to try to eliminate a person’s voice hearing with using treatment to try to change a person’s sexual preference. I was struck when I first read this comparison because I at the same time kept reading about ACA’s push to support bans on conversion therapy for sexual preference. Romme repeated this comparison at the World Hearing Voices Congress.

Initially, I kept thinking about the level of distress people must feel who hear voices that tell them to harm themselves or others. But I have since met, talked with and listened to so many people who hear voices — and who have really taken control of their lives by changing their relationship to those voices — that I am beginning to think that Romme is right. In my lifetime, homosexuality was included as a diagnosable mental disorder in the Diagnostic and Statistical Manual of Mental Disorders. It took a rights movement to change that. The Hearing Voices Movement — a human rights and social justice movement — is now well underway, with networks in 37 countries and counting.

 

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Laren Corrin is a counseling graduate student at the University of Southern Maine. Laren is an advocate for alternative frameworks for psychosis and complementary approaches to wellness. Contact Laren at larencorrin.com.

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

When the caring is too much

By Christine Sacco-Bene and Fay Roseman January 13, 2020

With the proliferation of research and information focusing on human-animal interactions, counselors are more aware of opportunities to incorporate animal-assisted interventions as part of their clients’ treatment. However, there is a population of clients who have been overlooked in this equation until recently — veterinarians. In fact, the mental health of these professionals is an emerging area of research and mental health treatment. We (the authors of this article) have also seen the pressures of this field firsthand with our family members and friends who are veterinarians and veterinary students. The sheer level of stress and strain they experience on a day-to-day basis has a significant impact on their work and personal lives.

For that reason, this article focuses not on animal-assisted interventions or the benefit of animals in their humans’ lives but rather on the increasing need of mental health attention to the helpers who take care of our pets and service animals. Note that although the information presented here may be applicable to others who work to care for animals, we are focusing specifically on veterinarians and veterinary students in this article.

We depend on veterinarians to be kind, compassionate and attentive to their patients and their patients’ owners. Because of the multifaceted nature of veterinary service, the occupational stress of these interactions and the inherent professional isolation of the field can result in a number of mental health challenges, including compassion fatigue, burnout, depression and anxiety. Veterinarians face some of the same challenges that other health care professionals face, including working with a large number of stressed clients (people and animals), long hours, and limited financial resources. However, they also have the added pressures of meeting the difficult requests and expectations of pet owners, making the best decisions given difficult situations, and dealing with unwanted or sick animals.

In the Centers for Disease Control and Prevention report “Prevalence of Risk Factors for Suicide Among Veterinarians — United States, 2014,” Randall Nett and colleagues chronicled that veterinarians were found to experience serious psychological distress at a rate higher than the general U.S. adult population. Their survey of over 10,000 veterinarians in the United States further detailed that more than 1 in 6 veterinarians have experienced suicidal ideation. Belinda Platt and colleagues, in their study “Suicidal Behaviour and Psychosocial Problems in Veterinary Surgeons: A Systematic Review,” noted that these challenges have also contributed to the increasing rate of death by suicide among veterinarians. This information draws attention to the need for further consideration and development of support and assistance strategies for this community of helpers.

While neither of us has worked directly with this population, we do have a personal interest in this area. Christine has a close friend who is currently in her final year of veterinary medical training. The financial stress related to the cost of being in this professional program and uncertainty about how she will be able to pay off her college loans after graduation have caused her and her family significant worry. Even more startling are the stories about the strains the veterinary program puts on its students related to schedule, physical and mental demands, money, travel, etc. Christine’s friend has shared accounts of her peers breaking down in tears on a regular basis (sometimes several times a day), not sleeping or eating properly, pushing themselves to do more practice, and maintaining late night and early morning study times, sometimes alone and sometimes in groups, to prove themselves worthy to their faculty. The demands leave little (if any) time to engage in self-care, which seems to be affecting their current mental well-being and may be setting a precedent that will affect their mental health as they progress through their careers.

Fay’s daughter is a veterinarian who became interested in the high rate of suicide among veterinarians while she was in school for veterinary medicine. She explored the potential connection between compassion fatigue and suicidality and shared her work with Fay. After Fay’s daughter graduated and entered into veterinary work, she experienced the loss of colleagues to death by suicide. Our mutual concern about the high rate of death by suicide among veterinarians and the stigma felt by numerous veterinarians about seeking mental health counseling has prompted us to raise awareness of this issue with other counseling professionals. 

What veterinarians are saying about mental health

Some of the mental health issues that veterinarians face are similar to those faced by the general population. However, international studies, particularly in Europe and Australia, report more significant mental health concerns within the veterinary profession when compared with the general population or with other health care professionals. The 2012 article “Suicidality in the Veterinary Profession: Interview Study of Veterinarians With a History of Suicidal Ideation or Behavior,” by Platt and colleagues, indicates that specific challenges of workplace relationships, career concerns, patient issues, unreasonable work hours/work volume, and responsibilities related to clinical practice management are all contributing factors to veterinarians’ mental health issues. Research also notes that student debt and ethical dilemmas, most notably around issues of animal care and euthanasia, generate the highest levels of stress for this population. In a 2018 article for JAVMAnews (Journal of the American Veterinary Medical Association), R. Scott Nolen noted that veterinarians show a higher rate of psychological distress and have slightly lower degrees of well-being than does the general population. The seriousness of this dilemma is more significant when considering that 25% of veterinarians have considered suicide at some point in their lives and 1.6% have attempted suicide.

In their review of the practice of veterinary social work, Elizabeth Strand and colleagues found evidence suggesting that veterinarians may experience stress, anxiety and depression as early as their first year of study. High-achieving students are often drawn to veterinary medicine, and among this group, failure is not an option. Veterinary school is demanding and requires a great deal of time and energy from students, beginning with the acceptance process and continuing through clinical practical experiences. Rates of depression, self-harm, and suicidal ideation increase during the clinical year when students are completing medical rotations in various specialties of veterinary medicine. The rigor of each rotation and the requirement of completing multiple rotations, which can be located either near or far from home, present other challenges for managing stress and the life skills of students. Although the social support offered by family, friends, and veterinary faculty was found to be beneficial to these students, we believe the specialized training of mental health practitioners might improve outcomes for veterinary students during their course of study.

The debt acquired through the course of study can become a significant contributing factor to the stress levels experienced by veterinarians at the beginning of their careers. A review of the 2019 cost of veterinary medicine programs throughout the United States indicates that a four-year residential program can range from $168,000 to $329,000, whereas a nonresidential program can cost between $223,000 and $460,000. The median debt carried by veterinary school graduates ranges from $96,000 to $329,000. Given the significant cost of a four-year veterinary degree, it is easy to identify another reason for increased stress, anxiety and depression among this population.

The function of a veterinarian is not only to provide top-quality medical care to animals and to maintain a relationship with pet owners but also to do so in a compassionate manner, even when it creates significant stress for the veterinarian. Many veterinary professionals become overwhelmed when they need to offer emotional support and comfort to patients’ owners because they are not adequately equipped to handle the owners’ emotional responses. This is especially true when having to convey messages about a patient’s illness or death.

In her article “Moral Stress the Top Trigger in Veterinarians’ Compassion Fatigue,” Susan Kahler noted that giving bad news, managing adverse events, interacting with difficult clients, working in teams, and balancing work and home life create diminished levels of wellness for veterinarians. This work cannot be done in isolation, and the support staff in a veterinary hospital is a key component to the relationship between veterinarian, pet and pet owner. People trust that veterinarians will interact sympathetically with them, but managing these multiple relationships, in addition to providing ethical and professional care and respecting the dignity of the patient and patient’s owner, can be a challenge. This is especially relevant when considering that veterinarians encounter difficult issues — including cases of trauma, illness, abuse, terminal illness and death — on a regular, sometimes daily, basis.

Another identified contributing factor to the mental health issues of veterinarians is the ongoing pressure inherent in the daily operation of a clinical practice. In addition to the stress of managing the business side of the clinical practice (billing, inventory, equipment, payroll, legal, etc.), veterinarians are now dealing more frequently with “emotional blackmail,” which involves attempts to guilt these professionals for charging for their services. Just as we have seen in other industries, consumers of veterinary services are increasingly turning to social media to complain about products and service. In “Media’s Emotional Blackmail Is Killing Veterinarians,” Dr. Sarah Boston, a veterinary surgical oncologist, explained, “There are several results of this irresponsible reporting. The obvious one is the direct damage to the veterinary hospital and staff. There is also the widespread damage it does to all veterinary professionals when they receive the message that what we do is not valuable and should not cost money, and that we are terrible people who are only in it for the money.”

Suggestions for all helpers

Until recently, wellness and mental health self-care were not included in the curricula of veterinary training programs. Because veterinarians tend to be empathetic and nurturing, they focus their efforts on caring for and promoting the health and well-being of animals and routinely put the needs of patients and patients’ owners above their own. In her article on moral stress, Kahler explained that moral stress is unique in that the typical stress management techniques are useless and may even contribute further to mental health challenges. She encourages these professionals to redefine their work ethic to include self-care.

Self-care is really a moral imperative for all professionals in the helping fields, including veterinarians. Helping professionals have a moral obligation not just to facilitate patient care but also to take care of themselves. In collaboration with university training programs, mental health care professionals and counselor educators can help start this process by integrating self-care, stress management skills, and education about mental health issues and substance abuse into veterinary school courses. The College of Veterinary Medicine and the College of Social Work at the University of Tennessee created a collaborative partnership in which focus is given to animal-human interactions, including the issues of compassion fatigue and conflict management.

University counseling centers can also be invited to have greater presence during professional development seminars with veterinary students. This can help erode the stigma of students and professionals seeking mental health care when it is needed. The colleges of veterinary medicine at both Ohio State University and Colorado State University have taken proactive positions in providing resources and education to their students about mental health and self-care.

In addition to reaching out to veterinary programs to capture the attention of students, professional counselors might consider reaching out directly to veterinary professionals. The integration of tools to manage school-work-life balance should be incorporated at both the student and professional levels.

Moral stress and its associated challenges — compassion fatigue, burnout, depression and anxiety — can feel insurmountable to manage. Veterinarians are generally problem-solvers, analytical thinkers and high achievers. They tend to be task oriented and strive toward order. These characteristics certainly help veterinarians to be good at their jobs, but they do little to help these professionals remain good “in” their jobs. Although veterinarians are empathetic toward their patients, some may lean toward low self-awareness and struggle with understanding or dealing with their own emotions. Incorporating opportunities to promote emotional intelligence during veterinary programs and professional development trainings can help these professionals to become more aware of their emotions and the emotions of others, which in turn facilitates better management of themselves and their relationships with colleagues, staff members and patients’ owners.

Mental health professionals can assist veterinarians with increasing awareness of their emotional reactivity and help them take a more proactive approach to self-understanding and emotion regulation. Daniel Goleman popularized the psychological theory of emotional intelligence and its five components: self-awareness, self-regulation, internal motivation, empathy, and social skills. These components can easily be assimilated into training and wellness interventions. Emotional intelligence enhances the individual’s ability to reroute their thinking, allowing them to move away from their initial emotional response to situations (including avoidance) and toward more action-based reasoning.

Many times, veterinarians with a history of suicidal thoughts or behaviors do not talk about or share their experiences with anyone because they feel guilty or ashamed. Their silence may also be attributed to a fear that reaching out will affect their job, or simply to a feeling that they do not have time to seek help. Providing a space for group work, whether in person or virtually,  allows veterinarians to develop support networks. Kahler explains that group time presents veterinarians with a setting to talk about and debrief their experiences and memories together in an open, safe forum. When this group interaction occurs, the group members start making sense of their situations and learn that they are not isolated in their experiences.

One of the major stress factors for this group of professionals is their reported lack of time. Especially for those with busy schedules or those who work in rural areas, telemental health services may be a particularly attractive option.

In addition, bibliotherapy is a brief adjunct intervention that is helpful with a variety of psychological problems. It can be a resource for veterinary professionals with busy schedules or for those who work in locations far from traditional mental health offices. Bibliotherapy is used to increase clients’ understanding about what they are experiencing, and it promotes agency in their treatment. In their systematic review of the use of bibliotherapy in the treatment of depression, Maria Rosaria Gualano and colleagues explain that there is a self-help element to bibliotherapy. It teaches, through the reading of specific material, a number of strategies designed to regulate negative emotions and explains how to practice them in daily life. Bibliotherapy interventions are best used in conjunction with counseling. They can be used between counseling sessions to enhance clients’ commitment to working toward health and well-being.

Finally, mental health professionals can help by providing education, maintaining open opportunities for collaboration, and advocating with the veterinary field to promote well-being and reduce stigma around mental health issues and counseling.

Conclusions

The suicide rate among veterinary professionals is higher than that of other professional fields due to the unique responsibilities of veterinarians. Veterinarians, like other helping professionals, are at risk of giving too much of themselves to their patients and their patients’ families, their staffs, and their businesses and leaving little time for themselves because of their natural qualities of compassion, empathy and caring. A variety of stressors, starting during veterinarians’ programs of study, can lead to mental health issues over time.

On the basis of what we have learned, we believe that providing access to counselors and other mental health professionals could help veterinary students become more proactive in managing some of the emotional challenges they may face as they move through their programs of study. In addition, counselors working with veterinarians in the community can help these clients identify any unhealthy coping methods and provide opportunities for promoting resiliency and wellness. This may require offering strategies that extend beyond the counseling office because of the veterinary profession’s time demands.

Resources

Various resources are available to counselors working with these gifted healers and for veterinarians themselves.

The American Veterinary Medical Association (AVMA) lists several articles and resources for its members and for those who work as veterinarians. Among the areas highlighted under AVMA’s professional development dropdown menu at avma.org are well-being and peer assistance.

The University of Tennessee veterinary social work program provides referrals and resources to people in veterinary practice. The university’s S.A.V.E (Suicide Awareness in Veterinary Education) mental health education program, which was created to honor a colleague’s last wishes, has served as a model for mental health education in veterinary schools across the country (see vetsocialwork.utk.edu and vetmed.tennessee.edu/SAVE).

The National Suicide Hotline (suicidepreventionlifeline.org) provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, seven days a week.

 

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Christine Sacco-Bene is a licensed professional counselor and licensed mental health professional. She is an associate clinical professor in the Rehabilitation Counseling Department at the University of South Carolina. Over her 15 years as an educator, she has been an advocate for students and professionals in the field of counseling (and in all helping professions) to engage in self-care activities to support their mental well-being and professional growth. Contact her at christine.sacco-bene@uscmed.sc.edu.

Fay Roseman is an associate professor in the counseling program in the Adrian Dominican School of Education at Barry University in Florida, where she also served as the coordinator for practicum and internship. As a practitioner certified in the Myers-Briggs Type Indicator, she teaches career development and other courses in the master’s and doctoral programs. Contact her at froseman@barry.edu

 

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.