Tag Archives: Mental Health

The high cost of human-made disasters

By Lindsey Phillips March 1, 2018

The stories of the aftereffects of human-made disaster have become all too familiar: a refugee forced to make a dangerous journey to find a new home; the soldier deployed thousands of miles from home for months at a time; the person who finds his or her world turned upside down when a shooter enters the room and begins firing. It’s not surprising, then, that according to a report by the American Psychological Association, in 2017, 60 percent of Americans felt stressed about terrorism and 55 percent felt stressed about gun violence.

In addition, refugees fleeing war-torn countries have created an international crisis, and, among other things, they aren’t getting the mental health care they need. The International Medical Corps found that 54 percent of Syrian refugees and internally displaced populations in Syria, Lebanon, Turkey and Jordan suffered from severe emotional disorders, including depression and anxiety.

The increase in human-made disasters raises a question for counselors and others: Does the type of disaster — natural, human-made or technical — affect the severity of the trauma or the counseling approaches used to treat it? Devika Dibya Choudhuri, an associate professor at Eastern Michigan University, says sufficient research indicates that when human agency is involved, the disaster has a more traumatizing effect. Although natural disasters are traumatizing, there is often a huge response of communities taking care of one another, which tends to be a restorative factor, she explains.

“With human-made disasters … the aftermath is also conflicted,” says Choudhuri, a licensed professional counselor and American Counseling Association member who presented at the ACA 2017 Conference & Expo in San Francisco on group interventions in the aftermath of violence, terrorism and dislocation. “Most [refugees’] … traumatizing stories are not just [about] the original trauma. … The journey after is so profoundly traumatizing as well because not only are they ungrounded from the loss of home, but then all of these additional wounds are made. There is no safety anywhere, as opposed to that sense [after a natural disaster that] people are coming forward to help.”

Rebuilding trust, regaining control

Choudhuri, who worked with Cambodian and Bosnian refugees in the 1990s and has worked with Iraqi and Karen refugees since the 2000s, points out that survivors of human-made disasters are fighting on two fronts: struggling to survive in their environment and engaging in an inner conflict where the original strategies for survival during the trauma are no longer helpful. Thus, when it comes to trauma and human-made disasters, counselors should focus on restoring a client’s sense of control, not safety, she advises.

Hannah Acquaye, an assistant professor of counseling at Western Seminary in Portland, Oregon, works with refugees from war-torn countries such as Afghanistan and Iraq and parts of Africa. She finds that for refugees from countries where neighbors are fighting neighbors, the trauma is unique in terms of feeling a sense of betrayal. If the person holding the gun and causing the devastation is someone they know and used to play with growing up, then the trauma becomes especially troubling, she says. “It affects the way they trust people … and makes it harder to build a community back,” explains Acquaye, an ACA member whose research focuses on refugee trauma and growth.

Thus, rapport and trust are crucial for survivors of a human-made disaster. According to Mark Stebnicki, professor and coordinator of the military and trauma counseling certificate program in the Department of Addictions and Rehabilitation Studies at East Carolina University (ECU), empathy and listening are critical elements of establishing rapport and gaining the trust of these clients.

Establishing a therapeutic alliance can be problematic, however. Counselors often learn to build a therapeutic alliance by offering warmth and connection and by encouraging clients to tell their stories, Choudhuri points out. But for individuals who have experienced a “traumatizing offense through human agency … the betrayal and abandonment and loss of trust during the process gets triggered by the very warmth of the connection,” she explains. Counselors will often experience that after making a connection and getting the client to open up, the client never shows up again or ends up in the hospital, Choudhuri says.

Before uncovering the trauma, counselors must help rebuild and ground clients so that they will have resources to address the trauma, Choudhuri argues. “Rather than creating a therapeutic alliance, it’s about rebuilding the kinds of ways in which people can take care of themselves so that they don’t require the therapist to do that,” she explains. In fact, she advises that counselors should work with survivors of human-made disasters as if they will have only one session together. The first few sessions should focus on techniques that will help clients function in case they don’t return, she says.

One way counselors can help clients become autonomous is by providing them with tools to regulate their emotions. Somatic and emotion regulation techniques allow survivors of human-made disasters to notice their triggers on a sensorial basis and use their brain to counter this negative trigger, says Choudhuri, a certified eye movement desensitization and reprocessing (EMDR) therapist. In a sense, their brain becomes an ally, rather than an obstacle or hindrance, in their recovery.

One of Choudhuri’s clients suffered trauma after being held captive and tortured for several days. Smelling the cologne worn by one of his captors would trigger the client. After identifying this sensorial trigger, Choudhuri set out to counter it. She discovered that the client found lavender essential oil calming, so she directed him to take in the lavender scent anytime that he encountered the smell of cologne. The process works on two levels, Choudhuri notes, because “it’s addressing the sensorial piece, but it’s also giving control back [to the client].”

Choudhuri also finds that traumatic resilience is important when working with survivors of human-made disasters. Many resourcing and grounding techniques that counselors use can also make clients more resilient in the face of ongoing trauma, she notes. For example, Choudhuri finds the container technique helpful for her clients: She tells clients to think of a container with a secure lid (e.g., a jar, a jewelry box) and then to use that container to mentally store the parts of the trauma that get in their way and prevent them from moving forward.

Group work is another resource that can help survivors of human-made disasters rebuild a sense of trust. At the same time, Choudhuri says, “group work is really challenging, particularly for [people] who have had human-made disasters, because other human beings are a source of threat [to them].”

In fact, Choudhuri is careful to avoid touching clients who have been hurt by other human beings. Instead, she teaches clients how to give themselves a comforting touch. For example, she uses the butterfly hug method (clients cross their hands over their chest and alternately tap their hands to a heartbeat cadence) while she facilitates thoughts of being safe and loved. This technique works well with children and is one that clients can do themselves when they are upset, she adds.

Rather than asking individuals to share their trauma in groups, Choudhuri suggests having them process it in a way that allows group members to provide comfort to each other, thereby helping restore a sense of control, trust and efficacy. For example, counselors could have individuals teach each other how to engage in deep breathing. “It allows for people to feel empowered to … not just be on the receiving end but also on the giving end,” Choudhuri explains, “and then they’re giving something that they themselves are learning, which helps them learn it better.”

From Stebnicki’s perspective, groups not only allow counselors to identify people who need more individualized treatment but also provide a safe space to verbalize and normalize survivors’ feelings (e.g., anxiety, depression, grief, sleeplessness) about an event and prepare them for the forthcoming weeks. “If you get [clients] to open up and share feelings [in a group], then the group itself is your own best source of support because they can normalize what that scary event was like,” he says.

Bridging cultural differences

Stebnicki acknowledges that working with people who are culturally different from the counselor can be challenging. Clients who are refugees, immigrants and asylum seekers may pose an even greater challenge because American counselors are often far removed culturally from individuals from war-torn countries such as Syria and Afghanistan, he adds. But successful treatment relies on understanding clients’ cultures and how they heal, he asserts.

In some cultures, counseling as generally practiced in the Western Hemisphere doesn’t exist, so counselors shouldn’t force clients to share their stories, Acquaye says. Instead, counselors should focus on providing a safe, supportive environment and inform clients that they are in the moment with them, she advises.

Stebnicki, a member of both ACA and one of its divisions, the Military and Government Counseling Association, says that he distinguishes between civilian and military responses to human-made disasters. “Military is a culture unto itself,” he says. “Military personnel experience person-made disasters differently in that instead of detaching, isolating, running and going into shock like civilians do, they adapt and survive, and they aggress … [not] stress.” Unlike civilians, who typically respond to a shooting by running away, military personnel are generally running toward the gunfire, he points out.

At the same time, civilians and military personnel experience similar physiological, psychological and emotional responses to human-made disasters. However, military personnel also experience ongoing trauma stressors (such as multiple deployments) and generally do not undergo the full range of posttraumatic stress disorder (PTSD) symptoms until after their deployment or military service ends, Stebnicki says. Thus, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders “measures PTSD, but mainly in civilian life because it doesn’t take into account this … repeated exposure to trauma which military [personnel] are exposed to,” he argues.

In addition, military personnel often cannot easily take advantage of mental health services in the same way that most civilians can because of the stigma that military culture places on it, Stebnicki says. Using these services can sometimes put their security clearances at risk, cause them to get demoted or have others in the military lose faith in them and their ability to lead, he explains.

Despite these difference, many counselors try to treat military personnel as civilians and do not recognize the distinctions between civilian and military mental health, Stebnicki says. To help address this issue, he developed the certificate in clinical military counseling at ECU. The course trains professional counselors on some of the unique cultural differences in diagnosis, treatment and services for members of the military.

Making meaning of human-made disasters

In the face of a human-made disaster or a large-scale political event, people often feel helpless, like a small cog caught in a big wheel, Choudhuri says. In such cases, the counselor’s aim is not to help clients find an answer to existential/spiritual questions of why the disaster happened but to help them figure out a meaning to these events that they can live with, she says.

Meaning making should also involve some degree of personal growth, Stebnicki notes. He says that counselors can determine whether clients have experienced posttraumatic growth by their actions: Are they taking their medications? Are they going to counseling? Have they reconnected socially? If the answer is no, then there is no growth, he says.

The counselor’s job, Stebnicki contends, is to provide tools and resources to help clients take responsibility for finding meaning and growing from the trauma. However, he points out, growth is painful, so counselors must prepare clients to take small steps toward identifying ways of feeling safe and ultimately finding meaning.

Acquaye actively celebrates her clients’ small victories because she believes it encourages them. She had one client who was a refugee who was depressed because she didn’t know how to communicate in her new culture. Acquaye asked her to try to leave her apartment each day and walk around for five minutes. When her client was successful, Acquaye jumped up and down in front of the woman to celebrate her progress. Taking this small step forward helped her client begin to sleep regularly again, Acquaye says.

Choudhuri looks for ways to address clients’ despair without trying to change their beliefs about what happened. She finds EMDR helpful because it allows people to process internally without having to give the counselor details about their trauma. At the same time, clients are able to arrive at a meaningful narrative about their experience. “It may not be my answer, but it’s their answer,” Choudhuri adds.

Choudhuri provides an example of a Syrian refugee who participated in EMDR therapy that involved drawing and processing his trauma. At the end of the session, he said that regardless of the terrible things that had happened to him, he realized that every night has a morning. “It wasn’t that he got an answer or that he had a solution,” Choudhuri says, “but he got what he needed — hope.”

For many clients, spirituality plays a large role in meaning making. If the client’s and counselor’s spirituality differ, then the counselor should find common ground to discuss spirituality, Acquaye advises. The majority of her clients are Muslim and Acquaye is Christian, so in session, they discuss the general concept of God and who is in control of everything. “We can’t explain why people do what they do, but we can hold on to somebody who is greater than people and know that some good may come out of that,” she explains.

Self-care and counselor fatigue

Clients’ stories of trauma, suffering and loss can take a toll on counselors, resulting in counselor burnout, compassion fatigue or empathy fatigue. The cumulative effect of seeing multiple survivors of human-made disasters and other traumas can start to deteriorate counselors’ spirit to do well and damage their own wellness, Stebnicki notes. For that reason, counselor self-care must become a priority when working with survivors of human-made disasters.

Stebnicki differentiates between empathy fatigue, a term he coined, and other fatigue syndromes such as burnout and compassion fatigue. He explains that empathy fatigue results from a state of physical, emotional, mental, spiritual and occupational exhaustion that occurs as the counselor’s own wounds are continually revisited through a cumulation of different clients’ stories of illness, trauma, grief and loss.

The major difference between these types of fatigue syndromes is that empathy fatigue has an added spiritual component, Stebnicki notes. Horrific experiences such as genocide and torture go beyond the range of ordinary human experience and affect the mind, body and spirit, he explains. Thus, it is crucial that counselors are properly trained to be empathetic and compassionate, he says. In addition, because people experience and define spirituality in their own individual ways, counselors must understand their clients’ views of spirituality to assist them in cultivating hope and psychosocial adjustment to their trauma.

Acquaye acknowledges that she didn’t initially realize how much the stories of her refugee clients would affect her. If counselors are struggling with counselor fatigue, they need to seek help to avoid harming their clients, she advises. “It’s not about me. … If I claim I’m an advocate for my refugee clients, then I should get over myself and ask for help, so I’ll become a better person for them,” she says.

Choudhuri says counselors must also guard against making another common mistake. Because refugees often have little meaningful support, they are incredibly grateful when they do receive it, and there can be a danger in that for counselors. “If [counselors] work long enough with [refugees], it gets really easy to feel like a savior,” Choudhuri admits.

“One of the things that trips [counselors] up is this belief of indispensability — that there is nobody else, so I have to keep doing it even if I don’t want to,” Choudhuri adds.

She also finds that working with clients who have survived a human-made disaster can bring out something of a competitive nature in counselors: They assume (often incorrectly) that if the client can deal with the trauma, then they can too because they are the counselor.

Among the possible signs of counselor fatigue syndromes that Stebnicki notes are having diminished concentration, feeling irritable with clients, feeling negative or pessimistic, and having difficulty being objective or compassionate. “We’re good as counselors at giving advice to others and helping facilitate self-care strategies, but we don’t do it ourselves. We need to take our own best advice and get help,” he advises.

Stebnicki has found peer support helpful when dealing with fatigue syndromes. He and other colleagues meet once or twice a month to vent and share their stories. In fact, he notes that it is common to have ongoing peer support on-site for counselors and first responders at large-scale human-caused disasters. These support groups allow counselors to discuss what they saw, how it affected them, how they are responding and how they are going to overcome it, he says.

Acquaye is thankful for her supervisors and own personal counselor who help her guard against burnout. “I have to remind myself all the time that I’m not God … so I can’t carry my client because sometimes the stories are so heavy that you can’t sleep at night,” she says. She realizes that carrying the burden of her clients’ stories will serve only to make her negative and ineffective as a counselor.

Many counselors are drawn to working with refugees because they want to help, but before jumping in, Acquaye says, counselors should understand what their strengths and limitations are. “Ask yourself [if] you have enough strength for the kind of stories they will throw at you. [If not], it doesn’t mean you are not good enough. It just means that that is not your area,” she says. “When it comes to refugee work … you are going to go through the trauma yourself, so you have to ask yourself, ‘Do [I] have what it takes to go through that?’”

Lessons learned

How can counselors prepare to handle the specific needs of survivors of human-made disasters? “Training to be trauma informed becomes key. … There shouldn’t be counselors coming out of counseling programs who don’t have a basic understanding of trauma,” Choudhuri asserts. Yet, she finds that counselors often report not knowing how to deal with trauma and disaster mental health.

Choudhuri thinks that one area of disaster mental health where training needs to improve is clinical competency. Often, counselor educators aren’t practitioners, which can be problematic because they don’t see the chronic nature of clients’ issues and thus don’t prepare adequately, she contends. She argues that counselor educators should stay clinically active — perhaps even working with survivors of human-made disasters — to keep their finger on the pulse of what is happening.

Of course, Acquaye admits that counselors are never likely to have all of the training they need to handle disaster mental health straight out of school. Many of the skills must be learned on the ground. She recounts a time when despite her training on refugee trauma and posttraumatic growth, a client’s story scared her to the point that she was shaking. She had to remind herself that even though she had no idea how to treat the client’s many issues on the spot, she needed to start by listening to the client and then figuring it out as she went along by researching and assessing the client’s needs.

What people consider to be trauma or traumatizing changes over time, Choudhuri notes, so the symptoms that veterans displayed after the Vietnam War are not the same ones that soldiers returning from Afghanistan and Iraq have displayed. Today, counselors also have to take into account the fact that there is more aggression digitally, and digital aggression distances people from the trauma, she adds. For example, drone warfare has changed the rules of war, allowing people to kill from a distance. This makes killing more impersonal and affects the mental health of drone pilots differently.

“As conflict becomes handled differently, [so does] the kinds of betrayals and ways in which people can be hurt electronically. … [People’s] sense of danger and risk become different than if somebody broke into [their] house. They’re related, but they’re different,” she says.

One mistake that counselors often make when working with clients is expecting a more intense early disclosure of the traumatic incident, Stebnicki says. Stebnicki worked as a member of the crisis response team for the Westside Middle School shootings in Jonesboro, Arkansas, in 1998. In the aftermath, he witnessed a counselor go up to a student, take him by the shoulder and almost shake him to force disclosure of what the student had just experienced. Counselors must remember that everyone heals at his or her own rate, so survivors of human-made disasters may not want to discuss their experiences immediately after the event, he says.

Stebnicki has also found that people’s experiences vary based on their proximity to the disaster’s epicenter. “We all differ in stress and trauma in terms of the pattern, the frequency, the exposure, the magnitude/intensity. So, in other words, we all turn our stress response on differently,” he says.

In working with refugees, Choudhuri has learned that counselors can’t assume to know the trauma. One of her clients had been married off by her parents while in the refugee camp to a man who raped her. Was the worst part of her experience being in the refugee camp, losing her home or being raped? Choudhuri discovered that for the client, it was that her parents didn’t love her enough to have chosen a better husband for her.

“It wasn’t the violence that drove her from her home, it wasn’t the destruction of her life as a schoolgirl, and it wasn’t even the brutality of her experience in the marriage,” Choudhuri says. “It was the sense of being betrayed by her parents.” Thus, counselors should remember that the focus of the work is not about the trauma but about the client, she adds.

Choudhuri has also observed that although disaster mental health professionals have developed ways to work with people immediately after a disaster, they often fail to implement this guidance back home. She argues that counselors don’t respond to the ongoing, everyday disasters happening in their backyards — the microaggressions and microassaults that wear people down as they try to overcome obstacles of systemic racism, chronic poverty, violence and substance abuse — in the same manner as they respond to large-scale events.

“If we can point to the singular event, we can be horrified by it and [respond] with compassion and helping, but when we live in it, we numb ourselves … to it because we feel helpless,” Choudhuri says.

“It’s difficult because we all want a place of safety … so it’s easier to go away somewhere and work on [disaster mental health] and then come back [home] and be safe,” she points out.

Counselors need to resist the urge to let trauma and disaster response fade into the background because of the discomfort these events can generate, Choudhuri argues. Instead, they must keep disaster mental health in the foreground and help rebuild communities and individuals affected by disasters, including those less obvious disasters happening in counselors’ backyards.

 

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Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia. She has a decade of experience writing on topics such as health, social justice and technology. Contact her at lindseynphillips@gmail.com or through her website at lindseynphillips.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.

SAMHSA shutters database of evidence-based practices

By Bethany Bray January 19, 2018

A public database of evidence-based practices for the treatment of mental illness and substance abuse disorders has stopped accepting new entries.

Federal officials announced the discontinuation of the National Registry of Evidence-based Programs and Practices earlier this month. Overseen by the Substance Abuse and Mental Health Services Administration (SAMHSA), the online database lists more than 400 peer-reviewed interventions, the last of which was posted in September.

Established in 1997, the registry served as a source of information and best practices for medical and helping professionals and the public. Its discontinuation was met with disappointment by many across the mental health professions.

“The fact that the administration [of President Donald Trump] discontinued the registry without having a new system in place sends the unfortunate message that science and evidence-based practices are not a priority,” says David Kaplan, chief professional officer of the American Counseling Association.

This month, numerous news outlets reported that the government’s contract with a third party that managed the database had been terminated. The registry remains online while officials try to determine the best way to disseminate information on evidence-based practices going forward.

In a statement posted online, Elinore F. McCance-Katz, assistant secretary for mental health and substance use, pointed to flaws in the process used to select and vet practices for inclusion in the registry.

“For the majority of its existence, NREPP vetted practices and programs submitted by outside developers – resulting in a skewed presentation of evidence-based interventions, which did not address the spectrum of needs of those living with serious mental illness and substance use disorders. These needs include screening, evaluation, diagnosis, treatment, psychotherapies, psychosocial supports and recovery services in the community,” wrote McCance-Katz.

“This is a poor approach to the determination of evidence-based practices,” she said in the statement. “As I mentioned, NREPP has mainly reviewed submissions from ‘developers’ in the field. By definition, these are not evidence-based practices because they are limited to the work of a single person or group. This is a biased, self-selected series of interventions further hampered by a poor search-term system. Americans living with these serious illnesses deserve better, and SAMHSA can now provide that necessary guidance to communities.”

 

 

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The role of value in adult self-esteem and life satisfaction

By Harvey Hyman December 19, 2017

While reflecting on my clinical experiences with adult clients during my postgraduate internship, I discerned a common thread. The thread was that the feeling of being valueless was at the root of my clients’ depression, anxiety, anger and substance abuse, as well as the violence and verbal abuse experienced within couples.

Although the immediate cause of the perception of being valueless varied (e.g., pervasive childhood neglect or specific episodes of childhood physical, sexual or emotional abuse), the consequences were the same in each case — chronic dysphoria of one kind or another. It is simply not possible to esteem oneself, to be vulnerable with others, to feel able to positively impact the lives of others through relationships or achievements, or to expect an enjoyable and meaningful future when one is convinced that she or he lacks value.

During the past few months, I have been learning about and practicing a technique involving mindful self-compassion designed to increase my sense of personal value, and I have been working with willing clients to teach them the same technique. I have written this article to voice my perspective on how self-perceived valuelessness is the major factor in transdiagnostic client suffering and to share a technique for building belief in your clients that they possess value as human beings.

 

The meaning of value and valuelessness in human life

In common parlance, the word “value” signifies having such positive qualities as worth, goodness, merit, effectiveness, usefulness, importance, attractiveness and desirability. People who perceive themselves as possessing value are much more likely to have self-esteem, self-efficacy and life satisfaction than are people who appraise themselves as lacking value. Believing oneself to be valuable is associated with resiliency and posttraumatic growth because external hardships and adversities do not destroy value but, rather, reveal it.

To lack value means that one is not lovable, desirable or worthy of mattering to and belonging with others. There are few, if any, sources of emotional pain greater than believing that you lack value. I believe that clients who are convinced that they lack value are the ones most likely to suffer from depression and to engage in self-destructive behaviors such as alcohol or drug abuse, the self-sabotage of relationships, cutting, burning, eating disorders and suicide attempts. When you are certain you lack value, it is equally certain you will hate yourself and will consider or perpetrate acts of self-harm. You may even want to end yourself to stop the pain of living with this certainty and being your own worst enemy instead of your own best friend.

I understand that genetic abnormalities that cause bad brain neurochemistry, especially during times of stress, can trigger self-hate, depression and self-destructive behavior. However, I am convinced that most of the time distorted thinking about the self (as being bad, incompetent or certain to fail at everything) and maladaptive coping behaviors arise from our clients’ belief that they are valueless.

Believing that you are valuable but constantly berating yourself for being a piece of crap or sitting in a squalid room injecting heroin into your veins with a used needle are totally inconsistent. Believing that you are valueless also rears its ugly head in interpersonal relationships. People who know they are valuable can shrug off the unfair accusations, attacking comments, insults and rejecting behaviors of others by recognizing that they come from ignorance, mistaken assumptions, implicit biases, defensiveness or fear. On the other hand, people who see themselves as valueless will perceive dire threat and react with fight, flight or freeze when exposed to these things because they confirm their inner sense of valuelessness.

 

The association between value and triggering

A very common bit of psychological jargon that I hear today is the word “trigger.” It is used in the sense that some statement, action or inaction of one person set off an intense, immediate and automatic emotional reaction in another person who felt unsafe. This person responds with crying, threats of violence, actual violence, emotional contraction, fleeing the scene and the like.

When one spouse says “Shut the hell up” to the other, strikes the other or gets in the car and drives off to parts unknown following a dispute, we can say that he or she was triggered, but what really happened? I think what happened is that the spouse who acted out had a thin, fragile scab over his or her self-perception of being valueless and something the other spouse said tore it off.

Whether we remind ourselves that we are valueless through our own inner critic (the usual way) or someone else reminds us by their statements or conduct, it hurts just as much. And when that pain sets in, our self-esteem plummets from whatever shaky height we had lifted it up to. We then temporarily lose our effectiveness as people because we turn away from the world to soothe ourselves with substances or punish ourselves with self-attacking words or deeds.

 

Intrinsic versus extrinsic value

According to sources as diverse as the Judeo-Christian Scriptures, the philosophers Immanuel Kant and Martin Buber, and the Declaration of Independence, human beings have intrinsic value. Theologists may see intrinsic value as coming from people being created by a perfect Creator, whereas philosophers might see intrinsic value as coming from our possession of rationality and our capacity to act ethically by choosing the good.

To believe in the intrinsic value of the individual is to believe that our value is not contingent upon externals such as one’s most recent successes, the current size of one’s bank account or the current level of one’s physical attractiveness. For Viktor Frankl, value becomes evident when a person establishes an authentic meaning for his or her life. For Abraham Maslow, it is when a person self-actualizes his or her potential.

Despite so many sacred and secular voices in favor of intrinsic value, virtually none of the people I have met buy it. Rather, they engage in constant self-evaluation in relation to internal standards of achievement and attractiveness, as well as external comparisons with family members, friends, co-workers, professional colleagues and even star athletes, movie actors and celebrities.

Freud described this long ago as checking one’s self-evaluation in the mirror of one’s ego ideal and getting judged harshly by one’s superego for every discrepancy. Today we talk about the voice of the inner critic instead of the superego, but the process and consequences are the same. There is a constant need to reassure oneself of one’s value, and a failed attempt to do so is followed by self-attack, ego deflation and suffering. Kristin Neff, who has done pioneering research on self-compassion, has pointed out that self-attack is accompanied on a somatic level by release of cortisol and adrenalin, which make us feel sick.

 

Value and secure attachment

Why is it that a handful of people seem certain that they possess value while everyone else sees their value as questionable, fluctuating or even absent? The work of John Bowlby on attachment helps to shed light on this phenomenon.

Bowlby said that how infants and toddlers were treated by their parents, especially their mothers, had a huge impact on their sense of self. Infants and toddlers who received a consistent flow of love, caring, warmth, gentle touch, soothing vocalization and affirmation would develop what Bowlby called a “secure attachment” composed of feeling welcomed, loved, valued and wanted. The secure attachment was the germ of self-acceptance and self-confidence that fueled these children’s exploration of their environment and their ability to self-soothe when they experienced fear, physical pain or other adverse consequences.

In Bowlby’s framework, infants and toddlers who received love, warmth and caring in an unstable, episodic and inconsistent manner would develop an insecure or approach-avoid attachment style associated with a reduced sense of personal value and trust in others. The most damaged infants and toddlers were the victims of pervasive abuse or neglect who received the message that their caregivers hated them or did not care about them. These children developed an avoidant attachment style in which they reacted to others by distancing themselves emotionally and physically.

 

Therapeutic approaches to correcting self-perceived valuelessness

If secure attachment is the foundation of the self-perception that one has value, then the most effective therapy for clients who doubt their value or regard themselves as valueless should be some form of reparenting that has the effect of strengthening a weak attachment to others. Unfortunately, this type of therapy is demanding, prolonged and expensive, and is by no means guaranteed to work.

Cognitive behavior therapy is great at showing the falsity of automatic, negative thoughts about the self, but until the deep-seated conviction (the core belief) that one is valueless is gone, these thoughts will continue to arise. Trauma therapies work to desensitize, contextualize and reinterpret memories of adverse childhood experiences, but the conviction that one is valueless, resulting from pervasive abuse or neglect, is very tenacious. This conviction can represent the foundation of personality and self-identity and the form the ego took from parental shaping in childhood.

If it is not possible to remove and replace the psychological foundation of self-image, what can be done to solve this problem? My hunch is that behind the conveyance of a sense of value to the infant/toddler through parental holding, touching, warmth and affirmation is a programming of the brain (“I know I am loved”) and the heart (“I feel that I am loved”). Abuse, neglect or inconsistent parenting can confuse the brain of the infant/toddler (“I’m not sure I’m loved and lovable”) or program it to believe that “I am neither loved nor lovable.” These things can make the child’s heart feel the same message.

So, how can clients in therapy reprogram their brains to know and their hearts to feel that they have value? At this point in my investigation, I have only anecdotal evidence and nothing like the kind of systematically collected empirical evidence developed in the course of a randomized, controlled clinical trial based on an experimental design. Thus, my proposal is based on isolated experiences in the therapy office and is nothing like the sort of evidence-based protocol that an insurance company would want to see. On the other hand, positive clinical experiences can be the germ of subsequent studies to confirm or deny a hypothesis about those experiences.

The method I have been trying out on myself and some of my clients derives in part from what Kristin Neff and Christopher Germer call “mindful self-compassion.” The basic practice is to combine deep, slow, meditative breathing with eyes closed; an attitude of genuine compassion toward the self; the tender placement of hands upon one’s body (e.g., placing one open hand over your heart); and the inward repetition of chosen affirmations in a soothing voice.

I have tried out such affirmations as “I am worthy,” “I am valuable,” “I matter,” “I know my own goodness,” “I feel loved and included,” “I love and include,” “I am connected with all other beings and they with me,” “I trust that the universe supports me” and “the universe is unfolding in and through me, and I have an important role to play.” Individuals using this practice can create and try out different mantras until they have found some that resonate in a deep and profound way with them.

The meditative breathing serves to produce a trancelike, mildly euphoric state in which the parasympathetic nervous system is activated, the voice of the inner critic is switched off and there is a sense of warmth and expansive possibilities. The role of tender self-touch is to provide mammalian comfort and reassurance — to put oneself in a place of safety and trust.

The combination of meditative breathing with eyes closed and self-touch enables clients to become attuned to themselves in a way that could not happen in the therapy office with the distraction of glances, conversation, pauses and concern over the counselor’s opinion. When imbibed in this atmosphere of self-compassion and self-attunement, the self-affirming mantras take on the ring of truth, not New Age phoniness. Doing this exercise with sincerity is a form of self-reparenting that features the three elements that Dacher Keltner considers essential in loving mammalian connection: warmth, gentle touch and soothing vocalizations.

At this point, I have no evidence that this particular practice by itself can convert individuals who are convinced that they are valueless to people who know and feel they possess value. However, I am observing in myself and my clients that combining this practice with another therapy has a powerful, synergistic healing effect and that this practice has clinical promise.

 

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After 25 years of law practice, Harvey Hyman retired, studied Buddhism and world religions, and entered graduate school to obtain a master’s degree in mental health counseling. He graduated this past October and is now registering for a counseling internship in the Sacramento, California, area. He hopes to work in the field of trauma psychology. Contact him at harveyhyman56@gmail.com.

 

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

A light in the darkness

By Bethany Bray October 30, 2017

Erin Wiley, a licensed professional clinical counselor in northwestern Ohio, once had a client tell her that seasonal depression was like diving into a deep, dark pond each fall. Wiley understands the comparison. With seasonal depression, “you have to prepare to hold your breath for a long time until you get across the pond, reach the other side and can breathe again,” she says.

Wiley routinely sees the effects of seasonal depression in her clients — and in herself — as summer wanes, with the days getting shorter and the weather getting colder. Ohio can be a hard place to live when daylight saving time takes effect and the sun starts setting just after 4 p.m., she says.

Seasonal depression “feels like a darkness that’s chasing you. You know it’s coming, but you don’t know when it’s going to pin you down,” says Wiley, a member of the American Counseling Association. “[It’s like] getting pinned down by a wet blanket that you just can’t shake, emotionally and physically. … For those who get it every year, you can have anxiety because you know it’s coming. There is a fear, an apprehension that it’s coming. [You need] coping skills to have the belief that you have the power to control it.”

For Wiley, the owner of a group practice with several practitioners in Maumee, Ohio, this means being vigilant about getting enough sleep and being intentional about planning get-togethers with friends throughout the winter months. Keeping her body in motion also helps, she says, so she does pushups and lunges or walks a flight of stairs in between clients and leaves the building for lunch. If a client happens to cancel, “I will sit at a sunny window for an hour, feel the sun on my face, meditate and be mindful,” she adds.

Seasonal depression, or its official diagnosis, seasonal affective disorder (SAD), can affect people for a large portion of the calendar year, Wiley notes. Although there is growing awareness that some people routinely struggle through the coldest, darkest months of the year, it’s less well-known that it can take time for these individuals to start feeling better, even once warmer weather returns in the spring. According to Wiley, seasonal depression can linger through June for her hardest-hit clients.

“It takes that long to bounce back,” she says. “They’re either sinking into the darkness or coming out of it for half the year.”

Symptoms and identifiers

SAD is classified as a type of depression, major depressive disorder with seasonal pattern, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. According to the American Psychiatric Association, roughly 5 percent of adults in the U.S. experience SAD, and it is more common in women than in men. The disorder is linked to chemical imbalances in the brain caused by the shorter hours of daylight through the winter, which disrupt a person’s circadian rhythm.

People can also experience SAD in the reverse and struggle through the summer, although this condition is much rarer. Wiley says she has had clients who find summers tough — especially individuals who spend long hours inside climate-controlled, air-conditioned office environments with artificial lighting.

Regardless, a diagnostic label of SAD isn’t necessary for clients to be affected by seasonal depression, say Wiley and Marcy Adams Sznewajs, a licensed professional counselor (LPC) in Michigan. Sznewajs says that SAD isn’t a primary diagnosis that she sees often in her clients, but seasonal depression is quite common where she lives, which is less than 100 miles from the 45th parallel.

“I live in a climate where it is prevalent. I encounter it quite a bit and, surprisingly, people are like ‘Really? This makes a difference [with mental health]?’” says Sznewajs, an ACA member who owns a private practice in Beverly Hills, Michigan, and specializes in working with teenagers and emerging adults. “We change the clocks in November, and it’s drastic. It gets dark here at 4:30 in the evening, so kids and adults literally go to school and go to work in the dark and come home in the dark.”

Likewise, Wiley says that she frequently sees seasonal depression in clients who don’t have a diagnosis of SAD. “I notice it with my depressive clients,” she says. “I have been seeing them once a month [at other times of the year], and they ask to come in more often during February, March and April, or they need to do more intensive work in those months. It’s rare for someone to be healthy the rest of the year and struggle only in the winter. It’s [prevalent in] people who struggle already, and winter is the final straw. They need extra help in the winter and reach out [to a mental health professional] in the winter.”

In other instances, new clients begin to seek therapy because life events such as the loss of a job or the death of a loved one push them to a breaking point during a time of the year — typically winter — when they already feel at their lowest, Wiley notes.

Cindy Gullo, a licensed clinical professional counselor in O’Fallon, Illinois, says that she doesn’t encounter clients who have the SAD diagnosis very often. However, she says that roughly 2 out of every 10 of her clients who have preexisting depression experience worsening mood and exacerbated depression throughout the fall and winter months.

The symptoms of SAD mimic those of depression, including loss of interest in activities previously enjoyed, oversleeping and difficulty getting out of bed, physical aches and pains, and feeling tired all of the time. What sets seasonal depression apart is the cyclical pattern of symptoms in clients, which can sometimes be difficult to see, Sznewajs says. If a client presents with worsening depressive symptoms in the fall, counselors shouldn’t automatically assume that seasonal depression is the culprit, she cautions. Instead, she suggests supporting the client through the winter, spring and summer and then monitoring to see if the person’s symptoms worsen again in the fall.

“If they show improvement [in the spring/summer], and then I see them in October and they start to slide again, that’s when I have to say it could be the season. And certainly if they point it out themselves — [if] they say, ‘I’m OK in the summer, but I really struggle in the winter.’ It’s really when you start to notice a pattern of worsening mood changes in November and December [that alleviate] in the summer.”

Sznewajs recalls a female client she first worked with when the client was 13. She saw the client from October through the end of the school year, and the young woman showed significant improvement. The client checked in with Sznewajs a few times during the summer, but Sznewajs didn’t hear from her much after that. Then, when the client was 16, she suddenly returned to Sznewajs for counseling — in the wintertime. In recounting the prior few years, the young woman noted that her struggles usually seemed to dissipate around April each year, even though the pressures of the school year were still present at that point.

“‘I don’t know what’s going on with me,’” Sznewajs remembers the client remarking. “‘I’m a mess right now.’ It was very evident that there was a pattern [of seasonal depression] with her.”

Wiley notes that clients with seasonal depression often describe a “heaviness” or feelings of being weighed down. Or they’ll make statements such as, “It’s just so dark,” referring both to the lack of sunlight during the season and the emotional darkness they are enduring, Wiley says.

Gullo, an ACA member and private practitioner who specializes in working with teenagers, keeps an eye out for clients who become “very flat” and engage less in therapy sessions in the fall and winter. Other typical warning signs of seasonal depression include slipping grades (especially among clients who normally complete assignments and are high achievers at school), changes in appetite, sluggishness, weepy or irritable mood, and withdrawal from friends and family. For teens, the irritability that comes with seasonal depression can manifest in anger or frustration, Gullo says. For example, young clients may have an outburst or become agitated over small things that wouldn’t bother them as much during other times of the year, such as a parent telling them to clean their room, Gullo says.

John Ballew, an LPC with a solo private practice in Atlanta, estimates that up to one-third of his clients express feeling “more grim,” irritable or unhappy as winter approaches. He contends that the winter holidays “are a setup to make things worse” for clients who are affected by the seasons.

Overeating and overconsumption of alcohol are often the norm during the holidays, and this is typically coupled with the magnification of family issues through get-togethers, gift giving and other pressures, notes Ballew, a member of ACA. In addition, many coping mechanisms that clients typically use, such as getting outside for exercise, may be more difficult to follow in the winter. And although many people travel around the holidays, that travel is often high stress — the exact opposite of the getaways that individuals and families try to book for themselves at other times of the year.

“It’s a perfect storm for taking the ordinary things that get in the way of being happy and exacerbating them,” Ballew says. “People feel heavily obligated during the holidays, more so than in other seasons. It means that we’re not treating ourselves as well, and that can be a problem.”

[For more on helping clients through the pressures and stresses of the holiday season, see Counseling Today‘s online exclusive, “The most wonderful time of the year?https://wp.me/p2BxKN-4TI]

In the bleak midwinter

The first step in combating seasonal depression might be normalizing it for clients by educating them on how common it is and explaining that they can take measures to prepare for the condition and manage their feelings.

“Educating [the client] can give them control,” Sznewajs says. “People often feel shame about depression. Explain that you can take steps to treat yourself, just like you would for strep throat. You can’t will yourself to get better, but you can do things to help yourself get better. When you know what’s causing your depression, it gives you power to take those steps.”

Ballew notes that many of his clients express feeling like a weight has been lifted after he talks to them about SAD. “Many of them won’t think they have [SAD], but they will say, ‘Winter is a hard time for me’ or ‘I get blue around the holidays.’ They’re caught off guard by this unhappiness that seems to come from nowhere. People seem to feel a certain amount of relief to find that it’s something they will deal with regularly but that they can plan for and be cognizant of. It doesn’t mean that they’re defective or broken. It’s just that this is a stressful time. That helps us take a more strategic and problem-solving approach.”

Many counselors find cognitive behavior therapy (CBT) helpful in addressing seasonal depression because it combats the constant negative self-talk, catastrophizing and rumination that can plague these clients. CBT can assist clients in turning around self-defeating statements, finding ways to get through tough days and taking things one step at a time, Sznewajs says.

Gullo gives her teenage clients journaling homework (she recommends several journaling smartphone apps that teenagers typically respond well to). She also encourages them to maintain self-care routines and social connections. For instance, she might request that they make one phone call to a friend between counseling sessions.

Wiley guides her clients with seasonal depression in writing a plan of management and coping mechanisms (or reviewing and updating their prior year’s plan) before the weather turns cold and dark. She types out the plan in session while she and the client talk it over. Then she emails it so that the client will have it on his or her smartphone for easy access. The plans often include straightforward interventions — such as being intentional about going outside and getting exposure to natural light every day — that clients may not think about when dealing with the worst of their symptoms midwinter.

“It sounds simple, but those [individuals] who are down may not realize that the sun is shining and they better get outside to feel it on their face,” Wiley says. “We list exercises that are feasible. You might not join the gym, but what can you do? Can you walk the staircase at your house five times a day? Or, what’s one [healthy] thing you can add to your diet and one thing you can take away, such as cutting down to having dessert once per week, cutting out your afternoon caffeine or drinking more water. And what’s one thing you can do for your sleep routine? [Perhaps] take a hot shower before bed [to relax] and go to bed at the same time every night.”

Wiley also reminds clients to simply “be around people who make you feel happy.” She suggests that clients identify those friends and family members whom they enjoy being with and include those names on their therapeutic action plans for the winter.

All of the practitioners interviewed for this article emphasized the importance of healthy sleep habits, nutrition and physical activity for clients with seasonal depression. “All of these things are really hard to do when you feel lousy, so that’s why the education [and planning] piece is so important,” Sznewajs says. “Let them know that this [the change in seasons] is why you feel lousy, and it’s not your fault. But there are ways to feel better.”

Sznewajs typically begins talking with clients about their seasonal action plans in early fall and always before the change to daylight saving time. One aspect of the discussions is brainstorming how clients can modify the physical activities they have enjoyed throughout spring and summer for the winter months.

One of the cues Wiley uses to tell if clients might be struggling with seasonal depression is if they mention cravings for simple carbohydrates (crackers, pasta, etc.), sugars or alcohol when the days are dark and cold. They don’t necessarily realize that they are self-medicating in
an attempt to boost their dopamine, Wiley says.

Of course, exercise is a much healthier way of boosting dopamine levels. “Exercise is important, but it’s really hard to get depressed people to exercise,” Wiley acknowledges. “Telling them to join the gym won’t work when they just want to cry and lay in bed. So, turn the conversation: What is something you can do? If you already walk your dogs out to the corner, can you walk one more block? Take the stairs at work instead of the elevator, or park farther away from the grocery store.”

Effectively combating seasonal depression might also include counselor-client discussions about proper management of antidepressants and other psychiatric medications. Gullo recommends that her clients who are on medications and are affected by seasonal depression set up appointments with their prescribers as winter approaches. Sznewajs and Wiley also work with their clients’ prescribers, when appropriate, to make sure that these clients are getting the dosages they need through the winter.

Wiley will also diagnose clients with SAD if the diagnosis fits. “For someone who is really struggling and could benefit from [psychiatric] medication, the prescriber is often thankful for a second opinion. It adds weight and clarity to what the client is saying and what the doctor is hearing,” Wiley says. “It also helps the client to have a diagnosis so they don’t just wonder, ‘What’s wrong with me?’ It removes the blame and shame for people who are really struggling.”

Seeking the light

Many factors contribute to seasonal depression, but a main trigger is the reduced amount of daylight in the winter. It is vitally important for clients with seasonal depression to be disciplined about getting outdoors to feel natural light on their faces and in their eyes, Wiley says. She coaches clients to be disciplined about making themselves bundle up and get outside on sunny days or, at the very least, sit in their car or near a window for extra light exposure.

Wiley cautions clients against using tanning beds as a source of warmth and bright light to fend off seasonal depression. However, she acknowledges that she has seen positive results with tanning beds in severe cases of seasonal depression in which individuals were verging on becoming suicidal. In those extreme cases, counselors must weigh the long-term risks of using a tanning bed versus the more immediate risks to the client’s safety, Wiley says.

In addition to encouraging those with seasonal depression to get outdoors, Gullo and Sznewajs have introduced their clients to phototherapy, or the use of light boxes. Roughly the size of an iPad, these boxes have a very bright light (more than 10,000 lumens is recommended for people with seasonal depression) that clients can use at home.

Sznewajs recommends that clients use a light box first thing in the morning for at least 30 minutes to “reset their body,” increase serotonin and boost mood. If a client responds positively to phototherapy, it also serves as an indicator that he or she has SAD (instead of, or in addition to, nonseasonal depression), she notes.

Neither Gullo nor Sznewajs require clients to purchase light boxes. Instead, they simply introduce the idea in session and suggest it as something that clients might want to try. Insurance doesn’t typically cover light boxes, but they can be purchased online or at medical supply stores.

Gullo does keep a light box in her office so she can show clients how it works. She also recommends “sunrise” alarm clocks, which feature a light that illuminates 30 minutes before the alarm sounds. The light gradually becomes brighter and brighter, mimicking the sunrise. Gullo uses this type of alarm clock at home and finds it helpful.

The light box and sunrise alarm clock “are game changers,” Gullo says, “and a lot of people don’t know they exist.”

Powering through

In The Lion, the Witch and the Wardrobe, the second book in C.S. Lewis’ The Chronicles of Narnia series, characters struggle through never-ending cold that is “always winter but never Christmas.” Grappling with seasonal depression can feel much the same way: an uphill battle in a prolonged darkness in which occasions of joy have been snuffed out.

The key to making it through is crafting and sticking to a plan. Sznewajs says she talks with clients in the early fall to help them prepare: Yes, winter is coming, and you’re probably going to feel lousy, but it won’t last forever, and there are ways of getting through it.

“People need to understand that this is a totally predictable kind of concern,” Ballew concurs. “It’s not weak or self-indulgent [to feel depressed]. This is a hard time of year for many people, and you need to plan for it. … We [counselors] are in a great place to validate clients’ concerns, but also help them to strategize beyond them.”

 

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To contact the counselors interviewed for this article, email:

 

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

Letters to the editor: ct@counseling.org

 

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

Healthy conversations to have

By Kathleen Smith July 26, 2017

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

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

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

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

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

Biases and fears

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

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

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

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

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

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

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

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

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

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

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

Having the conversation

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

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

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

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

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

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

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

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

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

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

Psychopharmacology in counseling classrooms

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

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

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

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

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

Areas for growth

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

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

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

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

 

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

Letters to the editor: ct@counseling.org

 

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