Tag Archives: Mental Health

Life after traumatic brain injury: Lessons from a support group

By Judy A. Schmidt October 8, 2018

Support groups are wonderful opportunities for people with similar life experiences to meet each other, share their stories and encourage one another. Group members benefit from learning coping strategies and everyday tips for dealing with various experiences. For people with traumatic brain injury (TBI), support groups offer informal opportunities for understanding a shared experience that greatly changed their lives, often within a few seconds’ or minutes’ time. They are left with physical, cognitive and emotional outcomes that impact their relationships, work and independence, often leading to loneliness and isolation.

As noted by the Brain Injury Association of America, more than 2.5 million adults and children experience a TBI in the United States each year, and support groups play a vital role in their continued recovery and re-entry to everyday life. A TBI dramatically interrupts life for these individuals and their families. Extended hospitalizations for physical recovery and long-term cognitive training for rewiring the brain alter all aspects of life, with treatment continuing for up to a year after the incident.

 

Effects of TBI

The effects of TBI are varied and highly individualized. The extent of the physical and psychosocial impacts depends on the type of injury (closed, open or acquired) and the severity of the injury. Thus, depending on the area of injury, people with TBI may deal with deficits in memory, executive functioning issues and poor judgment.

Frontal lobe injuries may lead to changes in mood and personality, difficulty making decisions and difficulty with expressive language, all of which are executive functions.

Injuries to the parietal lobe, which helps with perceptual abilities, may lead to difficulties naming words (anomia), finding words (agraphia) or reading (alexia), as well as problems with perceptual abilities that integrate sensory information. The ability to distinguish right from left may also be affected.

Damage to the temporal lobe may involve hearing loss, Wernicke’s aphasia (difficulty grasping the meaning of spoken language), problems categorizing information such as objects and short-term memory problems.

Brain injuries to the occipital lobe, which controls our vision, may lead to visual field problems, distorted perception and difficulty with reading, writing and word recognition.

Injury to the base of the skull at the site of the cerebellum creates difficulties with balance, equilibrium and coordination, as well as slurred speech.

Acute and long-term rehabilitation from TBI involves physical, occupational and speech therapy, as well as cognitive neuropsychological evaluations. As individuals recover from the physical damage, it is important for counselors to be a part of the rehabilitation team to manage adjustment to the physical injuries, acute stress and cognitive disability. In addition, the psychosocial aspects of TBI are very disruptive. They can be long-lasting as these individuals and their families begin to adapt to everyday life. Counselors are needed to provide individual and family counseling, as well as psychoeducation about TBI and recovery.

 

Psychosocial aspects of TBI

The psychosocial aspects of TBI are also related to the area of brain damage. People with frontal lobe damage may have difficulty making decisions, maintaining attention to tasks and controlling impulsive behaviors.

When the parietal lobe is damaged, difficulties occur with eye-hand coordination, reading, math and writing.

Temporal lobe damage interferes with communication skills, learning and memory. Learning difficulties due to recognition and visual field problems may result from occipital lobe damage.

In assisting people with TBI and their families, it is important to understand how psychosocial areas of life are affected and how these areas impact the potential return to daily living. For example, an individual may not return to his or her pre-injury abilities and can experience problems returning to work or school. Difficulties with problem-solving, understanding others’ emotions and social cues, or just being able to carry on a conversation may isolate the person with the TBI and increase his or her feelings of loss. Other areas of life that may be affected include the ability to drive, participate in sports and exercise, which can create deficits in the person’s social life. Problems with executive functioning can lead to challenges making sound decisions. Because safety is a major concern, the individual with a TBI may need to be monitored consistently by family, which can lead to tensions and other problems.

These are all skills that most of us take for granted or complete without much planning and forethought. But for individuals with TBI, family and personal relationships can grow strained, and the ability to build new relationships is impacted. The person’s independence and self-esteem suffer greatly.

 

Lessons learned

As a rehabilitation counselor for an acute inpatient rehabilitation program, I work with individuals who have TBIs, as well as their families, to provide counseling for stabilization, adjustment to disability and assistance with developing coping strategies. Providing support to these patients and their families as they begin realizing the extent of the brain damage and start dealing with feelings of loss is a crucial part of recovery.

For three years, I facilitated a monthly outpatient support group for people with TBI and found the experience fascinating. Hearing stories of people having car accidents, motorcycle accidents, work accidents, anoxia (deprivation of oxygen) and other unexpected accidents was difficult and often heart-wrenching. Yet these shared experiences forged a bond among group members that was undeniable and very moving.

They shared what it was like to not remember exactly what had happened to cause their brain injury. They shared what it was like to lose track of time and details and to have to trust the information told to them by health care providers, family members and friends. The fact that they each had “lost a period of time” from their lives and hadn’t been the same since seemed to build a sense of trust and caring among the group.

I soon learned that as a rehabilitation counselor, I could understand the medical, cognitive, vocational and emotional results of their injuries, but I couldn’t fully appreciate the daily psychosocial impact that their injuries had taken and continued to take on their lives.

The time since being injured varied among the support group members — anywhere from two years to 18 years. Regardless, the psychosocial effects they experienced were extensive. They talked about their school and work being interrupted, about having to settle for less challenging options or not being able to pursue their goals at all. Some shared tales of broken marriages and relationships, of losing custody of their children.

Others talked about losing their sense of independence because they had to rely on their families for almost everything. Some could no longer live at home due to the need for constant supervision, so they had to learn to live in group homes. Pursuing sports or other recreation choices was hard because of physical limitations. Another significant loss was no longer being able to drive and depending on others for transportation. The lack of money for “extras” was particularly difficult for those group members with children.

Holidays posed another challenge for these support group members because of sensory issues with noise, lights and too many people talking at once. Others discussed experiencing the stigma of having a TBI and being considered “different now” by family members and friends. This was felt particularly strongly at social gatherings, where family and friends made infrequent contact with them. Isolation and loneliness were prevalent themes in their stories. Depression, anxiety and low self-esteem made daily life a struggle.

Research conducted by Jesse Fann and colleagues in 2009 and by Annemieke Scholten and colleagues in 2016 and subsequently published in the Journal of Neurotrauma shows that the rate of depression during the first year after a TBI is 50 percent. The rate is close to 60 percent within seven years after the TBI. So, it is crucial for counselors to have this awareness of serious mental health issues in people with TBI to properly assist them and their families in seeking appropriate treatment.

Members of the support group I facilitated discussed that being on medication was difficult due to the side effects and to the cost of the medication if they had little or no insurance. They felt that cognitive retraining programs and daily psychosocial programs modeled after those for people with serious and persistent mental illness helped tremendously. The aspects of these programs that they reported helping most were receiving cognitive behavior therapy and continuing to learn more about TBI. The psychosocial programs were highly regarded because of the increase in social activities, access to vocational rehabilitation and supported employment services, and integration back into the community.

At times, the support group was difficult to manage because of the cognitive and emotional deficits with which the individuals dealt. However, the members had their unique ways of helping each other and redirecting the conversations. It was very clear that they respected one another.

Our time together as a support group transformed us into a unique family, particularly because the group remained fairly constant in its membership. The members trusted each other and understood the struggles being discussed. However, they also felt safe in correcting each other and being bluntly honest (which people with TBI are). We did have some new members join along the way. They were welcomed with open arms, and veteran members exhibited an unabashed eagerness to help. It was always interesting to hear about the creative accommodations that our members developed to live life each day and how the professionals in their lives assisted them.

As the group grew stronger, the members felt it was important for me to record what they wanted others to know about TBI and people with TBI. Their primary messages were:

  • “Conversation and expressing one’s self can be difficult.”
  • “People with TBI may not like the same things as they previously did, so don’t force us.”
  • “Tasks may take longer for people with TBI, so wait for us.”
  • “Social situations can overload people with TBI.”
  • “TBI affects everyone around the person.”
  • “Those with TBI are still the same people they were before.”

During my time with the support group, I learned many lessons. First of all, I learned that life after a TBI requires constant adjustments that must be made each day to be productive and involved. I also came to understand that time does offer healing when abundant respect and empathy are present. But most important, I learned about living life as it happens from a wonderful group of resilient individuals.

 

 

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Judy A. Schmidt is a clinical assistant professor in the clinical rehabilitation and mental health counseling program in the Department of Allied Health Sciences, and an adjunct clinical assistant professor in the Department of Physical Medicine and Rehabilitation, School of Medicine, at the University of North Carolina (UNC) at Chapel Hill. She is the rehabilitation counselor for the acute inpatient rehabilitation unit for UNC Hospital, where she provides counseling services to patients and their families after traumatic brain injury, stroke, spinal cord injury and other neurological trauma. Contact her at judy_schmidt@med.unc.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.

Identifying colors to create a rainbow of cohesion in the workplace for helping professionals

By Jetaun Bailey and Bryan Gere September 7, 2018

The idea for this piece came about when I (Jetaun Bailey) was pursuing my master’s degree in counseling. I recall my professor stating clearly that burnout occurs often among helping professionals and that the average stay for a counselor employed at a mental health facility is two years.

As one of my assignments, I completed and presented a paper on ways for helping professionals to avoid burnout. However, not once in my presentation did I illustrate ways that the workplace could employ preventive services to combat burnout. At the time, my focus was on using self-care and, ultimately, I received a grade of 100 on that project. However, in reflecting on my counseling career, I realized that workplace training programs overlook helping professionals by not addressing topics related to the complex workplace dynamics that may contribute to burnout, which is likely to increase, because the demands in the counseling profession can be overwhelming.

According to Amanda Stemen’s 2014 article, “Burnout: Who’s taking care of the care takers?” management in the helping professions focuses more on clients than on employees. Many factors are related to burnout. Low salaries are one contributing factor but not the most significant. Many of us who enter the helping professions, counseling in particular, understand that we are not pursuing a lucrative career. However, lack of managerial support is believed to be a significant factor in burnout. This lack of support isn’t necessarily intentional; it is thought that many in management believe that helping professionals have innate abilities to solve their work-related problems. However, in many cases, counselors work in isolation, without support from management and peers, and know its effects.

Thus, management’s support is critical in reducing burnout among helping professionals. In speaking with Terra Griffin, a manager at an acute behavioral hospital unit for children and adolescents, she revealed that the turnover in the unit was among the highest in the hospital. Such high employee turnover costs organizations time and productivity. One of the staff’s chief complaints was management’s failure to provide them with relevant training to meet the demands of the job and promote workplace cohesion, which had led to many problems within the teams.

Stemen’s article suggested the need for professional development in addressing burnout. She reports that providing professional development opportunities customized to employees’ interests encourages growth that benefits both the individual employee and the organization.

 

Mind-mapping

One professional development approach is to employ mind-mapping concepts. This is accomplished by creating a specific topic or question so that each person in the training session can see other points of view rather than just his or her own. This nonintrusive approach facilitates group cohesion. Researcher Tony Buzan, the author of Use Your Head, developed the mind-mapping concept in the 1970s. It is designed to facilitate the sharing of ideas and concepts to solve problems.

Through observation, Griffin employed this concept in a series of training sessions simply by asking employees in a unit where turnover had been problematic a simple question: “What is your favorite color?” Initially, the employees did not seem eager to participate in the training session. Remarkably, however, when Griffin focused the initial session on that single question, changes in body language occurred among the staff immediately, as if thinking about their favorite colors had some sort of healing effect. Afterward, they were eager to share their favorite colors and the ways they identified with those colors personally.

Interestingly, although employees weren’t given information about the psychological meaning of each color ahead of time, they ended up describing them similarly to how they were presented on Griffin’s color chart. Furthermore, they could identify their similarities and differences in relation to their multiple colors. This helped shed light on some of the difficulties the employees faced in creating a more cohesive work environment.

Three therapeutic teams were present at each training session, each of which was composed of two therapists, one psychiatrist, several nurses and several behavioral specialists. During their self-exploration of the colors, Team 2 realized that many of its members shared the same favorite color, red, while the two therapists identified with blue. Incidentally, of the three groups, Team 2 was confronting the most difficulties. Many of the team members who identified with red were having difficulties sharing leadership responsibilities and were disregarding the leadership authority of the two therapists who identified, unconsciously, with blue. Once members of Team 2 were able to understand their difficulties, they began to discuss ways that their team could work more cohesively. As a result, Team 2 set team goals, with respecting one another identified as the top priority.

Instead of asking employees direct questions about their workplace problems, this exercise of looking at their favorite colors appeared to be a nonintrusive method that encouraged employees to share their differences. Griffin’s simple question elicited many answers with respect to therapeutic problems occurring in this workplace of helping professionals, and thus promoted resolutions to some stressful issues.

 

The psychology of color

Intrigued with the feedback from the staff during these sessions as they compared their favorite colors to their personalities with respect to their workplace relationships, we set forth to emulate this training. Ultimately, we implemented a similar version in a group of training sessions for graduate students who would be entering the helping profession as practicum and internship students. Their feedback and interactions were outstanding. We learned much about our students that we had not known, and this helped us revamp our practicum and internship training program for students and site supervisors.

As a result, we set out to explore how many nonintrusive, evidence-based training programs of this nature were available. We conducted a content analysis of evidence-based studies on the psychology of color. We also sought to determine the extent to which such training materials are designed to facilitate workplace cohesion among helping professionals.

Using the American Psychological Association (APA) database and electronic resources, we searched APA PsycNET, PsycINFO and PsycARTICLES from their inception through 2018. Furthermore, we used the Google Scholar search engine. The search phrases we used were “evidence-based practices on color psychology” and “training curriculum on color psychology.” The criterion for inclusion for review was that the title contained the search phrase; studies that did not meet the criterion were excluded.

After completing the content analysis, we could not find a single evidence-based study on color psychology or training curriculum related to the topic. We also were unable to determine the extent to which such training curricula facilitated workplace cohesion among helping professionals. There appears to be a significant gap in the literature pertaining to the actual use of color psychology in the facilitation of workplace cohesion in human services or among helping professionals. We did not find any specific evidence-based studies that provided empirical information on training materials on the subject that lead to workplace cohesion. The absence of this information reflects the extent to which the topic is largely unexplored and illustrates what little recognition it is accorded.

In “Colors and trust: The influence of user interface design on trust and reciprocity,” Florian Hawlitschek and colleagues indicate that the literature available on the psychology of color suggests that color preferences associated with personality influence interaction patterns in the employment setting. This illustrates that understanding the role that color preferences play in group behaviors and settings is critical to interprofessional collaborations, especially among helping professionals. Furthermore, other literature has suggested that colors have individual meanings based on a person’s cultural background or racial and ethnic group. Therefore, the influences of color should be interpreted with caution.

However, what made this training so unique is that Griffin did not use any assessment tools to determine anyone’s colors. Instead, she asked each person his or her favorite color and thus gave life to their individuality based on their cultural or racial and ethnic backgrounds without probing for any specific details (colors hold a universal meaning of harmony in many cultures). This mind-mapping technique seemed beneficial. Griffin’s leadership played an important role in helping the employees navigate through their favorite colors by connecting to their personalities and the way they fit within the scheme of their work productivity to create or disrupt cohesion.

 

Conclusion

As the dynamism within health and human service delivery creates more interdependencies, there is a growing need for professionals to collaborate to achieve better client outcomes. However, there is little information on the role that the characteristics of interdisciplinary teams play in promoting synergy that influences such outcomes.

Shared values, mutual respect for colleagues’ expertise, and patient-oriented goals and outcomes are reflections not only of the diverse interests and asymmetry of power of the various partners in care, but also differences in their personalities and preferences. Therefore, fostering workplace cooperation and cohesion is essential for effective, competent, cost-effective, culturally responsive and comprehensive service delivery.

Creating mind-mapping trainings designed to honor individual uniqueness, such as the identification of favorite colors, can help us achieve such cohesion. These trainings draw us into companionship where we can evaluate our similarities and differences through our individual uniqueness, thus creating a meaningful and purposeful work environment for helping professionals and the clients they serve.

 

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Jetaun Bailey is an assistant professor at Alabama A&M University, where she serves as director of clinical training. Contact Jetaun at jetaun.bailey@aamu.edu or baileyjetaun@hotmail.com.

 

Bryan Gere is an assistant professor at Alabama A&M University, where he serves as coordinator of clinical training in rehabilitation counseling. Contact Bryan at bryan.gere@aamu.edu.

 

Terra Griffin, a licensed professional counselor supervisor with more than 15 years of experience in counseling management, supervision and training, contributed to this article.

 

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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.

Finding balance with bipolar disorder

By Laurie Meyers April 24, 2018

Licensed professional counselor (LPC) John Duggan didn’t plan on bipolar disorder becoming one of his specialties, but providing emergency room support gave him a close-up view of the consequences when the disease was left uncontrolled. Duggan, who is also a licensed clinical professional counselor (LCPC), noticed the escalation in manic and hypomanic crises that accompanied the increased light and time change in spring. He also saw people who had been diagnosed with depression but whose manic or hypomanic symptoms had gone undetected until they ended up in the emergency room with full-blown mania, psychosis or dysphoria.

Some of these individuals had no one to help them remain stabilized after leaving the hospital. Seeing the need for, as Duggan puts it, “boots on the ground,” he began seeing more and more clients with bipolar disorder in his private practice in Silver Spring, Maryland. Duggan, who is now the manager of professional development at the American Counseling Association, says some of those clients came as referrals from counselors who didn’t feel qualified to work with individuals struggling with bipolar disorder.

It is not uncommon for counselors to be hesitant to take on clients with a bipolar diagnosis, according to practitioners who specialize in the disorder. At the same time, there are many individuals with bipolar disorder who truly need the support of counselors and other mental health professionals to help them manage their condition. Although the public — and perhaps even some mental health professionals — may think that the disease is rare, the National Institute of Mental Health (NIMH) estimates that approximately 2.8 percent of U.S. adults currently have bipolar disorder and that 4.4 percent will experience it in their lifetime. NIMH also estimates that approximately 2.9 percent of adolescents currently have bipolar disorder.

Some mental health practitioners may buy in to the stereotype that clients with bipolar disorder are volatile and resistant to treatment, whereas others may be daunted by the disorder’s elevated risk of suicide. The Substance Abuse and Mental Health Services Administration estimates that for those with bipolar disorder, the lifetime risk of suicide is at least 15 times higher than it is for the average person. However, Duggan and others who treat bipolar disorder say that counselors have a crucial role to play in helping clients manage the disease.

Bipolar basics

Counselors are already trained to obtain a detailed client history that includes, among other things, emotional symptoms, family history and sleep and lifestyle habits, all of which can be crucial to spotting bipolar disorder.

“Bipolar clients often seek help only when depressed. Because of this, their manic or hypomanic symptoms are often not reported or observed,” explains Valerie Acosta, an LPC who counsels a number of clients with bipolar disorder in her Richmond, Virginia, practice.

A first step is for counselors to educate clients. Although they may be familiar with the symptoms of depression, they are much less likely to know how mania or hypomania present, adds Acosta, a member of ACA. Many clients think mania involves feeling very “up” and happy, but symptoms actually include intense irritability, anxiety and distraction, she explains.

Sleep patterns are also instructive when looking for evidence of mania or hypomania, says Regina Bordieri, a licensed marriage and family therapist in New York who specializes in bipolar disorder. “If they’re not sleeping, are they feeling energetic or tired?” she asks. Most people feel tired after a short night’s rest, but in hypomanic or manic phases, those with bipolar disorder feel energized despite very little sleep, Bordieri explains.Bordieri also asks clients about times when they weren’t depressed. Did they have high levels of energy and feel like they could get a lot done? Depressed moods that alternate with periods of intense activity and feelings of almost limitless energy may be signs of bipolar disorder.

Because it can be difficult for individuals to recognize their mood and behavioral shifts, family members and partners can also play a significant role when it comes to identifying and gauging symptoms, Bordieri says. Then, of course, there is the other role that family plays in diagnosis — namely, family history. Bipolar disorder is strongly tied to genetics, so clients with a family history of bipolar disorder are more likely to develop the disease.

Duggan urges counselors who are treating clients with bipolar disorder to work closely with medical professionals. Consulting a client’s primary care physician (with the client’s permission) is particularly crucial during diagnosis so that physical causes such as sleep disorders, thyroid disorders or a reaction to medication won’t be mistaken as symptoms for bipolar disorder.

Counselors — and clients — should also be aware of their ideas concerning which symptoms and forms of bipolar disorder are most debilitating, say Acosta and Bordieri.

“Bipolar II is not a milder form of bipolar I, but a separate and different diagnosis,” Acosta explains. “Bipolar I is also not necessarily more difficult to treat. … While the manic episodes in bipolar I can be severe and dangerous, the depressive episodes associated with bipolar II can be longer lasting, causing severe impairment to the individual. While clients with bipolar II have hypomania and not full manic episodes, their depressive episodes can be more debilitating than the depressive episodes of bipolar I.”

Although the depression of bipolar II may take a greater overall toll and be harder to treat, the mania inherent in bipolar I comes with its own set of “baggage.” In the popular imagination, mania — especially more extreme episodes — is the phase most associated with bipolar disorder and contributes to the perception that those who have the disorder are “crazy.” Mania is also extremely disturbing for clients and is highly stigmatized, especially when it leads to hospital stays, Bordieri says.

Ultimately, however, each client’s experience of bipolar disorder is different, Acosta says. “A therapist might be working with two people with bipolar II, and these individuals may present with very different symptoms,” she says. “Helping clients and their families to understand the individual’s unique symptoms, and have a variety of tools and strategies for managing their moods and specific symptoms, is essential for recovery.”

Managing medication

The counselors interviewed for this article stress that because of the neurobiological nature of bipolar disorder, medication is an integral part of treatment. Cheryl Fisher, an LCPC practicing in Annapolis, Maryland, whose specialties include bipolar disorder, says that counselors should work closely with a psychiatrist when treating these clients. In fact, when Fisher sees new clients with bipolar disorder who are working with a primary care physician, she strongly urges them to begin seeing a psychiatrist. Fisher, a member of ACA, believes that psychiatrists possess the specialized psychopharmaceutical knowledge necessary for prescribing the medication “cocktail” that works best for each individual with bipolar disorder. And because counselors see clients more often (and for longer chunks of time) than their physicians do, Fisher thinks that counselors are in a better position to track the effectiveness and side effects of clients’ prescriptions.

Counselors can also help clients become better self-advocates, says ACA member Dixie Meyer. Sometimes clients aren’t comfortable speaking up at the doctor’s office or are unaware that they are even experiencing side effects, she says. Counselors are in a position to spot such problems.

Meyer gives the example of a client who was showing signs of lithium toxicity. “I asked him when was the last time he had his blood levels checked [lithium requires regular blood testing to guard against toxicity]. He asked me what I was talking about. Somehow, he never knew he needed to have levels checked regularly.”

Meyer, an associate professor in the medical family therapy program at the St. Louis University School of Medicine’s Relationships and Brain Science Research Laboratory, says counselors should also be aware that clients with bipolar disorder might be given antidepressants for depression that can cause the onset of mania or hypomania.

“Clients might feel like, ‘Wow, I’m really starting to have a good mood,’” she notes. “They don’t really think to bring that up to the doctor, but the counselor can easily recognize the difference between remission of depression symptoms versus the development of manic symptoms. [Clients] might become more impulsive, snippier, their motor behavior more agitated … Counselors and family members are often the best [resources] to spot mood shifts.”

Sometimes clients don’t want to take medication for bipolar disorder because they have experienced unpleasant side effects, says Meyer, who frequently gives presentations to counselors on the importance of understanding their clients’ medications. She urges counselors to talk through this decision with clients. Meyer informs her clients with bipolar disorder that all medications have side effects, some of which may be temporary. She then asks these clients to give the medications some time and encourages them to talk to their physicians about which side effects might be permanent.

If the side effects of the medication aren’t going to go away, Meyer talks with clients about whether the side effects are something they can live with. In some cases — especially with medications that cause significant weight gain — the client’s answer is no. In those situations, Meyer says that she, the client and the physician go back to the drawing board and look for other medications or explore whether lifestyle changes might help reduce the side effects.

Meyer says all counselors should have a copy of the Physicians’ Desk Reference on hand so that they can quickly look up any medication. She also recommends Drugs.com as an excellent online resource.

Sometimes clients with bipolar disorder get stabilized and decide that they don’t need to take their medications anymore. When that happens, Acosta says that she “reflects back” what happened the last time the client stopped taking his or her medication. (Spoiler alert: It wasn’t good.)

Fisher tries to educate clients about bipolar disorder, emphasizing that a biochemical reaction underlies their mood shifts and that the medication helps buffer that process.

Medication, however, is not the only tool in the box to help individuals with bipolar disorder. Counselors can provide the emotional and lifestyle keys that help clients manage and, hopefully, decrease their mood and behavior shifts.

Prevention and stabilization

Multiple research studies continue to demonstrate the link between the circadian rhythm and bipolar disorder. Researchers are still teasing out the specifics, but what is clear is that maintaining a schedule — particularly a sleep schedule — that hews to the circadian rhythm plays a key role in controlling the disease.

Research has shown that insomnia is not just a symptom of depression but can also cause it. Likewise, Bordieri says, disturbed sleep can be either a symptom of hypomania/mania or the trigger for an episode.

Sleep is one of the first things that Fisher investigates with all clients, but it is particularly important in those with bipolar disorder. “I ask them what their sleep routine is,” she says. “How do you end your day? How do you prepare your body to rest? What is your sleeping environment like?” Fisher talks about how the blue light from devices such as smartphones and tablets disrupts sleep and advises clients to establish total darkness in their bedrooms.

Some clients reveal that a racing brain regularly prevents them from going to sleep. For these clients, Fisher recommends tools such as guided meditation or performing what she calls a “brain dump” — emptying the mind by writing down all of the thoughts that are keeping clients awake.

Acosta encourages clients with bipolar disorder to go to bed at the same time every night, wake up at the same time every day and take their medications at the same time daily. She has found this routine has a stabilizing effect.

Fisher and Duggan both believe sleep is so essential to mental and physical health that if good sleep hygiene isn’t working, they advise clients to get a sleep aid from their physician.

Duggan has found that the changing of the seasons can also have a profound effect on bipolar disorder. It’s a component of the bipolar resiliency program he came up with called SMART.

S — (Control) stress, sleep, maintain a schedule, seasons: Duggan asks clients with bipolar disorder to track their moods and sleep. He also teaches sleep hygiene and makes note of clients’ responses to the different seasons. Summer, when there is a lot of activity going on and plenty of sun, is usually a good time for many clients with bipolar disorder. But as the season draws to a close, Duggan reminds them that once fall arrives and there is less light, they are likely to start feeling less upbeat and may feel overwhelmed. He urges these clients not to overschedule themselves in summer and to step up their self-care efforts when the calendar turns to September.

M — Medication as prescribed

A — Adjunctive treatment such as yoga, acupuncture, massage or other complementary or alternative practices: Duggan says these are all areas that are outside of his expertise but that clients have found helpful. He also works with clients on self-soothing techniques and meditation. If a client is going through a severe manic or depressive phase, however, he strongly recommends against mindfulness. “I don’t want them to ‘be’ with the bad depression or the bad mania,” he explains.

R — Recreation and relationships: Duggan urges clients with bipolar disorder to stay engaged socially and to “do things that bring you joy, that you love, that give you a sense of flow.”

T — Therapy and counseling as needed

Fisher is a proponent of what she calls “nature therapy.” Research has shown that nature has a beneficial effect on mental health, so she urges clients to find a way to get outside — even if only for a short time — every day.

“Encouraging clients to track their moods can be a very valuable tool,” Acosta adds. “There are a wide variety of apps that clients can download to help with tracking their moods. Daylio is one that a lot of my clients like to use. By recording this information over time, clients learn about how their moods cycle, and this helps them to better understand the nuances of their moods, their triggers, and what helps and does not help with stabilizing their moods. I routinely review data from these apps — or paper mood charts — with my clients. I also routinely review symptom charts with my clients to help them monitor their symptoms.”

Some of Acosta’s clients have also had their own highly personal methods of tracking problematic mood changes. One client monitored her mood elevations by the number of packages that appeared for her in her apartment lobby (overspending). Another client could connect his manic symptoms to times when he would spend several days engrossed in building things (an increased focus on goal-directed activities).

Developing this degree of self-awareness can be beneficial for clients with bipolar disorder. “Linking symptoms to behaviors, thoughts and triggers can help to foster recovery,” Acosta says.

Meyer also teaches clients to spot patterns. She has premenopausal women chart their menstrual cycles so they will be aware, for example, that three days before their periods begin, they will feel more depressed. Meyer instructs clients to note their moods throughout the day and record what was going on. She believes that when clients can identify these patterns and recognize that there was a specific reason they were particularly manic or depressed, it provides them a greater sense of control.

Meyer teaches clients to self-soothe on hard days by going for a walk, going to the park and sitting on a bench or doing whatever else makes them feel good in a healthy way. 

“It’s really important … that our clients be empowered with a strategy for their symptoms,” Fisher says. For instance, if clients with bipolar disorder are having a down day and feel as though they are shifting toward a depressive episode, they could start to manage the switch by making a plan to get together with a friend or even just calling someone close to them.

Acosta tries to equip clients with bipolar disorder against life stressors. “They need to find healthy ways to cope with stress,” she says.

Acosta teaches clients mindfulness meditation and gives assignments outside of session, such as trying yoga or a new form of exercise. She believes that physical activity helps rein in racing thoughts. Acosta also recommends music for relaxation.

Seeking support

In addition to individual therapy, Acosta has found that group therapy is very effective for clients with bipolar disorder. She runs a monthly support group for adults over 18. “Some participants have been living with bipolar disorder for decades, and some have just been diagnosed,” Acosta says. “This is an open group, so members are constantly joining and leaving the group. On average, we have three to 10 participants per group. Because this is a therapy group, participants bring in and discuss any issue that they’re currently dealing with in their lives. Some of the topics of discussion include challenges such as the struggle to be on time for work or losing a job because of their bipolar symptoms, relationship conflicts, the side effects of medication, healthy strategies for managing symptoms, grieving the losses in their lives caused by their illness and building healthy living strategies.”

Acosta also provides education as needed in the group on topics such as understanding symptoms, exploring apps to track mood and locating resources for further education and support. She believes the peer support is what is most helpful to group participants.

“Many people have never met someone else with bipolar disorder, and learning that they are not alone or the only person dealing with the challenges of bipolar disorder can be extremely comforting and helpful,” she says. “Seeing peers recover, build healthy relationships and obtain their goals and dreams is most powerful.”

Support for these clients is essential, agrees Meyer, who recommends that counselors help recruit family members and romantic partners as a kind of support team whenever possible. Loved ones can be there when counselors can’t and are often the first to spot mood changes, she explains. “We also know when clients are in good, healthy relationships, it helps stress levels, and that helps keep them in good health,” Meyer adds.

Sometimes support can come from the strangest of sources, notes Fisher, relating the story of a woman who was in particular need of connection. “I had a client who had a trauma history in addition to bipolar disorder, and she was engaging in really unhealthy behaviors and self-loathing. She was just not in good shape,” Fisher says. “She came in one day, I did a checkup, and she showed really high levels of depression.”

Fisher didn’t think the client was in immediate danger, but she felt bad leaving her without another source of support, particularly because it was a Friday and Fisher was going away for the weekend.

“I asked, ‘Who can you be with? Who can you talk to?’’ Fisher says. “The client said, ‘No one. There is no one.’”

The woman was estranged from her family, and her only “network” involved her sexual hookups.

Suddenly, Fisher had an idea. She had just bought a betta fish for her office, so she asked the client to watch it for her over the weekend.   

Fisher saw the client the following Monday — sans fish — and asked how she was doing. The client replied that she was feeling better and more upbeat.

“Then she started talking about her weekend and spending time with ‘Olive’ and watching TV with ‘Olive,’” Fisher continues.

She asked the client who Olive was. Olive was the name the client had bestowed on the betta fish. The client had neglected to bring Olive back because she didn’t want to leave the fish in the car but promised to return her later in the week.

Fisher told the woman to keep the fish but was curious as to why she had named her Olive. The client said that Olive made her think of hope — like the olive leaf the dove brought back to Noah’s Ark to show the waters were finally receding after the Great Flood described in the Bible.

What lesson did Fisher take away from this experience? “We have to get our clients to connect — even if it’s just with a betta fish,” she says.

Fisher urges counselors to overcome any reservations they might harbor about treating clients with bipolar disorder. “Get more training if you’re uncomfortable,” says Fisher, who encourages counselors to ask themselves why they might be uncomfortable and then to address those reasons.

Counselors already possess the skills needed to empower these clients, Fisher adds. “We have clients who are walking in the door with this diagnosis and identifying it with who they are,” she says. “Bipolar disorder is not who they are — their diagnosis is not their identity. People think, ‘My body is betraying me. I feel like crap. I’ve alienated all my friends — I am the monster.’ Counselors can exorcise the demon of the [bipolar] diagnosis.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

Podcasts (counseling.org/knowledge-center/podcasts)

  • “Bipolar Resiliency Program” with John Duggan (HT056)

Webinars (aca.digitellinc.com/aca)

  • “Depression/Bipolar” with Carman S. Gill

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

  • “Counseling Adults Who Have Bipolar Disorders” by Victoria Kress, Stephanie Sedall and Matthew Paylo

 

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

Letters to the editor:ct@counseling.org

 

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

 

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

By Jori A. Berger-Greenstein April 4, 2018

Take a moment to imagine the following scene, with you as the protagonist: A few days ago, you woke, went for a run, had breakfast and headed to work, where you attended a committee meeting. The next thing you remember is lying in a hospital bed and being told that you had a stroke. You seem unable to move or feel one of your legs.

You are in a double room with an elderly man who has had many relatives and friends visit, although he seems not to be doing well. You’re not sure, however, because you feel foggy. Is this a side effect of the medication they keep giving you?

You are dressed in a hospital johnny and confined to bed. A nurse checks your vital signs on the hour, often waking you when you’re sleeping. An intravenous tube in your arm is connected to a bag with some sort of liquid in it, and you are hooked up to monitors, although you’re uncertain of what they are monitoring. Beepers sound regularly, prompting the nurses to come check you, look at the monitors or change out the bag.

A doctor visits in the mornings, along with a group of medical students, reminding you of Grey’s Anatomy, complete with looks back and forth and eye-rolling. They talk among themselves as if you aren’t there, using medical jargon that you don’t understand. Your family members are anxious and tearful. You hear them talking to the doctor about transferring you to another facility because your insurance won’t continue to cover your stay in the hospital. You also hear your spouse on the phone with relatives who live across the country but want to come see you.

As the patient, how might you be feeling? What might you be thinking?

Now imagine that instead of being the patient, you are a mental health provider called in to assess the patient for depression. How might you respond?

The above scenario and others similar to it are commonplace for many providers who operate in the field of behavioral medicine, which the Society of Behavioral Medicine defines as the “interdisciplinary field concerned with the development and integration of behavioral, psychosocial and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation.”

As recognition of the psychological and behavioral factors involved in medical illness has increased, so has our ability as mental health counselors to serve a valuable function in patient care. Providers and researchers alike now recognize the importance of approaching health care more holistically rather than compartmentalizing medical versus psychological well-being.

Understanding context

Primary care providers, the first stop for most people’s health-related complaints, operate under ever-increasing pressures to provide care for more people in less time. The average visit lasts 10 to 15 minutes, with the goal of assessing presenting symptoms (typically while simultaneously entering patient information into a computer system) to ascertain their cause and thereby provide information about how to treat them. There often isn’t time to gather the context of these symptoms, increasing the likelihood that important details can be missed. Likewise, there isn’t sufficient time to fully discuss the pros and cons of treatment options, the potential barriers to treatment and whether a patient is willing or able to follow through on the treatment recommendations.

In contrast, mental health providers often have the luxury of coming to understand patients/clients more fully. This includes understanding and appreciating the contexts in which patients/clients find themselves, understanding how these individuals are coping and making meaning of what is happening, and forming a trusting relationship with them, which is consistently demonstrated to be predictive of adherence to care and improvements in health-related parameters.

As Thomas Sequist, assistant professor of health care policy at Harvard Medical School, stated in a New York Times article in 2008, “It isn’t that [medical] providers are doing different things for different patients, it’s that we’re doing the same thing for every patient and not accounting for individual needs.”

It can be said that medical providers are trained to identify and treat symptoms in order to identify disease so that a patient can be effectively treated — which is, in fact, their role. In contrast, mental health providers are trained to treat people and illness — illness being one’s experience of disease rather than just a compilation of symptoms or diagnostic labels.

The process of assessing for mental health symptoms

A variety of mental health conditions are characterized by symptoms that overlap with those attributable to medical conditions. For example, symptoms of an overactive or underactive thyroid mimic anxiety and depression, respectively. Psychosis can mimic neurological conditions, mood disorders can mimic endocrine disease, anxiety can mimic cardiac dysfunction and so on.

Through training mental health clinicians to identify symptoms that may indicate a medical cause and knowing how to assess for the possibility of a medical workup, we can make earlier referrals for medical care. This, in turn, helps us to identify diagnoses more quickly, leading to easier/more efficacious treatment and better validating concerns.

One’s cultural identity and the resonance of cultural norms are also important to assess and monitor. For instance, a patient may be reluctant to engage with an English-speaking provider, may have a vastly different conceptualization of illness as punishment (in stark contrast to the Westernized biopsychosocial model) and may need validation for his or her reliance on faith and spirituality.

Collaboration

Collaborating as mental health clinicians directly with medical professionals toward the common goal of helping those who need our care can be invaluable. Examples include ruling out mental health disorders, identifying appropriate treatments in the case of comorbidities, providing emotional support to patients who have been diagnosed with a medical disorder and supporting physicians who may be overwhelmed. For instance, medical treaters may not know or understand the presentation of symptoms associated with trauma or the intricacies of providing trauma-informed care.

Being knowledgeable as mental health clinicians about medical-related symptoms, the language and jargon of medicine, and strategies for navigating the medical system provides us with critical credibility. This credibility can make or break our ability to collaborate as mental health clinicians.

Providing care

At its best, behavioral medicine functions as a prevention-focused model with three levels of care:

1) Primary prevention refers to preventing a problem from emerging to begin with. Examples of this might be establishing obesity prevention programs in public schools for young children or working with high-risk families to promote safety practices. The idea is to work with groups that may be more vulnerable to risks at some point in the future and to prevent those outcomes from occurring.

2) Secondary prevention involves working with people who have developed a problem of some sort, with the goal of preventing it from worsening or becoming a larger problem. Examples include working with people who are prehypertensive in order to prevent hypertension and subsequent cardiovascular disease or stroke, and working with people with HIV to increase their adherence to antiretroviral medication to reduce viral load, making them less infectious to others and providing them with more healthy years of life.

3) Tertiary prevention refers to helping people manage an already-existing disease. This might involve increasing quality of life for people enduring a condition that won’t improve, such as a spinal cord injury, multiple sclerosis or late-stage renal disease, and supporting people in the later stages of a disease that is imminently terminal.

Transtheoretical model (stages of change)

Although mental health clinicians may be familiar with efficacious interventions for a given condition, we may not be perceived as credible if we do not understand and respect the client’s/patient’s motivation. No mental health provider’s repertoire is complete without an understanding of the transtheoretical model and how to utilize it to increase an individual’s motivation for positive change.

Assessing where a client/patient might be in the stages of this model (precontemplation, contemplation, preparation, action, maintenance) helps us to better target our interventions in a respectful way by taking context into consideration. Clients/patients in the precontemplation stage might benefit most from education and are less likely to be receptive to recommendations for lifestyle changes, whereas those in the action stage may not need as much of an emphasis on motivation. For a thorough description of the transtheoretical model, I would refer readers to William Miller and Stephen Rollnick’s seminal work, Motivational Interviewing: Helping People Change.

Concrete needs and specific skills

The majority of causes of death and disability in the United States are those caused or treated, at least in part, by behavior. Nationally, the top 10 causes of death, according to the Centers for Disease Control and Prevention (2015), include cardiovascular and cerebrovascular disease, cancer, pulmonary disease, unintentional injuries, diabetes, Alzheimer’s disease and suicide. Changes in lifestyle, knowledge/education and interpersonal support can be successfully utilized as part of all three levels of prevention. In fact, these are areas in which mental health providers can be extremely valuable.

Primary prevention: Data suggest that the single most preventable cause of death is tobacco use, which can dramatically increase the risk of developing cancer, pulmonary disease and cardiovascular disease. Comprehensive smoking-cessation programs can be quite effective in managing this, as can education to prevent young people from initiating cigarette use.

Sedentary behavior (and, to a lesser extent, lack of exercise) is also strongly associated with health problems, perhaps most commonly cardiovascular disease and cancer. Concrete strategies for introducing nonsedentary behaviors (using the stairs, standing up once an hour, walking) can be incorporated into one’s lifestyle with less effort than a complex exercise regimen.

Getting proper nutrition, practicing good dental hygiene and consistently wearing sunscreen, helmets and seat belts are other examples of primary prevention in behavioral medicine. Motivating people who have not (yet) experienced the negative consequences of their risk behaviors is an approach that mental health providers are trained to provide.

Secondary prevention: The rates of obesity have risen dramatically in the past decade and are associated with a wide variety of serious medical complications, including diabetes, cardiovascular disease, stroke and cancer. If treated effectively, the risk of such complications can be reduced significantly. Examples of interventions found to be useful include aerobic exercise, dietary change (such as adhering to a Mediterranean diet and managing portions) and monitoring weight loss.

Although the specifics of these interventions may be most appropriately prescribed by dietitians and physical therapists, mental health providers can add value by helping to increase clients’/patients’ motivation and adherence, providing more thorough education about recommendations and collaborating with other providers.

Tertiary prevention: Spinal cord injury, most often caused by motor vehicle accidents, falls or violence, can have a devastating effect on a person’s life. These injuries are not reversible, but mental health providers can prove valuable in tertiary prevention efforts. These efforts might involve providing existential support; helping patients to navigate the medical system and ask for/receive support from significant others; and identifying strategies for improving quality of life and accessing tangible resources to sustain some aspects of independence.

Getting started

So, how might clinical mental health counselors “break into” the system? The ideal is an integrated care model in which mental health providers are colocated within the medical setting. This serves a dual function of facilitating mental health referrals and making it easier for patients/clients to see us because we’re just down the hall or up a flight of stairs from the medical providers. It also ensures that we remain visible to medical providers and allows for us to easily demonstrate our value.

Short of this, and for those who are less interested in focused work in behavioral medicine, the following suggestions may be helpful:

1) Attend trainings. This is a crucial first step before mental health counselors can ethically market themselves as being knowledgeable about behavioral medicine. As an example, with rates of diabetes increasing, and associated adjustment and psychological sequelae common, learning all you can about the disease and strategies for managing it provides you with some expertise and a valuable referral option. This is consistent with current recommendations for branding a practice.

2) Develop a niche. Your services can be all the more compelling if you have developed a niche for yourself that fills a gap. Research your area and the specialties that mental health providers are marketing. Is there something missing? For instance, many providers may be offering care for people who are terminally ill, but are there providers specializing in working with young people in this situation? Are people who specialize in working with pediatric cancer also advertising services to treat siblings or affected parents?

3) Being mindful of your competence and expertise, connect with medical providers and let them know that you are accepting clients. For instance, if you work with children or adolescents, consider reaching out to pediatricians. Research consistently finds that the only linkage to care someone with mental illness may have is through his or her primary care physician. Providing these physicians with literature about your services makes it easy for them to pass along your information to anyone they think may benefit. Mental health counselors can connect with medical providers via personal visits to physicians’ offices or through direct marketing to professional organizations. Note that approaching small practices may be the better option because they are less likely to already be linked with another service (hospitals often have their own behavioral health clinics/providers).

4) Connect with specialty care providers. These providers tend to have greater need of mental health professionals who are familiar with a given diagnosis.

5) Don’t be afraid to contact a medical provider treating one of your clients. This can provide a means for collaborative care and could also serve to gain you credibility, while indicating that you are glad to take referrals. Clearly, this should be done only if clinically indicated and only with the client’s permission.

6) Finally, be prepared to describe your experience, training and competency areas in a brief fashion. In the busy world of medicine, time is quite valuable. Mental health providers’ skills in waxing poetic can get in the way of communicating the essence of what we want to get across.

Ethics

This article would be incomplete without a mention of ethics. Behavioral medicine is a field rife with ethical concerns. Perhaps the most salient of these is competence. From an ethical lens, it is critical that we, as mental health counselors, recognize the limits of our competencies — that is, we are not trained in medicine and thus cannot ethically diagnose a medical condition, recommend treatments that could be potentially harmful or assure patients/clients that medical evaluations or treatments are unnecessary. All of these actions require the input and monitoring of medical treaters, who can guide our efforts in care. Patients/clients also need to be clearly informed of both our benefits to and limitations in their care. The world of medicine changes rapidly, and the half-life of training in medicine and medical care is short. Ongoing education is critical.

Let’s return to the scenario described at the beginning of this article. The shared goal for all providers — medical, psychological and other — is to provide efficacious and meaningful care in a way that improves the patient’s health and quality of life. By utilizing our respective areas of training, competencies and strengths, we can better understand the context of symptoms, which can guide our care. This is the cornerstone of providing ethical care.

 

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

Jori A. Berger-Greenstein is an assistant professor at the Boston University School of Medicine and a faculty member in the mental health counseling and behavioral medicine program. She is an outpatient provider in adult behavioral health at Boston Medical Center, where she serves on the hospital’s clinical ethics committee. She also maintains a private practice. Contact her at jberger@bu.edu.

Letters to the editorct@counseling.org

 

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

Five strategies to develop mental health models in schools

By Dakota L. King-White March 12, 2018

Over the past 13 years, I have dedicated my career to developing mental health services and models within the academic setting as a school counselor, mental health therapist and now as an assistant professor in counselor education, where I engage in community action research to develop mental health models in schools from pre-K through 12th grade. From my research and experiences, I have observed that students’ ability to learn is significantly affected by their mental health.

Many of our nation’s students have been exposed to traumatic events and regular life stressors that act as barriers to their success. Exposure to violence and other traumatic experiences can have a lifelong effect on academic achievement. Within the school setting, this can be manifested in a number of ways, including trouble concentrating, low grades, a decline in test scores and students avoiding school or dropping out of school entirely.

Making an investment in prevention and intervention services can help to address students’ overall development and thus enhance their ability to succeed socially, emotionally and academically. The school setting is an ideal place to provide mental health support to students. However, it is extremely important for schools to align mental health support with academic achievement goals. This calls for greater collaboration among mental health professionals, teachers, administrators, parents, students, staff and other stakeholders in school settings.

Based on the work I have done in developing mental health models in schools, as well as guidance from the American School Counselor Association (ASCA) National Model, I believe that the following five components are key to effectively supporting both the mental health needs and academic achievement of our students.

1) Create mental health programming based on data-driven decisions.

2) Collaborate to address the mental health needs of students.

3) Provide a tiered system of mental health support.

4) Evaluate mental health services to ensure they are addressing the academic achievement gaps.

5) Communicate the outcomes to key stakeholders.

Make data-driven decisions

Developing mental health models in schools is a preventive measure by which mental health professionals analyze data ahead of time and design programming based on need. This approach allows stakeholders to assess the needs and develop services that truly address the academic, social and emotional gaps. Schools have an obligation to create programming based on their students’ needs.

When developing mental health models in schools, it is imperative to analyze data from several sources. One key component involves looking at data that focus on academic achievement. Report cards, test scores and other instruments that measure academic achievement must be considered. The main priority when addressing mental health issues in schools is to identify barriers that are affecting students’ academic achievement.

Once the needs have been identified, the next step is to create measurable goals to address the gaps. This step involves a collaborative approach that should include school counselors, mental health therapists, parents, teachers, administrators and students. Measurable goals provide a means for stakeholders to evaluate programming and help to ensure that it is supporting academic achievement.

Collaborate to address student needs

In a 2010 article for the Journal of Interprofessional Care, Elizabeth Mellin and colleagues identified collaboration among colleagues as being imperative when developing mental health models in schools. School counselors, mental health therapists, school psychologists and school nurses are the professionals most often tasked with delivering mental health services to students in schools.

School counselors are an excellent resource to support mental health models in schools. Quite often, however, school counselors are still labeled as “guidance counselors” in educational settings and are not always considered when schools are developing mental health services and models. Administrators and other stakeholders must be informed that the practice of school counseling has evolved, with “guidance” being only one component of the services that school counselors provide. According to the ASCA Ethical Standards for School Counselors, the school counselor’s role is to address all students’ “academic, career and social/emotional development needs.” School counselors must actively engage and advocate to inform stakeholders of their titles and responsibilities, which are based on their skill set and training. Their skill set and training include addressing many of the social and emotional barriers that affect the ability of students to succeed academically.

Mental health therapists are another valuable resource. When licensed as a clinical counselor or social worker, these professionals are able to diagnose mental health disorders and provide treatment to students. Another invaluable component of their skill set that often goes untapped is an ability to provide consultation to staff, teachers, parents and administrators. It is also important that mental health therapists collaborate with teachers, administrators, other staff members and families to demonstrate the correlation between mental health and academic achievement.

School psychologists are integral to the collaboration process when developing mental health models in schools. According to the National Association of School Psychologists, the school psychologist’s role includes providing assessments, providing interventions to address mental health concerns and working with teachers, staff, administrators and other stakeholders to create programming to address gaps. As noted by Joni Williams Splett and Melissa Maras in their 2011 Psychology in the Schools journal article, school psychologists who are trained as research practitioners offer a unique skill set that contributes to bridging the gap of research and actual practice of services to support academic achievement.

School nurses can also play a central role in developing mental health models in schools. Quite often, school nurses have mental and physical health records provided by school personnel, parents and outside health care providers. Because of the time these professionals spend with students addressing other health concerns, they are frequently able to screen for mental health concerns. This relationship provides school nurses opportunities to develop rapport with students. It is during these interactions that school nurses can detect changes in a student’s physical or mental health. School nurses can also provide insight to their colleagues about the mental health concerns they have observed within the school setting.

Teachers and administrators are additional important contributors to the development of mental health models in schools and must be equipped to identify mental health concerns in the school setting. In an effort to ensure that all school stakeholders are collaborating and properly equipped, regular meetings are essential. The more collaboration that takes place among the mental health team, teachers, parents, students and administrators, the more likely it is that students will succeed.

Provide a tiered system of support

Kelly Vaillancourt and colleagues described the benefits of a tiered system of mental health support in their 2013 article for the National Association of School Psychologists and the National Association of School Nurses. A tiered system of support for delivering mental health services also provides different levels of care to support students to succeed academically. Keep in mind that schools must use evidence-based strategies. This ensures that the most effective, empirically supported practices available are being used to help students succeed.

Tier one is the universal level of support in which all students have access to mental health services in a school setting. Within tier one, trauma-informed classroom methods are introduced to teachers, administrators and staff. Tier one includes implementation of a social/emotional curriculum for all students that is preventive in nature and that supports academic achievement by addressing social and emotional barriers. It is also imperative to use a strengths-based approach that looks at the positive attributes of the students and builds upon those attributes to provide services for the students. To further support students, families should be made aware of the services and information being taught at school.

Tier two is where targeted interventions are identified for students who need additional mental health support to eliminate barriers that are affecting them academically. Selective interventions are provided to students who exhibit behaviors that are hindering them. Mental health and other services provided at the tier-two level consist of small groups, classroom behavior management strategies for teachers and staff, individual counseling and additional professional development for stakeholders related to social and emotional barriers to academic achievement. Collaboration among the team is extremely important.

The third tier is the most personalized, with intensive strategies provided based on the student’s needs. Typically, this is done through a comprehensive process in which key stakeholders gather to collaborate and strategize about the needs of the student. The team should consist of the mental health team members, the student, the student’s parents or guardians, teachers, administrators and outside agencies that work with the student and family. As highlighted by Kenneth Messina and colleagues’ 2015 article in The Family Journal, family buy-in is crucial at this level because of the importance of collaboration between home and school to support the student’s academic achievement and to identify the student’s strengths. Mental health and related services at this level include, but are not limited to, individual counseling provided by a mental health therapist, crisis intervention, outside counseling services, small group counseling, behavior plans and additional professional development for stakeholders.

Evaluate and communicate

In an effort to improve academic achievement, mental health services provided in the schools must be based on data-driven decisions and evaluated to ensure that progress is being made to address the needs. Vaillancourt and colleagues noted that an effective mental health model includes consistent monitoring of student and program outcomes. This includes reviewing outcome data and analyzing the data to measure gaps, successes and areas of limitation. Evaluation of services is a continuous process.

Once programming or services are provided, it is critical to analyze the data and review the goals that were established for the student. It is imperative to have an outside reviewer provide feedback on the data and assess the outcomes of programming. The outside reviewer could be a mental health professional, teacher, curriculum director, administrator, local college professional or another professional within the district who has experience analyzing data.

Once the data are analyzed, it is vital to communicate the results to the stakeholders. Communicating the results to stakeholders has been found to build rapport and transparency among the team. Communication also allows for stakeholders to understand the impact and correlation between mental health and academic achievement.

Conclusion

There is a need to develop effective mental health models in schools because of the mental health challenges that affect students academically, socially and emotionally. Students will continue to be faced with these challenges, but it is important that schools address the barriers that affect students’ academic achievement. Mental health professionals, teachers, parents, students, administrators and school staff play a vital and collaborative role in the development, implementation and evaluation of mental health services aimed at maximizing students’ academic success. Through the five strategies discussed in this article, I believe that school districts will realize the success of mental health models being implemented within schools to support academic achievement.

 

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Dakota L. King-White is an assistant professor in counselor education at Cleveland State University in Ohio. She is a licensed school counselor and licensed professional counselor. Her areas of research include the development of mental health models in schools, children of incarcerated parents and 21st-century school counseling. Contact her at d.l.king19@csuohio.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.