Tag Archives: mindfulness

Pushing through the vape cloud

By Lindsey Phillips November 26, 2019

Four years ago, Hannah Rose, a licensed clinical professional counselor in private practice in Baltimore, started vaping as a way to quit traditional cigarettes, but she ultimately found that it was even more difficult to stop vaping. “I was vaping at work, round-the-clock, in between clients,” Rose recalls.

One day after leaving a yoga class, she instantly reached for her vape. In that moment, she felt conflicted because her nicotine addiction did not line up with her values of being mentally and physically healthy. This values conflict made her want to quit, but the thought of doing so gave her anxiety.

Part of Rose’s anxiety stemmed from the fact that nicotine, which is in most vape juices, can be highly addictive. One pod (about 200 puffs) of the electronic-cigarette brand Juul contains 20 cigarettes’ worth of nicotine. Gail Lalk, a licensed professional counselor (LPC) and licensed clinical alcohol and drug counselor in private practice at Young Adult Therapy in Morristown, New Jersey, says she has seen teenagers who have gotten addicted after vaping one or two pods.

E-cigarettes often introduce nicotine to teenagers who were not previously smoking traditional cigarettes. This has been the case for the majority of Lalk’s younger clients. Lalk asserts that she hasn’t had a single client younger than 18 who started vaping because they were trying to quit cigarettes.

Recent statistics confirm the popularity of vaping among teenagers. According to the Food and Drug Administration, from 2017 to 2018, e-cigarette use grew by 78% among high school students (from 11.7% of students to 20.8% of students) and increased 48% among middle school students (from 3.3% to 4.9% of students). In December 2018, Surgeon General Jerome Adams issued an advisory about the dangers of e-cigarette use among teenagers and declared it an epidemic in the United States.

But why have e-cigarettes gained popularity so quickly? The big draw is the flavor, says Rose, who has experience working with clients battling addiction. Traditional cigarettes aren’t known for their good taste. The first time someone smokes a traditional cigarette, they usually start coughing and are left with a tobacco or menthol aftertaste.

Compare that experience with vaping: It doesn’t feel harsh when the user inhales, yet the user still gets a buzz of nicotine. And this experience comes in almost any taste imaginable — mango, mint, apple pie, cake, bourbon, coffee and so on. The options are so plentiful that some online vape shops organize the flavors by categories such as cream and custard, candy, sour and beverage. 

However, after a recent outbreak of lung injuries associated with vaping, e-cigarettes have been coming under increased scrutiny. The Trump administration has proposed a policy to ban flavored vaping liquids, and several states such as Michigan, New York and Massachusetts have already enacted similar bans. In October, Juul announced it was immediately suspending sales of its e-cigarette flavors.

Watch your language

Jennifer See, an LPC and a licensed chemical dependency counselor in private practice in San Antonio, advises counselors to be honest with their clients about the attraction of vaping. “These substances make these kids feel good, even if it’s just temporary. So, saying that they don’t is just not a good approach,” notes See, a member of the American Counseling Association.

Instead, counselors should acknowledge that vaping can be pleasurable and ask clients what they like about it, she says. At the same time, clients can be reassured that they have the ability to quit, even though it will be difficult, and that the counselor will be there with them every step of the way, she adds.

When referring to the issue of vaping during intake or in session, counselors need to be specific about the language they use, See says. Smoking is not “an umbrella [term for vaping] because people don’t really associate [vaping] with tobacco or nicotine,” she explains. “It’s almost its own category.”

On her intake form, See used to ask clients if they were using nonprescribed substances such as alcohol, tobacco or nicotine, or whether they smoked. However, she was finding that clients who vaped often responded no to these questions because they didn’t consider it to be the same as smoking. Now, See clearly asks if clients vape or Juul (the most popular brand of e-cigarettes).

This advice extends to the language counselors use on their websites and in how they advertise their clinical services. Rather than listing only general terms such as substance use or smoking, counselors should specifically list vaping if they are trained and feel comfortable working with the issue, See suggests.

Rose doesn’t believe that vaping should be the focus of counseling sessions, at least not initially. “Vaping is not the problem,” she explains. “It’s just a symptom of the problem. So, counselors [first] need to tap into that core-issue work.”

As Rose points out, even 12-step programs view substances as symptoms of a larger issue. “The 12 steps are not about not drinking [or smoking],” she says. “The only step that even mentions alcohol or nicotine is the first step. The other 11 steps are all about introspective work, practicing integrity, and looking at what patterns of behavior are no longer useful.” The success of this approach lies in looking for the underlying issue, not treating the substance as the problem, she says.

Parents often call See in a panic because they have caught their child vaping and want the child to stop. Parents — typically out of concern and fear — may try to punish or shame their children into quitting. See avoids any hint of shaming her young clients for their choices or even making assumptions about their readiness to quit whatever substances they are using “because I think that is a great way to alienate [the client],” she says.

Rather than launching into a discussion about vaping, See instead starts her sessions by getting to know the client. She will ask about school, home life and friends. She may ask, “What do you do in your free time? What activities are you involved in? Did you recently move? Do you have any pets?”

Often, these conversations reveal the role that vaping plays in clients’ lives, See says. For instance, a client may have started vaping because they just moved and wanted to fit in with a new group of friends, or because they are stressed out about applying to college.

See specializes in substance use and abuse and has expertise working with clients and their family members on issues around vaping. She has found that younger kids want to talk about vaping not only in social settings but also in counseling because they don’t consider it illicit and because they feel it is novel or cool to bring up the latest vape tricks and challenges. One popular challenge is for users to “hit a Juul” as many times as they can for 30 seconds. Another involves the “ghost inhale,” in which users inhale the vapor into their mouths, blow it out in the shape of a ball, and then quickly sip it back into their mouths.

Finding the underlying issue

Using motivational interviewing, See eventually asks clients if they want to quit vaping, if they are worried about their health if they continue vaping, and what their goals are for therapy. Part of the purpose of this questioning is to figure out the underlying reason that clients are vaping in the first place, See says. Is it because they are anxious or depressed? Is it simply because they want to appear cool?

To help clients pinpoint their underlying issue, See asks them to keep a journal to track their thoughts and behaviors connected to vaping. Often, as clients track when and where they vape — for example, when they’re alone in their room, when they’re with friends in their car, or when they’re bored — they also discover the real reasons they do it.

Clients keep track of their vaping habits for a few weeks or in between sessions, and then with See’s help, they look for patterns and clues that point to the underlying reason. This exercise also helps clients gain greater awareness of how much time and energy they devote to vaping, See notes. Often, people spend much more time vaping than they would smoking a cigarette, she adds. “Vaping is almost like chain smoking,” she explains. “That’s just another element that people don’t take into account.” See says some of her clients were vaping for two to three hours per day and didn’t realize it until they started tracking it in their journals.

As Rose notes, “Counseling can be helpful to look under the surface of the behavioral piece and bring a level of mindfulness to what is the thought or feeling that precedes [a client] picking up that vape.” She contends that this is not the time for counselors to use a solution-focused approach to try to quickly get clients to stop vaping.

“Smoking or vaping is a symptom, and the core problem is something internal,” Rose asserts. That’s why she believes counseling has so much to offer to people who want to quit vaping — because counseling goes beyond merely reducing the symptoms and helps to address the underlying issue. “A good competent counselor can really bring a deeper level of awareness to that core issue, [and] if that wound begins to heal, it prevents the problem from continuing,” Rose says.

A few years ago, Lalk, an ACA member who specializes in working with adolescents and young adults, had a teenager come to her because she had attempted suicide, was depressed, had past trauma, and was using lots of substances, including vaping. For the next two and a half years, Lalk worked with the client on her anxiety, depression, and maladaptive behaviors such as lying. After successfully addressing these underlying issues, the client announced on her own that she wanted to quit vaping and be substance free when she started college. In addition to continuing with counseling, the client used a nicotine patch and was able to slowly wean herself off of nicotine. Lalk says this was possible because the client started from a state of good mental health.

A mindfulness ‘patch’

See has had clients who, without thinking, pulled out their vaping devices in session. That showed how much of a habit it had become for them, she says.

Rose admits that she used to be on autopilot with vaping, and the first few days after she quit, she found herself instinctively reaching for her device. Because vaping can help release a person’s anxiety, making them feel better, it can quickly become a habit, Rose says. The challenge is unlearning this habit, which is a deliberate process, she emphasizes.

Similar to See’s tracking activity, Rose has clients journal to help them become more mindful about how and why they vape. She asks clients to write down (or at least notice) what was going on before they vaped, including their thoughts and feelings and their environmental and internal cues. She tells clients not to judge or change the situation. She simply wants them to notice it and make note of it.

“That awareness makes it more difficult to continue engaging in the same self-destructive pattern, and that pain and discomfort lead us to eventually stop the pattern,” Rose says.

Meditation is another effective way for clients to practice nonjudgmental awareness. “Yoga essentially saved me from smoking because it forced me to be still in my own body, and my cravings started to decrease the more I did yoga and the more I got comfortable with myself,” Rose says. “Any kind of mindfulness practice in any capacity can really help calm that craving because it forces you to … pause and be aware instead of act on impulse.”

“When you’re trying to quit vaping, it’s likely to unmask other anxieties,” Lalk says. The trick is to find healthy ways to process this underlying anxiety. Lalk finds patterning techniques helpful for her clients in this regard.

Lalk uses the common technique of deep breathing to illustrate patterning. Counselors often tell clients to breathe in a numerical pattern: Breathe in for four seconds, hold for six seconds, and breathe out for eight seconds, for example. This technique works because of the counting pattern, Lalk says. “Once you start trying to do [this patterning], your brain shifts and it calms you down,” she explains.

Lalk encourages clients to find a patterning technique that works for them. It could be doing beats with their hands, taking deep breathes and counting, writing poetry, or going for a walk and looking for patterns (counting every orange object that they see, for example). The key is to be mindful while doing the activity, Lalk explains. “Running is a beautiful way to pattern because you can count your steps. Just running for the sake of running if you aren’t being mindful about it isn’t nearly as helpful,” she adds.

With the help of a relaxation patterning activity, clients can calm themselves as they discuss their underlying anxiety or other issue with a counselor. Lalk points out that people often hide from whatever makes them anxious. Counselors can work with clients to instead address and acknowledge their anxiety and move toward it, not away from it, she says. Lalk says one of her clients can do four different beats with each of his hands and feet. Once he starts doing his beats, he relaxes and starts talking about his underlying issues.

See also helps clients find mindful replacements for vaping. One of her clients tracked her vaping behavior and discovered that she mostly vaped in her car — a place she spent a significant amount of time driving to school, work and other activities. Together, See and the client reviewed various alternatives that she could engage in while in her car: Would playing music help? Did she need something to do with her hands, such as squeezing a stress ball or play dough or twirling a pen in her fingers? Was her vaping habit the result of an oral fixation?

They finally decided the client would keep a water bottle in her car, and every time she wanted to vape, she would take a sip of water instead. In many cases, it’s about figuring out what clients can do so that vaping is not at the forefront of their minds, See says.

Changing the narrative

Lalk points out that people who vape are not strangers to negative, shame-based and judgmental comments from others. But this sends the wrong message, she says. The person may have tried vaping at a party and, in a short time, become addicted. This doesn’t make them a bad person; it just means they are struggling, she says.

Counseling can help clients manage negative internal and external comments. Rose has her clients practice nonjudgmental awareness. For example, a client might set a goal of not vaping all week, but at the next session, he confesses that he did vape, which in his eyes, makes him a “horrible person.” Rose helps the client separate shame (“I am a bad person because I vaped this week”) from guilt (“I feel bad for relapsing and using nicotine”). Whereas feelings of guilt can be healthy, shame and negative thinking aren’t productive, Rose says. Clients can’t shame themselves into quitting, even though they often try to do just that, she adds.

Rose frequently uses narrative therapy to help clients identify and change these harmful thoughts. She asks clients to write down all of the thoughts they have about themselves at the end of each day. Maybe they vaped that day and feel like a failure, or maybe they went the entire day without vaping and feel good about themselves.

Rose encourages clients to be mindful of the story they are creating with their words and thoughts. She asks clients, “What is the narrative you have created about yourself and your vaping?” Sometimes clients have internalized a narrative of “I’m a smoker,” and the more they say this, the more it becomes true, Rose says. So, if a client states, “I’m a smoker who quit two months ago,” Rose works with the person to change the story to an empowering one, such as, “I don’t vape. I’m not a smoker.”

“Those narratives are going to illuminate some more core issues like self-esteem or a lack of self-worth,” she adds.

Focus on the wins

See suggests that counselors can also help clients focus on their small victories. “Every time you don’t [vape] is a win,” See says. “And if a day didn’t go as great as you wanted it to, then just press that reset button and start over. You can start over at any point in the day. You don’t have to wait until tomorrow.”

See collaborates with clients to identify rewards and motivations that would work best for them. That could be buying new shoes with the money saved from not vaping that week or not allowing themselves to watch a Netflix show until they make it one day without vaping. The goal is to have clients build up their toolboxes, so she has them come up with a list of about 25 things that aren’t substances that make them feel good, such as running or going out to eat at a favorite restaurant.

Having a sufficient stockpile of motivators in their toolboxes ensures that clients will have an alternative to turn to when the craving to vape hits, See notes. Having only a few options — even if they are strong motivators — can backfire because not every tool will work in every situation. For instance, if a client is stuck in class and can’t go running when the urge to vape arises, he or she will need another tool to use in that moment. Clients should also make their goal visible to help motivate them, See adds. For example, they can put the goal on their mirror so that they see it every day.

Rose recommends the app Smoke Free because it focuses on positive reinforcement, not consequences. “It’s very strength based,” she notes. The app doesn’t show a picture of an unhealthy lung or treat the user as naive. Instead, it focuses on the benefits of not smoking and the progress people are making toward their goals.

Upon opening the Smoke Free app, users see a dashboard displaying how long (down to the hour) they have been smoke free. It calculates the degree to which the person’s health is being restored with icons that display improvements (by percentage) for pulse rate, oxygen levels, and risk of heart attack and lung cancer. It also shows users how much money they have saved by not vaping. The app includes a journal component where users can note their cravings and identify their triggers. To further encourage users, it includes progress made such as life regained in days and time not spent smoking.

“A knowledge of consequences does not dissipate the problem,” Rose says. “We absolutely know that smoking is highly correlated with lung cancer, and yet millions of people still smoke.” Younger generations often feel invincible, so focusing only on the consequences of vaping isn’t a sufficient motivator, she adds.

Forming alliances

Counselors must take steps to reach children and parents even earlier because vaping is increasingly making its way into elementary and middle schools, says See, who wrote the article “The dangers of vaping” for the website CollegiateParent. With parents, it is also helpful to educate them on what to look for because vaping devices, which can resemble a flash drive or pen, are often hidden in plain sight and are easily overlooked, See adds. 

Lalk recommends that counselors also take the time to learn from their clients. Through her alliance with some of her seventh- and eighth-grade clients, she found out which local stores were selling e-cigarettes to underage patrons. These clients also confided that one store owner said he knew the kids were underage but that the possibility of getting caught and having to pay a $250 fine was worth it because each vape sold for $60.

This knowledge helped Lalk take action in her community, including writing an article on how the shops, rather than the children, should be prosecuted, and participating in a movement to create ordinances setting new rules for establishments that sell vapes to minors. The businesses in her town now have to secure permits to sell vaping products, part of which requires acknowledging that they will not sell to minors. If store owners are found in violation of their permits, they risk losing their businesses. 

Rose used to facilitate two hours of group counseling at a rehabilitation center five days a week, and she regularly witnessed the shame reduction and healing that can happen in groups. “I believe the opposite of addiction is not just abstinence,” she says. “The opposite of addiction is connection.”

Accountability is another big piece in quitting, Rose says. She often tells clients who are struggling to call a friend with whom they can be honest or to find another way to keep themselves accountable to their goal of quitting or reducing the amount of time they vape.

Rose personally found that documenting her journey of quitting in a blog post kept her accountable. Others reached out and told her that her post made them feel less alone and motivated them to quit too. In turn, she thought twice before using her vape again because she wanted to respond to incoming emails by confirming that she was still vape free.   

See agrees that accountability and healthy rewards are smart strategies for helping clients who want to quit vaping. Peer pressure can become a big issue, especially for teenagers who don’t want to feel like the odd person out when seemingly everyone else in their crowd is vaping, she says. She advises clients to let people know they are quitting and to surround themselves with people who will empower and support them in their decision.

Accountability becomes even more important with adults, See points out, because they have more freedom and don’t automatically have someone watching over or checking in with them. That’s why having a support system is so important, she says. When clients feel like vaping, they can reach out to someone they trust and ask them for five reasons not to, See says.

See says clients might also consider posting on social media that they are quitting and openly ask for support, or they could participate in a 30-day challenge. One of Lalk’s clients participated in a challenge the person referred to as “No-Nic November.” These positive challenges can provide a good counterbalance to the vaping challenges that are so popular on social media currently.

When See dropped one of her children off at college, she noticed the dorm had placed a whiteboard with the words “Healthy Ways to Deal With Stress” written at the top. The students were adding their own suggestions, such as going to a pet store and petting a cat or going for a run. See loved this self-empowering technique and plans to incorporate it into her own practice by adding a Post-it wall where clients can add their own healthy ways of coping or their own words of encouragement.

Taking the first step

Quitting can be overwhelming, and sometimes clients don’t know where to start. See advises these clients to begin by taking small steps. Harm reduction can be a particularly effective early strategy because it empowers clients, See says. “Once they see they can harm reduce, then maybe [they] can harm reduce all the way to zero use,” she explains. “But putting them at the bottom of Mount Kilimanjaro and saying ‘get up to the top right now’ is daunting.” Instead, she asks clients what their “climb” to being vape free looks like for them. Do they want to climb fast, or do they want to climb slow?

Recently, See worked with a teenager who had been vaping for three years. She had been scared by the recent health reports related to vaping and wanted to quit. See asked this client about her motivators, and the client said she wanted to quit to protect her health, for her parents who were pressuring her to quit, and because of the monetary costs associated with vaping.

See asked the client, “What does 30 days without vaping look like?” The client’s eyes bulged. The thought of it was too much for her. So, instead, See and the teen client talked and decided she would remove e-cigarettes from just one place in her life.

By tracking her habits, the client learned she vaped mostly in her car. So, See suggested she remove the vape only from her car and also not allow her friends to vape there. See also instructed the client to notice and write down how it felt not having the vape in her car. Did she miss it? Did she reach for it without thinking? Together, they also made a list of possible replacements she could keep in her car, including a pen, candy flavored like her favorite vape juice, and a stress ball.

“That was one part of the mountain that she could climb,” See says. Feeling empowered by her success, the teenager eventually decided that she was ready to tackle the prospect of no longer vaping in her room at home.

Others, such as Rose, decide to take a faster approach and quit cold turkey. She notes that counseling can bring a level of mindful awareness to quitting and help clients figure out the underlying reasons they turn to vaping to fill an internal void. “The nicotine [and] physical addiction is a part of it, but that’s not the core issue,” she asserts.

Since she stopped vaping, Rose’s mindfulness practice has increased. She has trained herself to pause before acting on impulse. “The mental aspect is infinitely more difficult to unlearn than the physical addiction — ‘I’m sad, I’m going to vape. I’m happy, I’m going to vape. I’m bored’ — that’s the most common — ‘I’m going to vape.’ It’s something to do, something to reach for, essentially something to [help] avoid just sitting with [one’s] self in one’s own skin,” she says.

As Rose opens her Smoke Free app, her dashboard proudly displays that she hasn’t vaped for six months, 16 days and 13 hours.

 

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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.

Volcanic adolescence

By Chris Warren-Dickins January 14, 2019

In the early days, Caroline, a 14-year-old girl, started each session with a chin thrust indignantly at her counselor. She wanted to be seen as a warrior, and she offered answers that were blunt as a sledgehammer.

And why should she drop her defenses? She had seen too many adults — teachers, social workers, friends of the family — try to engage with her at first, and then seemingly lose interest. In the end, she felt that she was just an inconvenience to everyone around her. Why should Caroline believe that this counselor would offer a different type of relationship?

With any new client comes the challenge of forming a therapeutic relationship, but when that new client is an adolescent, there are additional factors to consider. Aside from the legal issues of capacity and consent, I discuss 10 of those therapeutic factors below.

 

1) A holistic assessment: It is important to adopt a strengths-based approach to assessment of adolescents. In addition, it is worth reviewing that assessment more regularly than with an adult client because more things are likely to change with a growing adolescent. As Urie Bronfenbrenner pointed out, a young person’s development is the result of a complex system of relationships that constitute the child’s environment. Therefore, assessments of young clients will include their developmental needs, the extent to which caregivers are meeting their needs, and their family and environmental contexts, including the influence that their school and peers have on them. The assessment should also gauge the influence of technology in the young person’s life.

2) Emotional “distance” from problems: As an adolescent, Caroline needs her counselor to appreciate that she does not have the same “distance” as adults experience from their problems. Adolescents have little control over their lives. They have to stay in the same home or school, even if these things might be the source of their depression, anxiety or other presenting issue.

3) Grasp of emotional language: As a 14-year-old, Caroline still has not developed her emotional language, so volcanic eruptions of anger or shoulder shrugs of apparent indifference are her only means of expressing how she feels. We have to see past the shoulder shrugging, which can easily be interpreted as nonchalance, and open ourselves to the possibility that young clients want to express themselves but just don’t know how to yet.

Images are a useful starting point, even if it is just looking at a series of facial expressions to try and help these clients identify the emotions they are experiencing.

4) The dominance of transition: Transition features heavily in adolescents’ lives. Each year, they are at a different stage of educational development and, each year, they experience bodily changes. On top of all of this, their ideas about who they are and how they fit in with their peers and wider society are in a constant state of flux.

At this level of fluidity, a counselor can offer Caroline some sort of stability. One source of this stability can be the therapist’s professional boundaries. The counselor can also offer Caroline the benefit of his or her life experiences, providing a deeper context than Caroline’s young perspective. But the counselor’s older years and life experience do not provide complete insight, no matter what the client’s presenting issues is, so a person-centered approach is crucial. We, as counselors, do not know Caroline’s worldview until we explore it with her, and we have to be careful not to make too many assumptions.

5) Disruption tenfold: It is hard for adolescents to experience so much transition, but it is even harder to manage at the same time as dealing with mental or physical health challenges, a chaotic home life or a sudden major change experienced by the adolescent’s parents (e.g., job loss, divorce, bereavement).

Because of the volcanic eruptions of adolescence, there is a danger that adolescents will become scapegoats in these situations. Just because adolescents may shout the loudest does not mean they are the source of the problems. Often, parents bring their adolescents for therapy, and these adults are completely unwilling to consider that the need for change might also rest on their own shoulders, rather than expecting just the adolescent to change and the whole family dynamic to become settled.

6) Discrimination experienced by minority adolescents: If an adolescent client is a member of the LGBTQ community or is an ethnic minority, it is likely that they have endured some sort of discrimination. If adolescents have to make sense of this — in addition to the transitions they are experiencing in their bodies, at school and at home — it can be challenging to deal with.

Is it any wonder that we sometimes see volcanic behavior in adolescents in the form of outbursts and defiance, screamed at us in a burning rage? If we are to help these youngsters, we have to see past the behavior that spews out like lava. We must dare to imagine what unmet needs might be fueling this volcano.

To help us, we can consider Abraham Maslow’s hierarchy of needs, and we can assess to what extent our adolescent clients may be getting their basic physiological needs met. Perhaps they are hungry, or there is the constant threat of homelessness hanging over them. Or perhaps their basic safety needs aren’t being met because domestic violence is present in the home. We can continue working our way up Maslow’s hierarchy (love/belonging, esteem and, ultimately, self-actualization) to understand what unmet needs may be fueling what appears on the surface to be irrational and unacceptable behavior.

7) Trauma-informed care: If the adolescent has a history of trauma, it is especially important to see past his or her volcanic eruptions of anger. In a 2017 article in Counseling Today about young clients in foster care (“Fostering a brighter future”), Stephanie Eberts states that therapists need to “help these children heal” by acting as a “translator” of the child’s behavior: “This includes explaining what a child’s behavior means and what motivates it, and then equipping both the child and the parents … with tools to redirect the behavior and better cope with tough emotions.”

8) Testing (to discover and take reassurance from) the boundaries: Adolescents may test boundaries more than adult clients do. Modeling behavior is important, and this is where congruence comes into play. If young clients are constantly pushing the boundaries by turning up late to sessions or missing them entirely, you can communicate the resulting emotion you are experiencing as a result of their behavior.

I like to think of this like a sonar device: Young clients are checking to see if you are still emotionally there and whether they are also still present in the interaction. You can share this with young clients, showing that certain behavior has consequences. Then you can jointly look for a way to resolve the matter.

Psychotherapist Rozsika Parker wrote about parents’ relationships with their children, but the following statements could apply equally to counselors and their young clients. Young clients “need to learn that they have an impact, that it’s possible to hurt” an adult, but it is also possible to “make it up with them.” Parker encourages adults to “show joy, hate, love, satisfaction — the full range of emotions — that will help the child to know themselves.” Parker wrote that she “heard the same note of reproach in their wails when they teethed, as in the studied criticism of me they could launch as teenagers.”

9) The resistant adolescent: As with any resistant client, adolescents need to feel that they are choosing to be in the sessions. But what happens if they are given no choice? If a therapist is working with a young client and the client’s family, and the young client chooses to leave the session early, what should the approach be?

I have heard some therapists adopt the following approach: They tell young clients that they are free to return to the session at any time but that the session will continue with the other family members. I quite like this approach because it avoids sessions becoming hijacked and held hostage by young clients, which might be a parallel process to other times in which these young clients have held more power than they knew how to handle. For example, they might have been forced to adopt a parental role with a younger sibling, or even a neglectful parent, at an inappropriately young age.

10) Mindfulness and meditation: I have seen and heard some of the criticisms of mindfulness and meditation. I struggle with this because, when I was starting out in this profession, my mentors raved about mindfulness and meditation. I need to see where this debate goes, but in the meantime, I cannot help but believe that there might be some value in mindfulness and meditation in our work with young clients.

Everything we offer our clients involves a balancing act between thoughts, feelings and bodily sensations. Society is built to engage the thinking side of our awareness, and this casts a shadow over our feelings and bodily sensations. Yet all three are important sources of information. If we focus solely on our thoughts, we are arguably functioning at only a third of our capacity. Short and simple mindfulness or meditation exercises can help young clients tap all sources of information, while also giving them a moment of relief from the constant demands of life.

 

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Chris Warren-Dickins is a licensed professional counselor in Ridgewood, New Jersey. Contact him through his website at exploretransform.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.

Five pragmatic tools to become a nonanxious presence: Tips and tricks for being a mindful counselor

By John Wheeler June 26, 2018

One of the most uplifting and powerful things counselors can do for their clients is to become a “nonanxious presence.” The term, originally coined by Jewish Rabbi and family therapist Edwin Friedman, is used to describe an individual who provides a calm, cool, focused and collected environment that empowers others to be relaxed.

This can be especially helpful for clients who have varying levels of anxiety, are in crisis or share information that could be traumatizing. By being a nonanxious presence, the counselor can model emotional regulation and invite clients to see that there is more than the anxiety or other feelings they may be experiencing.

As a counselor-in-training and certified empowerment coach, here are the five pragmatic tools that I use in my own practice.

 

1) Don’t buy in to the story; it only makes your client a victim. Everyone has a story about life. They use this story to determine who they are, where they are from, who they hope to become and all the difficulties they have overcome. As counselors, we must acknowledge the stories our clients share and the significance they assign to these stories. However, we must further consider how clients may use these stories to limit themselves and give up control in their life. If, as counselors, we allow ourselves to be swept into the story, we do a disservice to our clients and allow them to serve in the role of victim.

How does that apply to being a nonanxious presence? By not buying into the story and the role your clients have assigned themselves, you invite them to see the story from a different perspective. When you resist the urge to emotionally join their story, you are able to see all the ways in which their story is playing out in their daily lives. You, as counselor, are then free to identify patterns of behavior and gain insight into clients’ lives, thus empowering them to create something greater than they currently have.

2) Be you and trust your training. As a counselor-in-training myself, it seems the hardest thing to remember is to be yourself and to trust your training. Many times, we can be swept up in what we must “do” as counselors and fail to connect with the client. If we get caught up in the information we must gather, the treatment goals we are measuring and the skills or techniques we plan to implement, we may miss the opportunity to make a true connection, which so many people are missing in their lives.

The most influential measure of success in counseling is the client-counselor relationship. Have you ever noticed that some of your best sessions take place when you are willing to simply be present with your clients and let go of using a specific technique? How different might your practice be if you were willing to just be you, had faith that you possess the training you need and allowed yourself to meet the client in the here and now? Truly being present with yourself also invites your clients to be with themselves and to lower their barriers. In the process, you become the nonanxious presence that allows for greater change in clients’ lives.

3) Empower your clients to know that nothing is personal. Take a moment and consider a time when you experienced difficulty in a relationship, either romantically or otherwise. How differently might you have reacted to the event if you had known it wasn’t personal? This is another tool I use as a nonanxious presence with my clients. I empower them to know that nothing they have experienced or believe was done to them is personal.

This approach can be particularly helpful when dealing with abuse, trauma or relationship problems that arise in session. Clients can sometimes use their abuse or trauma as a coping skill to ensure that no one is able to get that close to them again. It is a means for them to know they have control and will not allow more abuse in the future. Reframing your clients’ perspective to “it wasn’t personal” invites them to see where they were a convenient target for the other person to release what they were experiencing. When individuals choose to abuse someone, they seldom consider who the other person is; quite frankly, they are just looking to relieve whatever level of stress, anxiety or other feeling they are experiencing.

When using this tool with your clients, it is important to have a strong rapport and relationship with them because challenging someone’s view on abuse can be difficult for the person to accept. If you are able to empower your clients to see that nothing is personal, however, it opens the door for them to separate themselves from the abuse or trauma and to begin the healing process.

4) Practice having an interesting point of view about everything. The greatest tool I have learned from my training with Access Consciousness is to practice having an interesting point of view about everything. An interesting point of view is the place where you can hear, see or become aware of anything without judgment.

As counselors, we receive training in cultural competency and learn the importance of maintaining an environment of nonjudgment with our clients. This is exactly what invites our clients to trust, share and be present with us in session.

How many times have you been judged? How did that make you feel or react? Now imagine if you were sharing the most intimate parts of your life and became aware that someone had a point of view about you? I am not saying that counselors should not be observant and make notice of things taking place in session, but we must be willing to put our points of view aside and be with our clients.

Another way to use this tool is to teach our clients that they can also have an interesting point of view in any area of their own life. This can help them detach from the high level of emotions that prevent them from going beyond the problem. What might this approach add to your daily life inside and outside of your counseling practice?

5) Ask questions, never give answers. As counselors, we can fall into the habit of dispensing advice. As someone who studied for a few years as a life coach, one of the greatest tools I used was to always ask questions and never to give answers. As a nonanxious presence, you can empower your clients by asking questions that allow them to see what is true in their lives.

Depending on your clients’ level of cognition, the use of this tool can lead to greater levels of healing and insight into their choices in life. It also helps to eliminate the possibility of setting up the counselor as the “power” in the relationship and prevents clients from developing a high level of dependency. As counselors, we must allow our clients to see their difficulties from a different light and empower them to trust in themselves.

Questions always empower clients, whereas providing “answers” disempowers clients. Acknowledge that your clients are the experts in their own lives; we, as counselors, are simply a resource they can use to gain new information.

 

Many of us who choose this profession believe we are called to serve others or have the ability to make a difference in the world. If you truly embrace your role as a nonanxious presence in the lives of your clients and the power this can have to create change, I firmly believe that you will have a rewarding career. What if you were willing to not simply diagnose and treat your clients but to empower them to live their best lives? What if you were willing to acknowledge the gift that you are and the ability you have to invite something greater to exist on the planet? We often hear that “human beings are messy.” What if you being you, as a nonanxious presence, is exactly what is required to begin untangling the mess?

 

 

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John Wheeler is a graduate student at the University of Dayton and a counselor-in-training at Riverscape Counseling in Dayton, Ohio. His focus in therapy is helping to address people’s unique needs while also assisting in facilitating a healthy, self-sustaining outlook on life. He encourages clients to take a proactive approach in fostering a lifestyle that promotes mental, emotional and physical well-being. Contact him at wheelerj7@udayton.edu.

 

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Related reading, from the Counseling Today archives: “When help isn’t helpful: Overfunctioning for clients

 

 

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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.

Differentiation of self through the lens of mindfulness

By Kevin Foose and Maria Cicio February 7, 2018

A few years ago, while teaching a course in family therapy, a particularly bright and insightful student named Maria lingered after class one day and asked, “Isn’t differentiation of self similar to mindfulness?” I hadn’t quite thought of it like that before, but it certainly seemed plausible. “Let’s set aside some time to talk,” I suggested. With that single question began many months of conversations.

In 2015, a continuation of those hours of exploration transformed into an “anti-presentation” that was awarded “Best of Show” at the Louisiana Counseling Association Annual Conference. The examination continued the following spring at the American Counseling Association Conference & Expo in Montréal. In the end, it was inquiry rather than answers that animated our informal lyceum. Quest and question are born of a common root. And teaching is thin soup if only the student grows. The current work is an attempt to extend the spirit and tone of those many fruitful hours of meeting.

Attempting to define differentiation

Differentiation of self (DoS), since first being introduced by Murray Bowen in the early years of the family therapy movement, has remained a lofty, elusive and often misunderstood concept. As Bowen’s colleague, Michael Kerr, pointed out, differentiation contains so many unique conceptual facets that it defies simple definition.

Bowen himself, persistently mystified by the consistent misinterpretation of differentiation, noted late in his life in one of his more cantankerous moments that he wished he’d never “discovered” it in the first place. Anthropologist Gregory Bateson once said of Charles Darwin that he didn’t discover evolution, he made it up. The same may be said of DoS. Viewed through this lens, DoS becomes a story (the point of which is to communicate its creator’s intent) steeped in a deep faith in science and the relatively recent emergence of the Western nuclear family.

If we are to accept the premise that differentiation does indeed defy simple definition, or at the very least is so subtle and nuanced that it is open to numerous interpretations, the initial question that emerges is: What in the world are we actually talking about when we talk about differentiation?

Michael Cowen, one of my colleagues at Loyola University New Orleans, provides a useful foundation from which to launch this conceptual ship with his interpretation of differentiation as “the capacity to be aware of one’s own unique pattern of feeling, valuing and thinking, and to decide and act in ways that remain faithful to that awareness.” Cowen’s definition shifts the focus of differentiation away from some thing that one is or has or even does, toward a description of understanding and action. It is a process that, at its core, allows individuals to make distinctions between thoughts and feelings and to remain calm in highly emotional situations. It is the ability to be both a part of and apart from significant relationships, and it places a high premium on the ability to behave rationally. It is not, however, a call for a Spock-like hyper-rationality nor a ringing endorsement of the ruggedly individualistic American mythology.

For the sake of moving forward with consensus, nebulous as it may be, I (Kevin) am inclined to give Bowen the final say in the construction of a working definition of differentiation as “a way of thinking that translates into a way of being.” So the story goes.

If that description of differentiation is to be accepted, the question then becomes, how is one to cultivate such “a way of thinking?” And who might act as a reliable translator? This is the point at which the teaching of the Buddha, in general, and mindfulness, specifically, can offer a helpful perspective from which to view perceptions and human experience.

At first glance, Bowen and Buddha may seem to be a strange pairing. After all, Bowen’s search for understanding led him back to the tumult of his family of origin, whereas Buddha left home seeking transcendence and never returned. Logistically, Buddha’s eightfold path provides a different road map toward liberation and understanding than does Bowen’s eight interlocking theoretical concepts. But the wisdom gained beneath the Bodhi tree may not be as divergent from the family tree as one might think. When differentiation is examined through the prism of mindfulness, significant conceptual convergences begin to emerge. The potential implications for personal growth, insight and clinical practice merit a pause, perhaps a deep breath, and further contemplation.

Mindfulness

Mindfulness is essentially the act of being present. Anchored in continuous awareness of each emerging moment, it is the cultivation of a calm, dispassionate state in which experience can be examined with acceptance and nonjudgment. Mindfulness, not unlike DoS, is a process that provides the possibility of escaping the trappings of emotional reactivity.

In an excellent article examining mindfulness (“Mindfulness: A Proposed Operational Definition” in the September 2004 issue of Clinical Psychology: Science and Practice), a group of Canadian academics, led by Scott R. Bishop, pointed out that the insight that emerges through disciplined contemplative practice creates an open “space between one’s perception and response, ultimately making it possible to respond and interact more reflectively (as opposed to reflexively).” Rather than becoming tangled up in “ruminative, elaborative thought streams about one’s experience and its origins, implications and associations, mindfulness involves a direct experience of events in the mind and body,” wrote Bishop and his colleagues

In other words, we are able to stay tethered in the present, experiencing our life with courage and composure as it actually unfolds in our midst. In this awakened state, our mind is freed from anger, attachment to desire and misperception. Providing an alternative to being swept away in a flood of emotionality and elaborate misinterpretation, we are able to resist the urge to flee into ideations of the imagined future clouded by the residue of the past, or compulsively bend reality to meet idiosyncratic needs.

Mindfulness is the antidote to fear, confusion and anxiety. It is a practice and process that tethers us to the immediacy of our lives with the insight to see “relationships between thoughts, feelings and actions and to discern the meaning and causes of experience and behavior” (as described in “Mindfulness: A Proposed Operational Definition”). Essentially, mindfulness cultivates the ability to interact rather than react.

The greatest hurdle in defining a self or sustaining mindful attention is emotional reactivity. When emotions escalate beyond a critical threshold, a state of mind emerges in which rational thinking evaporates and agitation hijacks the cognitive process. It is impossible to differentiate in such an agitated state. We become prisoners to automatic emotional responses saturated in fear.

Buddha referred to this reactive state as “monkey mind,” in which fear becomes much like a loud, drunken monkey frantically screeching the alarm bells of danger in our brains. The ability to quickly regain composure and quiet the monkey mind is the cornerstone of both differentiation and mindfulness.

The quiet mind is fertile ground for exploring what Buddha called “store consciousness.” Long before Sigmund Freud proposed his theory of the unconscious (again, see Bateson above) or Bowen began his examination of psychobiological cognitive-emotional processes, Buddha was wandering about preaching the Dharma, teaching practices aimed at liberating people from misperception and attachment to mental formations that seemed to be just beyond the reach of everyday awareness.

Vietnamese Buddhist monk Thich Nhat Hanh writes in the introduction of Cultivating the Mind of Love: “In our store consciousness are buried all the seeds, representing everything we have ever done, experienced or perceived. When a seed is watered, it manifests in our mind consciousness. … The work of meditation is to cultivate the garden of our store consciousness.”

Getting back into harmony with our lives

Whatever we “attend” to will grow. And what we don’t attend to will tend to grow out of control without insight into content and coping strategies buried deep in our store consciousness. For multigenerational family systems theory, the seeds in the soil are the early experiences in the family of origin. Differentiation allows for a bit of psychic “weeding” to occur so that intimacy and integrity may grow.

Buddha, too, was attuned to the influence that family members have on one another. Perhaps more poetic, but no less prophetic, a Buddhist teaching examines the importance of the emotional climate of filial bonds, invoking the image of the garden again: “A family is a place where minds come in contact with one another. If these minds love one another, the home will be as beautiful as a flower garden. But if these minds get out of harmony with one another, it is like a storm that plays havoc with the garden.”

It is precisely in those moments when one finds oneself in the “I” of the storm where mindful intention allows the well-differentiated self to stay calm and sift through frenetic cognition that often causes impairment in our lives. The ability to sit in the midst of the tempest and remain present, self-aware and in close emotional contact with others is the essence of what Soto Zen monk Shunryu Suzuki calls “imperturbable composure.”

The well-differentiated self exhibits radical acceptance to what Jon Kabat-Zinn calls the “full catastrophe of living.” In this way, we remain open and curious to the actual events of our lives as they unfold, freeing ourselves from endless cycles of suffering and automatic reactivity. Whether we call this mindfulness or differentiation becomes an exercise in semantics.

Through work and practice, we become available to the full reality of our lives, with the insight and courage to quietly slip through the cracks of our conditioning and allow our ego-cramped consciousness to release its grip on our battered psyche. Quite simply, DoS and mindfulness bring us back into harmony with our lives.

For Buddha, the ultimate act of enlightenment is to wake up. The Dharma teaches that it is possible for any of us to awaken at any moment in our lives. Much like achieving a fully mindful present state, people often find embarking on the path of defining a self to be a daunting task.

Bowen was clear and consistent in his insistence that the fully differentiated self is a theoretical concept that is practically unattainable. It is a guiding light rather than prescription. However, with much work and practice, it is possible to increase one’s level of differentiation. Bowen pointed out that if we can “control the anxiety and the reactiveness to anxiety, the functional level will improve.” The task at hand becomes “getting beyond anger and blaming to a level of objectivity that is far more than an intellectual activity. … The overall goal is to be constantly in contact” with emotional issues involving ourselves and others.

A common thread

Although Bowen and Buddha’s conceptualization of the “self” superficially seems to be the point at which the Venn in the Zen between DoS and mindfulness begins to diverge, it is through interdependence that the deepest synthesis actually occurs. Whether one adopts a scientific or a spiritual perspective, the influence that each of us has upon the other is the thread that ties mindfulness and differentiation together.

Bowen was certain that the self exists. Buddha sent his disciples out into the world in search of the self and sat patiently waiting for the report back. Ralph Waldo Emerson, with his ever-present, transcendental wisdom, offered this: “All that is said of the wise man by Stoic or Oriental or modern essayist … describes his unattained but attainable self.”

Both Buddha’s and Bowen’s philosophical views were undergirded by a belief in the profound effect that each of us has upon one another. Bowen believed that successfully differentiating oneself within the system could have significant influence on all others in that system. He noted that if one is able to successfully define a solid sense of self and defend against requests from others to change back to old ways of being, then the entire system can catapult forward into higher levels of functioning.

The Dharma teaches that when one is awakened with compassion and wisdom, all are touched by the light. In Cultivating the Mind of Love, Hanh examines Buddha’s teachings, exploring the ways in which the Dharma opens each of us to the possibility of deeper understanding and more intimate connection. In his introduction, Hanh invites us to become fully present, and “the rain of the Dharma will water the deepest seeds of your store consciousness. If the seed of understanding is watered … the fruits of love and understanding will grow.”

Examining the teaching of interbeing and the delusion of separateness falsely constructed in the mind, Hanh concludes: “We must vow to practice for everyone, not just for ourselves. … Because of our ignorance and habit energies, we usually perceive things incorrectly. We are caught in our mental categories, especially our notions of self, person, living being and life span. We discriminate between self and nonself. … When we see things this way, our behavior will be based on wrong perceptions. Our mind is like a sword cutting reality into pieces, and then we act as though each piece of reality is independent from other pieces. If we look deeply, we will remove these barriers between our mental categories and see the one in the many and the many in the one, which is the true nature of interbeing. … Everything is touching everything else. … To bring relief to one person is to bring relief to everyone, including ourselves. This insight brings about the kinds of actions that are truly helpful.”

These are hopeful thoughts for troubled times. What is called for in this moment, if one is to view differentiation through the lens of mindfulness, is a “way of thinking that translates into a way of being in the world” that accurately perceives the deep connection that we have with the world surrounding us and the profound effect that each of us has upon one another. So the story goes.

Compassionate listening

Counseling is a reciprocal process of story and interpretation. As a conversational intervention, much attention has been given to the narrative telling of the tale — the “talk” in talk therapy. Often lost in the reciprocity is the transformative power of listening. As Hanh points out, when we listen to another deeply and compassionately, we help that person to suffer less. “One hour like that can bring transformation and healing,” he teaches.

If listening in this way does indeed, as we believe, lead to the alleviation of suffering, the question becomes, how does one engage in the process of compassionate listening?

The calm that accompanies the differentiated self, and a mindful stance tethered in the present, provide a helpful perspective from which to enter into another’s story. It allows one to avoid judgment without abandoning discernment and concern. This way of being allows the counselor to bear witness to the tumultuous content of clients’ troubled narratives without becoming overwhelmed. We can tolerate intense emotion without needing to flee for safety and care without getting carried away.

Deep listening contains the seeds of empathy. The calm that accompanies a well-differentiated presence opens up the space to create the distance necessary to examine problem-saturated narratives. The practice of active listening artfully folds the story continuously back upon itself, returning the client to present-moment awareness. The acceptance that accompanies awareness invites the client to slow down, resist the impulse to avoid the suffering and instead examine the story with compassion. The wisdom to accept that which is beyond our control paradoxically generates the flexibility necessary for transformation to occur.

Pragmatically speaking, compassionate listening is rooted in language. To listen in this manner, it is essential to remain firmly planted in the present, gathering content without getting lost in the labyrinth of past suffering or anxious projections of the future. When listening to stories of suffering, it can be easy to lose sight of the fact that the actual experience is the retelling of the tale here and now, not what occurred there and then. It is imperative to honor our clients’ suffering while also uncovering their strength.

The task is to attend to the content of the client’s story while staying deeply connected to the person. Listening in this way allows us to wonder what the client is trying to communicate about his or her struggle through the story. What meaning is seeking to be understood? What are the relational and emotional elements recurring in the client’s words? Compassionate listening is the conduit into the deepest sense of clients’ experiences. It asks, how can we be present to the struggle and help our clients confront the frustrating and most frightening moments of their lives?

At its core, compassionate listening holds the therapeutic space. It widens the client’s interpretation just a bit. It uses the client’s language, symbols and metaphors. It sees as well as hears, deconstructing the story, searching the margins for what has been edited out, pulling the thread of seemingly disjointed pieces and reflecting it back in recognizable form. This way of listening is ultimately a path toward healing that allows for safe passage through suffering. As American Buddhist nun Pema Chödrön points out, mindfulness allows us to choose an alternative course for our lives. A process such as DoS requires us to first notice the true nature of our experience, then disrupt our habitual patterns and do things differently and, finally, practice again and again, one moment at a time.

A client suffers and a change is necessary. The struggle often comes with not knowing how to manifest a healthy change. The client has likely been avoiding, wrestling with and running away from anxiety for years, creating deeply ingrained habits. In the space created by deep listening, the client can experience something different. Clients may be able to look at their anxiety for the first time with compassion and understanding. The paradox is that once they are able to sit with their struggle instead of avoiding it, anxiety loosens its grip on their lives.

DoS, viewed through the lens of mindfulness, creates the clarity and compassion for transformation to occur. Mindfulness aids in the process by creating awareness of our mind-body interaction so that we can become more skillful in our interpersonal, and intrapersonal, relationship(s).

Just as the counseling process makes space for emotions, thoughts, ideas and stories in session, mindfulness creates a similar space for our internal experience to occur. This is the “deep listening” to our own process. Mindful awareness allows for attunement, not only with our clients but with ourselves. It creates systemic and intrapsychic awareness to the ways that we get hooked into metanarratives and mental confines. Emotions no longer run amok, and we are available to be in relationship with others. As clinicians, we must first listen deeply to the mystery and history of our own stories before making contact with someone else’s.

The Beat Zen of Richard Brautigan leads us to a quiet place to begin in his poem “Karma Repair Kit: Items 1-4”:

1. Get enough food to eat,/ and eat it.

2. Find a place to sleep where it is quiet,/ and sleep there.

3. Reduce intellectual and emotional noise/ until you arrive at the silence of yourself,/ and listen to it.

4. ???

 

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

Kevin Foose is an assistant professor in the Department of Counseling at Loyola University New Orleans. He maintains a private practice that focuses on couples and adult individuals. Contact him at kjfoose@loyno.edu.

Maria Cicio is a graduate of the Loyola University New Orleans master’s in counseling program, class of 2015. A licensed professional counselor, she is currently working in community mental health in rural Oklahoma.

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.

Talking through the pain

By Laurie Meyers January 30, 2018

By the time the 43-year-old man, a victim of an industrial accident, limped into American Counseling Association member David Engstrom’s office, he’d been experiencing lower back pain for 10 years and taking OxyContin for six. The client, whose pain was written in the grimace on his face as he sat down, was a referral from a local orthopedic surgeon, who was concerned about the man’s rapidly increasing tolerance to the drug.

“He often took twice the prescribed dose, and the effect on his pain was diminishing,” says Engstrom, a health psychologist who works in integrated care centers.

The man’s story is, unfortunately, not unusual. According to the National Institutes of Health, 8 out of 10 adults will experience lower back pain at some point in their lives. As the more than 76 million baby boomers continue to age, many of them will increasingly face the aches and pains that come with chronic health issues. And as professional counselors are aware, mental health issues such as depression, anxiety and addiction can also cause or heighten physical pain.

Those who suffer from chronic pain are often in desperate need of some succor, but in many cases, prescription drug treatments or surgery may be ineffective or undesirable. Fortunately, professional counselors can often help provide some relief.

Treating chronic pain

At first, the client had only one question for Engstrom: “I’m not crazy, so why am I here?”

Although the man’s physician did not think that the pain was all in the man’s head, it is not uncommon for sufferers of chronic pain to encounter skepticism about what they are experiencing. “It was important … to defuse the idea that I might think he was imagining his pain,” Engstrom says. “So I [told him] that I accepted that his pain was real and that all pain is experienced from both body and mind. I told him that we would be a team and work on this together.”

Engstrom and the client worked together for five months. As they followed the treatment plan, the man’s physician slowly eased him off of the OxyContin.

Engstrom began by teaching the client relaxation exercises such as progressive muscle relaxation. “When in pain, the natural inclination of the body is to contract muscles,” Engstrom explains. “In the long term, this reduces blood flow to the painful area and slows the healing process. Contracted muscles can be a direct source of pain.”

Engstrom also began using biofeedback to promote further relaxation. In biofeedback sessions, sensors are attached to the body and connected to a monitoring device that measures bodily functions such as breathing, perspiration, skin temperature, blood pressure, muscle tension and heartbeat.

“When you relax, clear your mind and breathe deeply, your breathing slows and your heart rate dips correspondingly,” Engstrom explains. “As the signals change on the monitors, you begin to learn how to consciously control body functions that are normally unconscious. For many clients, this sense of control can be a powerful, liberating experience.”

As Engstrom’s client learned to control his responses, he began reporting a decrease in pain following the relaxation exercises.

Engstrom also used cognitive behavior therapy (CBT) methods, including asking the man to keep a daily journal recording his pain level at different times of the day, along with his activity and mood. Through the journal, the man started recognizing that his pain level wasn’t constant. Instead, it varied and was influenced by what he was doing and thinking at the time.

Engstrom highly recommends CBT for pain treatment because it helps provide pain relief in several ways. “First, it changes the way people view their pain,” he says. “CBT can change the thoughts, emotions and behaviors related to pain, improve coping strategies and put the discomfort in a better context. You recognize that the pain interferes less with your quality of life and, therefore, you can function better.”

In this case, the client was trapped by thoughts that “the pain will never go away” and “I’ll end up a cripple,” Engstrom says. He and the client worked on CBT exercises for several months, keeping track of and questioning the validity of such negative future thoughts. They also practiced substituting more helpful thoughts, including “I will take each day as it comes” and “I will focus on doing the best I can today.”

Chronic pain often engenders a sense of helplessness among those who experience it, Engstrom says, so CBT also helps by producing a problem-solving mindset. When clients take action, they typically feel more in control of their pain, he says.

CBT also fosters new coping skills, giving clients tools that they can use in other parts of their lives. “The tactics a client learns for pain control can help with other problems they may encounter in the future, such as depression, anxiety or stress,” Engstrom says.

Because clients can engage in CBT exercises on their own, it also fosters a sense of autonomy. Engstrom often gives clients worksheets or book chapters to review at home, allowing them to practice controlling their pain independently.

Engstrom notes that CBT can also change the physical response in the brain that makes pain worse. “Pain causes stress, and stress affects pain-control chemicals in the brain, such as norepinephrine and serotonin,” he explains. “By reducing arousal that impacts these chemicals, the body’s natural pain-relief responses may become more powerful.”

Although Engstrom acknowledges that he could not completely banish the discomfort his client felt, he was able to lessen both the sensation and perception of the man’s pain and give him tools to better manage it.

Taking away pain’s power

Mindfulness is another powerful tool for lessening the perception of pain, says licensed professional counselor (LPC) Russ Curtis, co-leader of ACA’s Interest Network for Integrated Care.

Mindfulness teaches the art of awareness without judgment, meaning that we are aware of our thoughts and feelings but can choose the ones we focus on, Curtis continues. He gives an example of how a client might learn to regard pain: “This is pain. Pain is a sensation. And sensations tend to ebb and flow and may eventually subside, even if just for a little while. I’ll breathe and get back to doing what is meaningful to me.”

Engstrom agrees. Unlike traditional painkillers, mindfulness is not intended to dull or eliminate the pain. Instead, when managing pain through the use of mindfulness-based practices, the goal is to change clients’ perception of the pain so that they suffer less, he explains.

“Suffering is not always related to pain,” Engstrom continues. “A big unsolved puzzle is how some clients can tolerate a great deal of pain without suffering, while others suffer with relatively smaller degrees of pain.”

According to Engstrom, the way that people experience pain is related not just to its intensity but also to other variables. Some of these variable include:

  • Emotional state: “I am angry that I am feeling this way.”
  • Beliefs about pain: “This pain means there’s something seriously wrong with me.”
  • Expectations: “These painkillers aren’t going to work.”
  • Environment: “I don’t have anyone to talk to about how I feel.”

By helping people separate the physical sensation of pain from its other less tangible factors, mindfulness can reduce the suffering associated with pain, even if it is not possible to lessen its severity, Engstrom says.

According to Engstrom, mindfulness may also improve the psychological experience of pain by:

  • Decreasing repetitive thinking and reactivity
  • Increasing a sense of acceptance of unpleasant sensations
  • Improving emotional flexibility
  • Reducing rumination and avoidant behaviors
  • Increasing a sense of acceptance of the present moment
  • Increasing the relaxation response and decreasing stress

Curtis, an associate professor of counseling at Western Carolina University in North Carolina, suggests acceptance and commitment therapy (ACT) as another technique to help guide clients’ focus away from their pain.

“ACT can help people revisit what their true values are, whether it’s being of service, having a great family life or creating art,” he notes. Encouraging clients to identify and pursue what is most important to them helps ensure that despite the pain they feel, they are still engaging in the things that give their lives meaning and not waiting for a cure before moving forward, Curtis explains.

Teamwork and support

In helping clients confront chronic pain, Curtis says, counselors should not forget their most effective weapon — the therapeutic relationship. Because living with chronic pain can be very isolating, simply sitting with clients and listening to their stories with empathy is very powerful, he says.

Counselors have the opportunity to provide the validation and support that clients with chronic pain may not be getting from the other people in their lives, says Christopher Yadron, an LPC and former private practitioner who specialized in pain management and substance abuse treatment. The sense of shame that often accompanies the experience of chronic pain can add to clients’ isolation, he says. According to Yadron, who is currently an administrator at the Betty Ford Center in Rancho Mirage, California, clients with chronic pain often fear that others will question the legitimacy of their pain — for instance, whether it is truly “bad enough” for them to need extended time off from work or to miss social occasions.

Curtis says it is important for counselors to ensure that these clients understand that the therapeutic relationship is collaborative and equal. That means that rather than simply throwing out solutions, counselors need to truly listen to these clients. This includes asking them what other methods of pain relief they have tried — such as supplements, over-the-counter painkillers, physical therapy, yoga or swimming — and what worked best for them, Curtis says.

The U.S. health care system has led many people to believe that there is a pill or surgery for every ailment, Curtis observes. This makes the provision of psychoeducation essential for clients with chronic pain. “Let them know there’s no magic bullet,” he says. Instead, he advises that counselors help clients see that relief will be incremental and that it will be delivered via multiple techniques, usually in conjunction with a team of other health professionals such as physicians and physical therapists.

Curtis, Yadron and Engstrom all agree that counselors should work in conjunction with clients’ other health care providers when trying to address the issue of chronic pain. Ultimately, however, it may be up to the counselor to put the “whole picture” together.

A 60-something female client with severe depression was referred to Engstrom from a pain clinic, where she had been diagnosed and treated for fibromyalgia. After an assessment, Engstrom could see that the woman’s depression was related to continuing pain, combined with social isolation and poor sleep patterns. The woman was unemployed, lived alone and spent most of her day worrying about whether her pain would get any better. Some of her previous doctors had not believed that fibromyalgia was a real medical concern and thus simply had dismissed her as being lonely and depressed. Despite finally receiving treatment for her fibromyalgia, the woman was still in a lot of pain when she was referred to Engstrom.

Engstrom treated the woman’s depression with CBT and taught her to practice mindfulness through breathing exercises and being present. Addressing her mood and sleep problems played a crucial role in improving her pain (insomnia is common in fibromyalgia). By dismissing the woman’s fibromyalgia diagnosis, discounting the importance of mood and not even considering the quality of her sleep, multiple doctors had failed to treat her pain.

Engstrom points out that in this case and the case of his client with lower back pain, successful treatment hinged on cognitive and behavioral factors — manifestations of pain that medical professionals often overlook.

 

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

Letters to the editor: ct@counseling.org

 

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