Tag Archives: Mental Health

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

 

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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.

Digesting the connection between food and mood

By Lindsey Phillips December 31, 2019

For most of her life, the woman would not let herself eat cake. She feared that if she started, she would never be able to stop. The presence of cake at every birthday party she attended tormented her. She grew so preoccupied with thoughts of cake that she had food fantasies about eating it.

The woman’s unhealthy relationship with food eventually led her to Michele Smith, a licensed professional counselor who operates a private practice called The Runaway Fork in Westfield, New Jersey. With Smith’s guidance, the woman decided to conquer her fear by eating a sheet cake while she was alone.

The client took her first bite, but it wasn’t the experience she had fantasized about. It tasted artificial and waxy. She thought perhaps it was only the frosting that she didn’t like, so she took another bite, this time focusing more on the cake itself. It only confirmed the horrible taste from her first impression. The woman ended up throwing out the entire cake.

The client’s craving for cake had caused her years of suffering, yet when she finally ate it mindfully, she discovered that she didn’t even like it, says Smith, who is also a licensed mental health counselor in New York.

“There’s all this unnecessary suffering around food, weight and body,” Smith continues. At the same time, “there seems to be a lack of services available for everyday people who do not have eating disorders [but] who want to discuss and heal their relationship with food, body and weight.”

For this reason, Smith, a certified mind-body eating coach and a member of the American Counseling Association, created her private practice to help people who struggle in their relationship with food. She doesn’t have a precise phrase to explain this special niche she has carved out with her counseling practice, but she says it differs from nutritional counseling, which focuses on helping clients figure out what to eat. Instead, Smith attends to who clients are as “eaters.” This includes connecting their relationship with food to other life domains and psychosocial factors — such as anxiety, depression and trauma — that professional clinical counselors work with every day.

Researchers are not completely sure how food fits into the overall mental health equation, but recent studies suggest a strong connection. In general, food can promote wellness in three ways: 1) by providing the brain with nutrients it needs to grow and generate new connections, 2) by tamping down inflammation and 3) by promoting gut health.

In 2017, the world’s first study of dietary intervention for clinical depression, called the SMILES trial, found that a modified Mediterranean-style diet (which encourages whole grains, fruits, vegetables, legumes, low-fat/unsweetened dairy, raw unsalted nuts, lean red meat, chicken, fish, eggs and olive oil, while discouraging sweets, refined cereals, fried foods, fast foods and processed meat) resulted in a significant reduction in depression symptoms when compared with the typical modern diet loaded with fast food, processed foods and refined carbohydrates.

A randomized controlled trial published last year in PLOS ONE supports the findings of the SMILES trial. Researchers found that adults who followed a Mediterranean-style pattern of eating for three weeks reported lower levels of anxiety and stress and a significant decrease in their depression symptoms.

These and other findings suggest that counselors should no longer think of mental health in isolation but rather as part of a complex system that includes what people eat.

A missing piece of the mental health puzzle

Lisa Schmidt, a licensed associate counselor, certified whole foods dietitian nutritionist, and instructor in the School of Social Work at Arizona State University, points out that people seldom think about what they eat. “The act of eating is considered a nuisance. It’s something people don’t have time for until they’re just so hungry, they have to eat something, and when you get to that point, you often make very poor nutritional choices,” she says.

For instance, people may grab fast food and eat it in the car on the way to their next meeting or to pick up their kids. Then, when they have trouble sleeping later that evening, they assume it is related to their feelings of anxiety, thus overlooking any possible connection to food, Schmidt adds. 

“Most people don’t know that the kind of foods we choose [to eat] can help us regulate our nervous system and perhaps is the missing link in mental health care,” Schmidt notes.

Schmidt, an ACA member in private practice in Scottsdale, Arizona, says that mood-related disorders often have a food component to them because nutrition-poor diets affect mood. The standard American diet, often aptly referred to by its acronym SAD, frequently leads to people being hungry and tired and having dysregulated moods, she continues. People often alternate between periods of escalation, during which they fuel themselves with caffeine, processed sugar and refined carbs, and periods of starvation. This unhealthy pattern leads to dysregulated moods, Schmidt explains.

In addition, stress (which is common in fast-paced, disrupted lifestyles) dysregulates people’s nervous system responses. When people are stressed and in fight-or-flight mode, their bodies secrete glucose into the bloodstream, fueling them to run away from real or imagined danger. Then the pancreas secretes insulin as it tries to regulate blood sugar levels, Schmidt explains. These swings in blood sugar levels affect mood and can lead people to become “hangry” — hungry and angry, she adds.

Two researchers at the University of North Carolina at Chapel Hill recently set out to study the underlying mechanism behind the complicated “hangry” reaction, and their results challenge the theory that hanger is the result only of low blood sugar. They found that hunger-induced feelings can lead to tantrums and anger when people are in stressful situations and are unaware of their bodily state. In other words, hunger pangs might turn into other negative emotions in certain contexts.

This suggests that people should slow down and pay attention to both their physical and their emotional cues. Smith advises her clients to carefully set the scene before eating, telling them that eating should be stress free, relaxing and pleasant. To achieve this, they might consider using a candle or playing calming music. They shouldn’t be using their phones, watching television or walking around, she says. And although some families use dinner as a time to reprimand their children, there shouldn’t be any arguing while eating, Smith adds.

Because the quickest way to relax the body and mind is through breathing, Smith instructs clients to take as many deep breaths as they need to calm down before they begin eating. She also recommends that clients put their forks down between bites or use their nondominant hand to help them slow down and fully experience their food.

Mindful eating also involves approaching the meal with all of the senses, Smith says. She often illustrates this type of eating in session by having clients — especially those prone to eating quickly or eating distractedly as they work or stare at a screen — engage their senses while eating a Girl Scout Thin Mint cookie. During this activity, Smith asks clients to forget about their ingrained diet rules, negative self-talk, or whatever else might be in their heads and focus on their bodily experience of eating.

First, she has clients look at the cookie so the brain will register that food is present. Next, she has them touch the cookie and notice its texture. Then Smith asks them to smell the Thin Mint because scent affects our pleasure or displeasure with food. Once clients put the cookie in their mouths, they slowly roll it on all parts of their tongues without biting into it. When they finally bite the cookie, they listen to the sound it makes and notice how it tastes and when the taste starts to diminish. At the end of the exercise, Smith asks clients to rate their experience as pleasant, unpleasant or neutral. 

This simple exercise is an eye-opening experiment for most of Smith’s clients, who often admit they would normally just throw the cookie in their mouths and not think twice about it. When people learn to slow down and eat mindfully, they become better at noticing when they are full or if they are no longer tasting their food. Smith says one of her clients discovered through the exercise that she actually didn’t like Thin Mint cookies, even though she had eaten them all of her life.

It’s one thing to tell clients what mindful eating is; it’s another thing for them to experience and feel it for themselves, Smith says. “Mindful eating as a practice can be helpful at reawakening [our] appreciation for food,” notes Schmidt, author of Sustainable Living & Mindful Eating. “As we wake up to how we feel and what we experience, we have the possibility of change.”

The emotional toll of restrictive eating

“Every diet is some form of food restriction,” Smith asserts. “When you eliminate certain foods or when you deem certain foods bad or forbidden, you’re actually going to create the overeating through that sense of deprivation.” For example, the night before someone starts a no-carb diet, he or she might binge on bread as a “farewell” (often referred to as “Last Supper” eating). People on diets never reach habituation, so when they are exposed to restricted foods, they may overeat them, which only reinforces the idea that they can’t be trusted around a particular food, Smith adds.

Licensed clinical professional counselor Heather Shannon wrote a book chapter on nutritional stress management strategies for volume one of the book Stress in the Modern World: Understanding Science and Society. She says the all-or-nothing, judgmental thinking that is common with most diets often creeps over into character judgment: “I’m bad because I ate that carb” or “I feel horrible that I cheated on my diet by eating that cupcake,” for example.

Shannon, who offers coaching and teletherapy as a psychotherapist at Lotus Center in Chicago, had one client who was fit and healthy but fixated on losing three pounds. One morning, the client woke up feeling great, but the second she stepped on her scale and saw she had gained one pound, her mood changed. She went from feeling wonderful to feeling horrible in two seconds.

Fixating on an outcome, such as the number on the scale or the number of times a person has gone to the gym that week, is a big part of anxiety, Shannon says, and it opens up the possibility of good and bad labeling (e.g., “I’m bad because I went to the gym only once this week”). Instead, she helps clients focus more on their habits and which habits make them feel good, healthy and connected to their bodies. “If you’re treating your body really well, then whatever the results are is how your body is supposed to be,” she says.

Smith, a certified intuitive eating counselor, helps clients let go of the dieting mentality and reawaken their intuitive eater. In the intuitive eating model, there are no “good” and “bad” foods. Smith describes it as “a non-diet, flexible style of eating where you follow your internal sensations of hunger and satiety to gauge what, when and how much you eat.”

Smith points out that not every client will automatically be ready to put all foods back on the table. Under those circumstances, counselors can instead help raise awareness around dieting and how it may be interfering in clients’ lives. For instance, counselors might ask: How has your diet affected or changed your relationships with others? How much time and money have you spent on diets? How has it affected your social life and mental health? What in your life has changed because of dieting?

Schmidt also tries to help clients adjust their mindset around food. “Nourishment is not determined by one episode,” she says. “It’s an eating pattern over time.” For this reason, she advises clients to follow the 80-20 rule, in which 80% of the time people make choices that are whole foods (mostly plant-based), and then they don’t need to worry about the 20% of the time that they have a treat or indulge.

“We eat for reasons that are other than just to feed our bodies,” Schmidt says. “We eat as part of celebrations, and food is pleasurable. So, adopting a very restrictive, Spartan way of eating” — particularly one that demonizes any particular food group — “… can become disordered eating and cause problems for some people. … And research shows eating this way will fail 95% of the time.”

Instead of adopting the latest diet fad, people should find a way to eat that they can follow for the rest of their lives and that simultaneously supports their health and mood, Schmidt says.

Using foods to cope with moods 

If clients understand biological hunger and still reach for food without feeling hungry, then they are often engaging in emotional eating, Smith says. This may mean that a client eats because of unresolved trauma or grief. Maybe the client has perfectionist tendencies and uses food to manage his or her anxiety. Or perhaps food is the way a client copes with being in a marriage or job that makes them unhappy.

Smith works with clients to figure out what they are feeling — such as anxious or lonely, for example — when they experience emotional hunger. “This is where the mental health piece comes in,” she says. “You’re talking about eating, but the root cause of the eating is really psychological issues. … They’re people pleasing. They need boundaries. They need to be assertive. They need to say no to people and they can’t, so they use food to cope.”

Shannon, author of the ACA blog posts “Nutrition for Mental Health” and “How Does What You Eat Affect How You Feel?” finds the internal family systems approach effective for uncovering underlying issues associated with emotional eating, especially if clients have a playful side. She first helps clients identify the part of themselves that is overeating by asking what this eating part of them feels like in their bodies. One client might feel it in their stomach, whereas another client might sense it as a coach whispering in their ear.

Shannon also instructs clients to personify the part of them that is overeating by naming it (for example, the Snacking Part, Cake, or even a human name such as Maria). Then, both she and the client can easily address and reference this personified part.

Shannon might ask the part, “What is going on when you overeat?”

And the part almost always provides an answer. For example, “Well, I feel like I work too hard, and I need this because it’s my pressure release valve” or “I feel like I can’t count on people, so I’m counting on food.”

Smith and Shannon both caution against having clients keep a food journal that tracks food intake or weight. They say that activity takes clients out of themselves rather than tuning inward. In addition, they warn, it can promote obsessiveness. But they agree that clients can benefit from journaling about their emotions and feelings associated with food. For example, a client could write down what he or she feels right after overeating as a way of identifying what emotions are associated with the behavior. 

Schmidt has clients keep a food and mood journal, but not to track food intake or to promote weight loss. Instead, the goal is to help clients build an awareness of when they’re eating and how they feel before and after eating. This ultimately gives them a better understanding of how food affects their mood and how mood can affect their eating habits.

She provides an extreme but not unusual example: While journaling, a client noticed that they did not eat anything until 2 p.m. They felt terrible but only had 10 minutes to eat, so they ingested a protein bar and soda. Immediately afterward, they felt good, but an hour later, the client was starving, mad and stressed again.

“Most people … spend less than two minutes a day thinking about what they’re going to eat. They just react,” Schmidt says. “So, building awareness of all our habits, including our fueling habits, is really important.” 

In addition, if people are not fueling their bodies in a healthful way, it will create difficulties for them, Schmidt says. Chronic pain, substance abuse, anxiety and depression are all issues for which food is a huge component, she asserts. Schmidt had a client who would eat seven to nine bowls of Froot Loops for breakfast while in recovery from drug use. People recovering from substance use may often transfer their addiction to food, especially highly processed, sugary types of foods, she says.

Smith encourages her clients to approach their relationship to food with a compassionate curiosity. Clients can view nutritional changes as an experiment to figure out how their bodies react or what works best for them, she explains. Also, if clients haven’t fully mastered their new coping skills and continue to engage in emotional eating, then Smith advises them to be compassionate with themselves and say, “I’m reaching for food, and I know I’m not hungry. I look forward to the day when I can cope with my emotions without using food.”

Staying within scope

Smith has noticed that many counselors shy away from discussing any issue related to food with clients, reasoning that it falls outside their scope of practice and because becoming a certified eating disorder specialist or nutritionist requires specialized training. But she encourages counselors to rethink this mindset. “It’s not out of [counselors’] scope of practice to talk about people’s relationship with food. It’s such a critical part of everybody’s day. So, to not look at it is missing a big part,” Smith says.

“You don’t have to talk about the grams of protein per se, which is out of our scope … to really help somebody,” she continues. “Because [clients are] dying to talk about it, and they need that space. And it’s connected to so many other life domains [e.g., trauma, grief, anxiety, depression, stress] which counselors are more than equipped to talk about.” 

As a certified health coach, Shannon says she would never prescribe foods for clients or tell them what they should or shouldn’t eat, but that doesn’t prevent her from talking about food in session. In fact, on her intake form, she screens for potential issues with food by including general questions such as: What do you generally eat for breakfast, lunch and dinner? Do you snack or skip meals? Do you overeat or under eat? Then, in her first session with clients, she discusses this information and asks follow-up questions to gain a better understanding of clients’ relationship with food and the way this could be affecting their mental health.

“Even if you’re not a nutrition expert, we all know some basic stuff. We all know whole foods are better than processed foods. We all know excess sugar is not helpful,” Shannon says. For this reason, she recommends that counselors screen for basic nutritional information to see if food might be a piece of the client’s mental health puzzle. 

Rather than telling clients what to eat, Shannon takes a behavioral approach and asks, “What are you eating, and how is that working for you? What do you think might work better?” Sometimes, she will also provide clients with helpful resources and advise them to talk to their doctor or a nutritionist about other options they could pursue.

Schmidt finds that discussing alcohol use with clients can serve as a great segue into talking about their diet in general. In her experience, alcohol often comes up with clients who have mood disorders, and because alcohol is a nervous system depressant, it is not advised for these clients. While discussing their alcohol use, Schmidt will ask other questions about their diet, such as if they eat breakfast consistently or if they eat lots of processed, high-sugar foods. From there, she might suggest that clients try to limit the amount of food with added sugars that they eat and experiment with eating fresh fruit as a snack or dessert most days of the week. Schmidt will also use the Healthy Eating Plate (created by Harvard Health Publications and nutrition experts at the Harvard School of Public Health) as a way to help clients visualize how to build meals that support balanced moods.

Schmidt recommends that counselors interested in the food-mood connection experiment with their own eating habits to see how this affects their mood. “It is particularly difficult for a counselor who has a poor diet to talk about the food-mood connection with a client,” she says. Similar to how counselors practice meditation themselves before teaching it to clients, Schmidt believes counselors should first reorganize their own way of eating to include mostly foods derived from plants, to limit caffeine, and to limit or eliminate alcohol.

After counselors have experimented on their own with the food-mood connection, Schmidt says, then they can ask clients to do a chain analysis. For example, if a client is having panic attacks, the counselor might ask, “What do you remember doing just before the panic attack? Did you have anything to eat or drink? If so, what did you eat or drink?” Maybe the client will say that he or she remembers drinking coffee or alcohol before the panic attack happened. The counselor could follow up and ask whether the client noticed any change in how he or she felt after drinking three cups of coffee or drinking alcohol to excess before having a panic attack. This technique will help clients connect their dietary choices, which are ultimately under their control, to the way their mood is affected, Schmidt says.

Smith acknowledges that counselors’ scope of practice does limit just how far they can go in addressing food issues with clients. For instance, counselors cannot provide nutritional advice to clients. “That creates this barrier that is hard to get around,” she says. “So, then, you do have to reach out to other professionals like nutritionists and dietitians and really work as a team.” She says counselors can either work with a nutritionist to determine what nutritional treatments and approaches are best for the client, or work with clients to ensure they are advocating for their own dietary preferences (such as using plans that focus on well-being instead of weight loss) with the nutritionist or speaking up when they feel a certain nutritional approach is harming or not helping them.

But at what point should counselors refer to a nutritionist? Counselors have referred clients to Schmidt, in her role as a nutritionist, because they suspected their clients had an eating disorder or were binging on foods. Schmidt thinks it is a good idea to also refer to an eating specialist if clients talk about food or their bodies frequently in counseling, are extremely overweight or underweight and the condition is disruptive for them, or have suddenly lost a significant amount of weight.

When finding referral sources, Schmidt recommends that counselors look for professionals trained in the Health at Every Size approach, which promotes size acceptance and serves as an alternative to the weight-centered approach.

Smith agrees that “the focus always has to be on wellness, not weight loss.” She advises counselors against referring clients to dietitians, nutritionists or doctors who track calories, encourage weigh-ins, or engage in fat shaming. Instead, she suggests looking for health professionals who teach intuitive eating and operate from a weight-neutral model.

Adding in the nutritional piece

People routinely look for mental shortcuts or a magic bullet to solve their problems, and this tendency extends to food consumption. From research, we know that people will tend to eat 30% more of a food that they deem “healthy,” Schmidt notes. Researchers even have a name for this tendency to overestimate the overall healthfulness of an item based on a single claim such as being low calorie or low in fat: the health halo effect. This halo effect appears to encourage people to eat more than they otherwise would because they feel less guilty about consuming the food.

Clients often come to see Smith because they are confused and don’t know what to do. They have dieted for years with little or no success, and they are confounded by all the conflicting nutritional advice. For Smith, it comes down to a core question: “How does this [food] feel in your body?”

“You’re making peace with food,” she says. “This is your journey of one, and only you can know whether pizza feels good or depleting and when and under what circumstances.” Counseling can help clients tune in to their own unique nutritional needs and preferences and connect this piece to how their mood is affected, Smith says.

Schmidt advises counselors to focus on the big picture and not get caught up in one particular approach to eating. Instead, it is about helping clients make their own connections between what they are eating and how it affects their moods.

Also, because everyone is unique, the nutritional advice that has benefited a counselor personally may not help the counselor’s clients. However, the majority of clients (and all people) need to eat more fruits and vegetables, so if counselors encourage them to do that, it could have a huge impact on clients’ health and mood, Schmidt asserts.

“Having a personal connection to food and its life-giving properties is one of the most amazing gifts we can give ourselves, as well as elevating the status of food and eating for our clients,” Schmidt says. “Helping clients understand that the process of food and feeding is a central part of their recovery is a message that’s independent of what they should be eating.”

“Nutrition is always a piece of the puzzle,” Shannon adds. “So, by understanding the nutrition …
even a little bit, you’re going to be potentially twice as effective working with your clients.”

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

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

Maldistribution: Mental health care in America

By Bethany Bray October 14, 2019

Access to mental health care varies greatly depending on where one lives in the United States. This variance is so great that Mental Health America (MHA) referred to the situation as a “maldistribution” of behavioral health providers in a recent report.

In Massachusetts, there is a mental health provider for every 180 residents, which marks the best ratio in the nation. On the other end of the spectrum is Alabama, which has the nation’s worst ratio at 1,100 residents for every one mental health provider. Texas, West Virginia, Georgia, Arizona, Tennessee, Mississippi and Iowa are the others states that have ratios of 700:1 or worse.

MHA, a Virginia-based nonprofit advocacy organization, compiles a report of mental health indicators each year from nationwide survey data, including information from the Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention. In tabulating its ratios, MHA included counselors, psychiatrists, psychologists, licensed clinical social workers, marriage and family therapists, and nurses specializing in mental health care in its definition of mental health provider.

MHA’s report, The State of Mental Health in America, was released in September.

When weighing access to mental health care and insurance against prevalence of mental illness, substance abuse, suicidal ideation and other factors, MHA ranked Pennsylvania, New York, Vermont, Rhode Island and Maryland as the top five states (in that order) for mental health in its most recent report. Nevada was ranked last in MHA’s list, preceded by Oregon, Idaho, Utah and Wyoming.

The organization also recognized Rhode Island as rising from 27th to fourth in its overall rankings over the past six years. In contrast, Alaska has gone from 17th to 46th, Kansas from 18th to 42nd, and North Carolina from 16th to 35th during that same time period.

MHA tracks a number of other mental health indicators in its annual report, including statistics on youth and adults with substance use disorders, depression and suicide, as well as insurance coverage and rates of treatment and other data. MHA notes that rates of overall mental illness (defined as “having a diagnosable mental, behavioral or emotional disorder, other than a developmental or substance use disorder”) among American adults have remained relatively stagnant, increasing from 18.19% to 18.57% between 2012 and 2017. However, suicidal ideation among adults rose from 3.77% to 4.19% over those six years.

Of note is a more than 4% increase in prevalence of past-year major depressive episodes in youth ages 12 to 17 (an increase of 8.66% to 13.01% from 2012 to 2017).

“While ensuring that youth with mental health conditions have greater access to care is vitally important, the only way to address the rising prevalence of mental health conditions in youth is to address the upstream causes on a population level,” wrote MHA. “States must invest time and resources into researching and understanding the causes for this drastic worsening of mental health in youth ages 12-17 and generating meaningful and effective policies and programs to address mental health concerns before they reach the point of becoming a diagnosable mental health condition.”

 

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Mental Health America’s The State of Mental Health in America 2020

When it comes to mental health, how does your state stack up?

View the full report and state rankings at mhanational.org

State-by-state ranking of adult mental health factors (page 16 of MHA’s report; mhanational.org)

 

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CT Online’s recap of MHA’s 2019 report: “America’s mental health disparities

 

 

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

 

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

 

Finding strength in sensitivity

By Lindsey Phillips September 24, 2019

When Louisa Lombard, a licensed professional clinical counselor in private practice in California, worked as a school counselor, parents would sometimes come to her saying, “My child is so sensitive. I don’t know why he’s like this. Everything is such a big deal. I parent my children the same way. Why is he like this? His brother’s doing great in school and not throwing tantrums and crying. What’s wrong with this kid?”

In actuality, nothing was “wrong” with the child. What the parents didn’t know was that their child had an innate temperament trait referred to as sensory processing sensitivity. Approximately 20% of the population has this sensitivity trait and is categorized as a “highly sensitive person.” Narrow that focus to the therapeutic world, and closer to 50% of psychotherapy clients possess this trait, according to Elaine Aron, a pioneer in the field of sensitivity, in Psychotherapy and the Highly Sensitive Person.

People with this trait often look carefully before entering new situations or retreat from overwhelming ones. For this reason, they are sometimes mislabeled as being shy, when in fact, an estimated 30% of highly sensitive people are extraverted.

Because no one person’s experience is the same, Aron identified four basic characteristics of the highly sensitive person (also known as the DOES model):

  • Depth of processing
  • Overstimulation
  • Emotional responsiveness and empathy
  • Sensitivity to subtleties

Aron points out that the sensory processing sensitivity trait is a survival advantage in some situations because it allows individuals to process information more thoroughly and increases their responsiveness to the environment and social stimuli.

So, why do highly sensitive people — who have this survival advantage — make up roughly 50% of therapy clients? Julie Bjelland, a licensed psychotherapist in private practice in California, thinks the number is so high because highly sensitive people are a) more responsive to therapeutic work and self-help and b) more likely to have higher levels of stress, anxiety and depression.

Heather Smith, an assistant professor of human development counseling at Vanderbilt University, posits that because these individuals process deeply, they are more inclined to seek out answers and are drawn to counseling for its penetrating conversations. In addition, she says, these clients may have developed low self-esteem because of negative stereotypes about sensitivity, or they might want tools to help them navigate times when they feel more emotional intensity.   

Misdiagnosing a trait for a disorder

According to Erica Sawyer, an American Counseling Association member in private practice in Vancouver, Washington, misdiagnosis of the highly sensitive person often occurs because people aren’t aware that the trait exists or of the trait’s specific characteristics. The scientific name for the trait — sensory processing sensitivity — doesn’t help. The similarity in name between sensory processing sensitivity and sensory processing disorder often leads to confusion. But sensory processing sensitivity is a temperament trait, not a disorder. (Aron notes on The Highly Sensitive Person website, hsperson.com, that sensory processing disorder, on the other hand, is a neurological disorder involving the senses.)

As Lombard points out, most therapists receive limited training on temperaments. She first learned about sensory processing sensitivity after graduate school when her oldest daughter started showing signs of the trait, including being sensitive to noise, facial expressions and food. As Lombard learned more, she realized that she is also highly sensitive. She had long suspected that she had attention-deficit disorder because she had a hard time paying attention in her college classes if another student was kicking a desk in a rhythmic pattern behind her or if there was a bright light overhead in the room.

In fact, because highly sensitive people can get overwhelmed and overstimulated more easily when a lot is going on around them, they can commonly be misdiagnosed with attention-deficit/hyperactivity disorder (ADHD), Bjelland says. However, whereas a highly sensitive person is typically able to concentrate in the right environment — when at home in a quiet room, for example — someone with ADHD might not be, she explains.

One confusing aspect to the highly sensitive temperament is that it doesn’t necessarily produce problems in daily life other than overstimulation, says Smith, a licensed professional counselor and an ACA member. Thus, when clinicians hear about a client’s distress due to overstimulation, they can erroneously attribute it to symptoms of a disorder, she explains. To help prevent this, Smith recommends that counselors investigate whether a client’s issue (such as anxiety, stress or an inability to concentrate) decreases if he or she is no longer in an overstimulating environment. If the client’s issue is still present, then it might be a symptom of a disorder.

Smith also points out that counselors often rely on observable behaviors to indicate a possible symptom or disorder. However, depth of processing is not easily observable, she notes. To help counselors learn to identify this characteristic, Smith describes some cues: Highly sensitive people think more about the meaning of life. If in an environment where they are not overstimulated and their ideas are valued, they have the ability to describe all facets of a problem and generate potential prevention steps or solutions — often before others realize there is a problem. They are observers, not the ones to jump into action. They often don’t make decisions quickly. When they speak, it seems as though they have grasped the insight or concept quickly, in large part because they have been thinking about all of these connections for most of their lives.

One tool that can help counselors assess for sensory processing sensitivity is Aron’s 27-item self-test (see hsperson.com/test/highly-sensitive-test). Smith, Julie Sriken and Bradley Erford analyzed the strength of this scale and found it to be a valid screening instrument that counselors can use in their practices (see “Clinical and Research Utility of the Highly Sensitive Person Scale” published in the Journal of Mental Health Counseling.) Smith presented on this topic at the ACA 2019 Conference.

However, to avoid labeling, Smith cautions counselors against placing too great an emphasis on the cutoff score of this self-test. Instead, she recommends having a conversation about how the client marked each item on the scale. This approach focuses less on the total score and more on the person’s experience overall and with each item.

Smith also advises counselors to be careful about interpreting the results from these test items or problem-solving a client’s distress too early on the basis of these initial conversations. In addition to risking misdiagnosis, counselors run the risk of not being seen as credible by clients who have been deeply thinking about issues related to this trait for a while, she says.

Wired differently

Misunderstandings about the sensory processing sensitivity trait also occur when it is assumed that this population is just sensitive to lights and sounds. It is more than that. The brains of highly sensitive people are wired differently than the brains of other people. A 2018 post on the website Highly Sensitive Refuge notes four differences in the brains of highly sensitive people:

  • Their brains respond to dopamine differently.
  • Their mirror neurons (which allow people to “mirror” the behaviors of others and be more empathetic) are more active.
  • They experience emotions more vividly than others (as enhanced by their ventromedial prefrontal cortex).
  • Their brains are more finely tuned to noticing and interpreting other people.

A recent fMRI study published in Brain and Behavior found that highly sensitive people have increased brain activation in regions related to awareness, action planning, empathy, and self-other processing. Lombard, who specializes in working with teenagers and adults who are highly sensitive, shows clients brain scan images from studies such as this one to illustrate how the highly sensitive brain differs in emotional situations such as watching a scary movie or seeing a picture of a loved one. She finds that these images help normalize the trait for clients.

On a podcast for Unapologetically Sensitive, Esther Bergsma, a counselor in the Netherlands and an expert on high sensitivity, reported that highly sensitive people have more brain activation, especially in the areas surrounding social context (e.g., wondering what others think about them, how others view them, or if others accept them). Bergsma pointed out that always being tuned into social contexts is a strength; it is only when people can’t regulate their emotions well that it leads to increased anxiety and stress.

Because people who are highly sensitive have to process more information and can experience nervous system overload as a result, they can be prone to chronic health conditions if they do not have adequate self-care and downtime, says Bjelland, author of The Empowered Highly Sensitive Person: How to Harness Your Sensitivity Into Strength in a Chaotic World.

She likens the way that highly sensitive people deeply process information to cups of water being dumped into the nervous system (“the container”). Highly sensitive people might have 100 cups that they dump into the container, whereas other people have only a few cups to dump. In other words, these individuals notice and process more detail. For example, a highly sensitive child in a classroom might simultaneously notice that a teacher is upset and the happy expression on a classmate’s face across the room and a tree branch tapping against the classroom window.

One way to simplify these brain differences is to think of the brain as two parts: the emotional brain and the cognitive brain. The emotional part of the brain in highly sensitive people is more activated, and if it becomes too activated, the cognitive part of the brain goes to sleep in a sense, Bjelland says. “That’s why [highly sensitive people] might have a hard time with emotional regulation and can get stuck in worry, rumination, anxiety and overwhelm,” she explains. “During times of high stress, the brain cannot tell the difference between a real threat and a perceived threat, so it sends out alarm bells in the system to prepare for fighting or fleeing. In those moments, [highly sensitive people] can’t even access facts, memory and rational thought because that all comes from [the] cognitive brain.”

However, counselors can teach clients ways to reactivate the cognitive brain to support their system and to let the brain know that it isn’t time to send out those alarms, Bjelland continues. For example, she uses a simple breathing technique to calm the body and let the brain know that the person isn’t in danger. Clients breathe in for four counts, hold for two counts, and exhale for seven; they repeat this for about five to seven breath cycles. “The exhale is very long and slow because that sends a signal to your brain that you are not in danger and that it can stop sending out adrenaline and stress hormones. When you exhale slowly, your brain realizes you are OK because that is not how you breathe when you’re in danger,” she explains.

The counting part (whether done out loud or silently) is important because it helps “wake up” the cognitive part of the brain, she adds.

Reframing the perception of sensitivity

As a highly sensitive person herself, Bjelland grew up hearing the negative messages often directed toward people with the sensory processing sensitivity trait: “Why are you so sensitive? What’s wrong with you? Why are you reacting that way?” When people hear those messages as children, she says, they do begin wondering what is wrong with them.

That internalized message is why psychoeducation about the trait is so important, along with validating clients’ experiences. Most highly sensitive people spend their entire lives feeling misunderstood and that something is different about or wrong with them, Bjelland says. Therapy is the place where these clients can begin changing this narrative and turning it into something empowering, she notes.

In her experience working with this population, Bjelland finds that clients often have a transformative experience once they realize that their temperament is normal, that they are not alone, and that they can take steps to improve their experience.

On the other hand, Smith has noticed that some highly sensitive clients experience a grief response after first learning about the trait. They may need time to grieve that they are unlike the other 80% of the population and yet live in a world designed by those without the sensitivity trait, she observes.

Sawyer, a licensed mental health counselor and art therapist, also helps clients reframe their negative experiences, such as being labeled crybabies as children. Counselors can help clients understand that they feel both negative and positive emotions more intensely than other people do. So, when they cried, they were just naturally expressing what they were sensing, which is normal for someone with this trait, she explains.

“They don’t have the problem,” Sawyer says. “It’s the perception that they have a problem that can turn it into one.” So, rather than thinking that they can’t control their emotions, clients can come to understand that with the right support, they can regulate their emotions. They can also take pride in the fact that they feel not only sadness on a deeper level than most people do but also experience incredible happiness, Sawyer says.

Lombard carefully selected the name of her private practice, Strong and Sensitive, to counter the tendency to equate sensitivity with weakness. Many of her clients come in with low self-esteem because of negative stereotypes about being sensitive. She reassures them that it is a normal temperament variation and not a problem. By normalizing the trait, counselors can help clients to embrace it and see it as a strength rather than a weakness, Lombard adds.

Smith teaches clients to more effectively communicate with those who seem to point out sensitivity as a problem. For instance, rather than taking on the onus to defend their sensitivity, clients could ask the other person, “What part of my sensitivity are you having a problem with?” This question reverses the normal assumption that something is wrong with the client’s sensitivity and shifts the conversation to how the other person may need to adjust his or her language or thinking to help problem-solve the relationship dynamic.

Susceptibility to the environment

Research has shown that in a positive developmental environment, highly sensitive children are more likely to thrive than are their peers who are not highly sensitive. However, in a stressful environment, highly sensitive people tend to do worse than do their peers who are not highly sensitive. In other words, this population is highly susceptible to both the good and bad aspects of their environment — a concept known as differential susceptibility.

A highly sensitive person once told Bjelland that when she was younger, her parents made her wear a wool sweater. After repeatedly asking her parents if she could stop wearing it because the material bothered her, they simply replied, “Wear it anyway.” Bjelland notes that this is an example of a highly sensitive person not being supported, and that circumstance can lead to problems.

Bjelland has also noticed that if a highly sensitive child has anxiety, then almost always one or both parents do too. Therapists can’t easily help anxious children if they have an anxious parent, she says, because the child mirrors the parent and will feel unstable if the parent also feels that way.

Parents who are highly sensitive should also be on counselors’ radar because they can suffer from overstimulation and neglect of self-care, Lombard says. The highly sensitive population is also more negatively affected by sleep deprivation, which is common for parents of young children, Lombard notes. She has noticed that highly sensitive parents are sometimes so focused on being the best parents they can be that they don’t take good care of themselves, pumping breast milk constantly or not making time for meaningful adult conversation, for example.

Lombard and Sawyer both recommend that highly sensitive parents get extra support in the form of family members, friends, daycare or a nanny. If finances are an issue, these parents could consider setting up a rotation with another trusted parent to watch each other’s children on occasion, Lombard says. She also encourages highly sensitive parents to wear earplugs or noise-reducing headphones when appropriate because they turn the noise down a bit and can lessen overstimulation.

Other life changes such as a death in the family, menopause, illness or other stressful events can make highly sensitive people feel unbalanced and overwhelmed, especially if they aren’t taking care of themselves, Bjelland says. If they experience too much emotional activation, they may temporarily lose access to the tools and strategies they normally use to cope with overstimulation, she adds.

To counter this, Bjelland tells clients to keep a “positive journal” to record positive events, such as someone saying something nice to them, or techniques that make them feel good, such as going on a hike in nature. Then, when they are having a bad week, they will have a visual record of self-care tips and positive reminders.

The acceptance of sensitivity within a culture also affects one’s environment. Some clients, but especially men, deny having this temperament because society reinforces the idea that sensitivity is not a positive characteristic, Smith says. (Research suggests that the sensory processing sensitivity trait is equal among men and women.) Thus, counselors should be careful about labeling clients as highly sensitive.

Lombard agrees. In fact, if a client grew up in a machismo culture that considers sensitivity to be negative for men, then she might not directly use the term “highly sensitive person” because it may distract from their treatment or therapeutic progress. “Depending on the culture and family of origin, men can carry more shame around [their heightened] sensitivity,” Lombard says. Instead, she mentions that all people have different temperaments and explains that some situations, such as witnessing a car accident, for example, might affect them differently. She also teaches these clients many of the same coping skills without labeling them as being for highly sensitive people.

Bjelland, who is a global educator on this trait and teaches courses for highly sensitive people, doesn’t see as many self-esteem issues in cultures where sensitivity is more accepted. “In the United States where it’s not so accepted, we see a lot of self-esteem issues. And that’s connected to shame too. Most of us walk around with the narrative that something is wrong with us because that’s what we’ve been told,” she says. “Helping to change the client’s narrative to a positive one, where they recognize why this trait is important to the world, is incredibly important.”

Recently, a male client who identified as highly sensitive came to see Sawyer because he needed a safe space to talk. He was struggling to find and maintain a romantic relationship because he found that women often wanted a stereotypical man — someone bold, assertive and athletic. As they talked, Sawyer discovered that he had internalized the belief that being sensitive was negative, which caused his own social anxieties and made relationships even harder for him. After Sawyer reassured the client that he possessed a normal temperament trait and explained its four main characteristics, he felt less self-judgment.

Although simply providing psychoeducation around the trait can be liberating for some clients, counseling often requires a longer process to help clients begin shifting their negative self-perception of being “weak” or “weird,” she adds.

Mindful changes in an overstimulating world

The good news is that highly sensitive people can makes changes so that their lives are more compatible with this trait and they can more readily cope with the challenges posed by living in an often insensitive and overstimulating world.

Bjelland recommends that highly sensitive people carve out two hours of alone time per day and dedicate one complete day each week to downtime. Not surprisingly, many clients balk at this suggestion, saying they don’t have the available time to do that. Bjelland will ask them to try it for one week and, according to her, they will universally report that they had more energy and were more productive because they were more focused, calm and balanced.

Bjelland also advises clients to follow a slower routine in the morning to help set the tone for the day. Why? Think of the nervous system like a motor, she says. If a highly sensitive person jumps out of bed to get the kids ready for school and then races into work, their nervous system revs up, she explains.

The process of slowing down applies to the bedtime routine as well because, as Bjelland points out, this population often struggles with sleep issues. “If a highly sensitive person wakes up from having a good night’s sleep, they get to have their full 100 points of energy for the day, but if they’re having sleep issues, maybe they’re only going to get 50 points for the day, and they’re already starting out depleted,” she says.

She often tells clients to adopt a ritual of doing the same five things before bed, such as taking a warm bath, reading a nonstimulating book, listening to soft music, meditating, and shutting off all electronics. By the time they reach the third action, the brain realizes sleep is coming, she explains.

“You’re teaching them a new type of self-care because [they’ve] been trying to do what the 80% [of the population that is not highly sensitive] are doing, and it’s not working,” Bjelland adds.

Smith agrees that counselors may need to have conversations centered on how self-care for these clients may differ from what rejuvenates other people. For example, if a highly sensitive person tries to relax by going to a concert with lots of lighting and sound effects after work with friends, he or she may instead feel drained and overstimulated by the end of the night.

Overstimulation is a difficult challenge for people with the sensory processing sensitivity trait because they need so much downtime, Lombard points out. She finds mindfulness techniques helpful for teaching these clients how to stay in the moment and self-regulate. For example, a highly sensitive person may find a coffee shop with loud music and people talking overstimulating. However, counseling can provide the client with strategies to successfully navigate such a space. For instance, perhaps the client limits his or her amount of time in the coffee shop or brings noise-canceling headphones, Lombard suggests.

Because these clients feel so deeply, they often need help learning to calm their nervous systems, Lombard continues. Highly sensitive people “are taking in so much more sensory information, and it’s really overwhelming,” she says. “And sometimes [they’re] not even aware, if [they’re] not mindful, of what it was that made [them] feel down or anxious.” She asks her clients to meditate daily using an app such as Calm or Ten Percent Happier and practice breathing techniques to help them become more mindful, present and calm.

Sawyer also suggests that clients use meditation apps such as Headspace or Insight Timer and practice yoga. Sometimes, even the simple act of closing one’s eyes, listening to nature sounds, or going to a quiet spot such as a bathroom or car can be helpful, she adds. The key is finding activities that “help retrain the brain to slow down [and] pay more attention to what’s happening in [the] body,” she says.

Retraining the brain in this way also helps highly sensitive people realize that they have some control and do not have to feel overwhelmed all the time, Bjelland says. For example, every time clients catch their mind wandering during meditation and bring it back to what they’re focusing on, such as their breath, it is like strengthening a muscle. Then, if clients become overwhelmed at work or a large event, they have trained their brains to notice, and they recognize that they need to take a break, she explains.

To help clients exercise this “muscle,” Bjelland instructs them to ask themselves two questions every time they go to the bathroom: 1) How am I doing? and 2) What do I need? This process makes them aware of preventing depletion or overwhelm, she explains. “Highly sensitive people tend to be very externally focused because they’re always scanning the environment for other people’s needs,” Bjelland says. “Most highly sensitive people need to be taught how to explore internally to learn what they need without always filtering it through other people’s needs.”

Of course, the heightened sensitivity to one’s environment also has benefits. Smith has often heard highly sensitive people talk about spending time in nature because there isn’t as much stimulation there. It is a place where they can escape and delight in the beauty of the natural world.

For some highly sensitive people, listening to a bird chirp or watching a sunset can elicit intense feelings of joy or elation, Sawyer says. Spending time in nature — simply walking barefoot in the grass, for example — can also help calm the nervous system, she adds.

Lombard recommends that counselors take these clients outside if they can or, alternatively, bring the natural world into their offices with nature sounds or a water fountain to help create a sense of calm. Lombard has noticed that clients often feel calmer when they see, touch or hear water, so she frequently has clients listen to the sounds of a rainstorm or flowing brook.

Learning to communicate one’s needs

Although highly sensitive people’s empathetic nature often makes them great partners in life and work, relationship issues are one of the primary reasons that they seek counseling. “Highly sensitive people in relationship are going to be so attuned to what the other person is feeling that sometimes they allow that to dominate over their own needs,” Smith says. For example, they may take on more work to please their boss even when they are already overwhelmed.

Smith finds role-play beneficial for helping these clients learn how to assert themselves in relationships. In counseling, they can safely practice communicating their own needs even if it initially seems strange or dramatic to them, she says.

Because highly sensitive people often hold themselves up to the standards of the 80% of the population that is not highly sensitive, they may not be aware that they need more downtime or need to do less so they can maintain their health and wellness, Sawyer says. To help these clients identify their needs and build new habits and coping strategies, she sometimes has them create a values collage of images that speak to them or make them feel good. Through this visual exercise, clients often will discover a common theme, such as nature. The values collage also serves as a reminder of ways that clients can calm an overstimulated nervous system the next time they find themselves in a stressful or overwhelming situation, Sawyer says.

For example, if a client’s collage contains mainly pictures of the ocean, Sawyer will ask how much time the client is spending near the beach or water. If the client says only once or twice a month, Sawyer will recommend increasing the time that the client engages in activities that will replenish them. For example, the client could go for regular walks on the beach or, if that isn’t feasible, pull up YouTube videos of ocean waves and sounds or simply take a bath to connect with water.

Working with these clients also involves helping them learn to set boundaries and communicate their needs, Sawyer says. She finds that nonviolent communication, an approach developed by psychologist Marshall Rosenberg, is a useful tool for highly sensitive people because it provides them with structure for setting boundaries. This type of communication involves:

  • Observing what does or does not contribute to their well-being
  • Identifying how they feel in relation to what they observed
  • Identifying the needs or values that cause their feelings
  • Making a request to fill that need or have that need met (the concrete actions they would like to see)

Sawyer provides a hypothetical case example. A highly sensitive person is worried about going on vacation with her friends because they are extraverted. The client also fears she will be expected to participate in every activity they have planned and that she won’t get enough downtime. First, Sawyer would help this client identify her needs and preferences for this trip. The client says she would like to have the room farthest away from the common areas because it will provide less stimulation if others stay up late talking. She would also like to tell her friends that she will opt out of an activity to stay in and read.

Next, Sawyer and the client discuss her fear of appearing antisocial if she communicates these needs to her friends. Sawyer uses emotional freedom techniques to help the client ease that fear and calm her nervous system. She asks the client to identify her fear. The client responds, “I feel nervous about talking to my friends.” Sawyer then asks where she feels that fear. The client says, “My stomach feels like it has butterflies.”

After ranking the intensity of the feeling (on a scale from 1 to 10), the client taps different pressure points while repeating the phrase, “Even though I feel nervous about speaking to my friends, I deeply and completely accept myself.” The goal is to have the intensity of her fear drop to a 2 or below.

Next, Sawyer and the client role-play scenarios of the client having this conversation with her friends. For example, she could say, “I’m someone who needs downtime. Would it be OK if I stay in from an outing so I don’t feel so anxious?” or “I’m excited about this trip and love hanging out with you, but I wanted to let you know that I will probably need a couple hours of alone time each day.”

Being a more sensitive counselor

Highly sensitive people “have higher responsivity to counseling interventions,” according to Smith. “Where they have positive fit with the counselor, they do better or they have more of a treatment response, and they seem to get more out of the counseling relationship.”

But how can counselors ensure that they are a good fit for a highly sensitive client? Smith recommends that counselors first think about their own temperament because it will inform any strategy they use. Are they highly sensitive, or are they among the other 80% of the population? At the same time, highly sensitive therapists shouldn’t assume that clients’ experiences are the same as their own, she adds.

“The 80% are very capable of working with highly sensitive people, but they need to be very careful of their own biases because they represent the majority,” Smith continues. “They may jump to a conclusion, or they may have some internalized negative biases of people who are highly sensitive.” If counselors aren’t aware of their internal biases, they risk unintentionally perpetuating some of those negative messages in the therapeutic process, she says. “And the highly sensitive person is coming to counseling because they’re looking for something different than what they’re getting in society.”

The good news is that “many counseling approaches would work well if the counselor is able to adapt it in light of what they know of the client’s high sensitivity,” Smith says. For example, if the counselor stares intently while the client is doing a sand tray intervention, then the client could become overstimulated and have a negative experience, making the intervention less effective, she explains. Instead, the counselor could step back and say, “I’m going to let you do this activity for 10 minutes. I’ll be over here doing my notes.”

Counselors should also think about the way they use language and how the highly sensitive person might perceive it. “The highly sensitive person is probably going to pick up more on nuanced language because, in general,” Smith says, “they’re wired to pick up more subtleties in their environment.” This also includes tone of voice, surroundings in an office, and nonverbal language, she adds.

Bjelland advises counselors to consider the environment in their offices. Is the lighting too bright? Is the client looking into a window? What is the texture of the couch? Does the office have a lot of strong smells such as cleaning products, perfumes or incense?

Smith also cautions counselors to be careful with cognitive behavior therapy. Because highly sensitive people process their environment and emotions deeply, asking them to think about cognitive distortions — the simple ways that the mind convinces a person that something isn’t true — can seem simplistic to them. It can even come across as patronizing to ask a highly sensitive client to reframe a cognition when he or she is having thousands of cognitions on a very deep level, Smith adds. Instead, she suggests saying, “Are these cognitions or depths of processing working well for you, or are these cognitions moving more into rumination?”

Counselors should also be careful when using interventions that might not value the depths of processing because they may unintentionally indicate that there is something wrong with the way the client is processing information, she notes.

Counselors also have the opportunity to reinforce clients’ gift of high sensitivity by validating the strengths and positives of the trait, Smith says. For example, a teacher might feel frustrated because he or she can’t soothe a crying boy. But a highly sensitive child in that same class probably would have noticed that the boy is upset because his crayon rolled under his desk, or the highly sensitive child might even notice the crayon rolling under the desk before the other child does and could grab it and prevent the boy from getting upset in the first place.

Thus, working with highly sensitive people can have far-reaching effects. As Bjelland points out, “You’re really creating a domino impact across the globe when you help a highly sensitive person lift off that layer of overwhelm and help them access those gifts and teach them how to care for their sensitive system because when they are thriving, they go out and help people and make a difference in the world. It’s just who they are.”

 

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The highly sensitive therapist

Many professional counselors don’t just treat highly sensitive clients — they have the sensory processing sensitivity trait themselves. Find out how they manage the benefits and challenges of this trait in the article “Advice for the highly sensitive therapist,” available exclusively at CT Online.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

 

Letters to the editor: ct@counseling.org

 

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