Tag Archives: mindfulness

Is mindfulness a cure-all approach?

By Samantha Cooper March 7, 2023

a view of tall pine trees from the ground looking up to the green tree tops and sky

Francesca Pianzola/Shutterstock.com

When it comes to self-care and counseling, there is perhaps no topic discussed more than mindfulness. In fact, there are entire apps dedicated to mindfulness practice, with Calm and Headspace being two of the most well known. Mindfulness is touted as a sort of “cure-all” for all people’s issues. Too stressed? Try mindfulness. Anxious? Depressed? Try mindfulness.

Mindfulness as a counseling tool is still fairly new, so there is some debate surrounding its effectiveness as a treatment. But that may soon change based on recent research. Elizabeth Hoge and colleagues, in a study published in JAMA Psychiatry in 2022, found that mindfulness was as effective as anti-anxiety medication in the treatment of anxiety disorders. In the study, participants took either a mindfulness course, which included a 2.5-hour class each week and 45 minutes daily at-home practice, or a dose of Lexapro over six months.

Given the potential benefits of using mindfulness as a mental health tool for issues such as anxiety, counselors must carefully consider when and how to best incorporate mindfulness practices into their sessions.

A useful approach

Maggie Yuan, a licensed mental health counselor (LMHC) and program director at Doc Wayne (a nonprofit focused on sport-based therapy) in Boston, says that there are three tenets to any mindfulness practice: observe, describe and participate.

“The first goal [of mindfulness] is to really open up the mind. It’s the practice of observing, coming into awareness and allowing that awareness to steer you in whatever direction it takes without resistance. And it’s just about noticing your thoughts and emotions,” she explains. “The second part is focusing the mind, which involves focusing attention on the specific internal states or externals impacting you.” The third part, she adds, is “just participating, trying to be engaged in the activity without judgment.”

The possible uses of mindfulness as a mental health cure are almost endless. Mindfulness-based therapy can be used in a variety of ways and to treat a spectrum of disorders, which likely contributes to its popularity as a therapeutic tool. “Mindfulness-based therapy, for instance, can be used with intellectual disorders, autism spectrum, trauma, eating disorders, anxiety, depression, bipolar disorder and sexual dysfunction disorders,” says Alexandra Mejia, an LMHC based in New York.

Although some counselors think that almost any disorder can be at least partially treated with mindfulness-based counseling, Drew Mikita, a licensed professional counselor (LPC) with a private practice in Colorado, says that certain disorders such as psychotic disorders may be harder than others to treat with this approach. “There’s so much going on [with psychotic disorders] from a biochemical standpoint,” he notes. “It’s going to be very challenging to get somebody who’s in an active hallucination to [ground themselves], but that’s probably who needs it the most.”

Mikita also thinks that neurocognitive disorders, such as dementia, would be difficult to treat via mindfulness because the client may have difficulty accessing the skills they need such as taking in their surroundings. But it wouldn’t be impossible, he adds.

Mindfulness-based counseling can take many different forms, including breathing exercises, meditation and grounding techniques, and they are often used in conjunction with other types of therapies.

James Killian, an LPC at Arcadian Counseling in Connecticut, integrates mindfulness-based treatment into his practice by using acceptance and commitment therapy, which involves a client becoming aware of their feelings, accepting those feelings and then letting them go. “It’s learning how to be present in the moment, open[ing] up to what’s happening and doing what matters from a values-based perspective,” he says. This clinical approach is heavily steeped in mindfulness, which is something he really likes about it.

Jennifer Carey, an LMHC who works at a private practice in Massachusetts, incorporates mindfulness into internal family systems, a form of therapy that believes we all have different parts or subpersonalities (e.g., perfectionist, people pleaser, sadness, anxiety) within us.

“The parts are fine if they’re in balance,” she explains. “But when they go to an extreme and hijack our system and take away our calm, our confidence, our centeredness and our clarity that’s when there’s a problem.”

Mindfulness practices, such as meditation and breathing exercises, help clients explore and get to know these different parts of themselves, and it allows them to examine all the different aspects of their life from a place of neutrality, she says.

“If you can come from this place of calm and quiet, you can approach it differently,” she adds, as opposed to having the emotions, like anxiety, controlling you.

Mindfulness vs. meditation

People often conflate the terms “mindfulness” and “meditation” and don’t understand how they differ. Yuan says that when people think of mindfulness, they often picture meditation instead — someone sitting for a period of time and engaging in self-talk, guided meditation from apps and breathwork.

“I think of mindfulness as a state of mind and a state of being, whereas meditation is more of a practice or a technique to help you achieve mindfulness,” she says.

A lot of people might find the idea of meditation impossible, either because of their religious beliefs or because they feel as though they cannot sit still in silence for long periods of time.

“I had somebody tell me they weren’t ready for meditation because their anxiety was so crippling [that] sitting … and being alone with their thoughts was too overwhelming,” says Mikita, an associate professor of psychology at Colorado Mountain College. So he suggested the client try yoga as an alternative to meditation because it is more active and could still serve as a distraction for the client’s anxiety.

“I think of meditation almost as an advanced mindfulness practice,” Mikita continues. Yoga is “kind of [like] dipping your toe into that mindfulness, that thought awareness and presence.”

Carey uses meditation as one of her main therapeutic tools. Meditation is “connecting with your breath, connecting with the present moment, to meet your racing thoughts or uncomfortable emotions of physical sensations with neutral nonjudgment,” she says. It’s “taking a pause and being able to separate yourselves from some of those thoughts. … And other times, it’s more like a guided imagery.”

A variety of mindfulness tools

Meditation is one type of mindfulness practice, but sometimes it’s just not the right mindfulness tool for a particular individual. In that case, there are a lot of other tools that clients can use instead.

Mikita says mediation doesn’t work well for him personally, so he prefers to use other mindful practices. For example, he may sit outside and enjoy the natural beauty that surrounds him.

He also doesn’t assume that one type of mindfulness practice will be the best approach for his clients. Instead, he says he works with clients to find the mindfulness practice that is right for them. They sometimes try a few different practices in session, and he will remind them that many mindfulness exercises may feel forced at first but not to give up. He will also show them studies and research as to why meditation or other mindfulness practices may work for them.

Mikita’s favorite mindfulness exercise is the 5-4-3-2-1 technique. During this exercise, the client looks around at their surroundings and engages their five senses (e.g., five things they see, four things they feel, three things they hear, two things they smell and one thing they taste) to help bring them back into the present moment.

“It also allows you to be distracted from some of the maybe static or white noise that we often get in our inner monologues of being depressed” or worrying about what will happen next, he says. “It allows us a little bit of breathing room by finding that moment of being present.”

Killian helps clients find the best mindfulness tool by asking them what comes to mind when he brings up mindfulness. This helps him gain a better understanding of how clients view mindfulness. “I’ve heard everything from a state of heightened enlightenment or meditation [to] misconceptions,” he says.

After learning more about their understanding of mindfulness, Killian teaches his clients how and why it can be beneficial and helps them learn techniques that work for them. He finds that the body scan technique is often helpful for clients who don’t have a lot of time to practice mindfulness. With this technique, a client pays attention to their physical self and notices the different sensations they feel in their body as well their reactions to those sensations as they “scan” their body from head to toe. Killian also asks clients to take mental notes of their thoughts and feelings they have during the exercise.

This exercise is a versatile tool because the body scan can last as long or as short as the client needs, he says.

Mejia tells her clients that almost any activity — even brushing their teeth, showering or examining a piece of fruit — can be turned into an opportunity to practice mindfulness as long as they focus on the feelings, thoughts and sensations that are happening in that moment.

Mindfulness practices can also be incorporated at any point during a counseling session, Mejia adds. Counselors can begin a session with mindfulness exercises to help prepare them for the session. They can also break up a session with a mindfulness exercise if the client is starting to be overwhelmed, or they can end using this approach to help a client relax after a tumultuous session, she says.

Trauma-informed mindfulness

When mindfulness exercises are led by somebody who is inexperienced, however, issues can occur. During a conference Carey attended, an inspirational speaker (who was not a licensed mental health professional) led the audience in a mindfulness exercise, and the experience ended with one of the participants having a severe emotional reaction. This happened, Carey says, because the speaker was unable to properly reground the group after the meditation session.

There were ways that this could have been prevented, Carey notes. Before the experience, the speaker could have informed the participants about the purpose of the exercise and the brain science behind it. During the session, the speaker could have had the participants ground themselves and informed them that if they felt their minds begin to wander, they could just bring their attention back to their breath.

Afterward, it would have been a good idea to guide “participants in a nonjudgmental and compassionate way to have a moment to process what came up for them,” Carey adds. The speaker could also have had a licensed mental health professional help them conduct this mindful exercise.

Even when mindfulness exercises are led by an experienced professional, there are drawbacks to using meditation as a mindfulness tool. David Forbes, an LMHC and an associate professor of school counseling at Brooklyn College of the City University of New York, says that sometimes, especially if a client has experience severe trauma, mindfulness practices can be triggering to the point that the client needs to stop.

Forbes also notes that Willoughby Britton, a clinical psychologist and leading researcher in mindfulness-based interventions, has found that mindfulness practices can produce difficult triggering events for anyone, not just those with a trauma or psychological history, and at any time, not just when engaging in an intensive mindfulness retreat.

A study published in Clinical Psychological Science in 2021 found that 58% of the 96 participants reported at least one adverse meditation-related effect, such as hypersensitivity, nightmares, anxiety, dissociation or flashbacks. In addition, 37% reported that their symptoms interfered with their daily life, and 6% had side effects that lasted at least a month.

Mindfulness requires people to pay attention to their internal experiences, Forbes says, so if someone is focusing on unpleasant events or feelings, it can trigger emotions such as anxiety, panic and fear. Therefore, he stresses the importance of counselors being trauma informed when using mindfulness interventions, so they can help clients deal with these feelings if they come up.

“Not all of mindfulness is pleasant. There are some meditations that can be difficult to do because of the content,” Mejia says. “There are also meditations that have [clients] sit with emotions or sit with difficult experiences or thoughts on their mind that can be unpleasant.” But sitting with these difficult or unpleasant emotions is necessary, she explains, because that will help the emotion become more manageable or less intense.

This process should be gradual. Clients shouldn’t start by meditating and reflecting on difficult trauma, Mejia says. Instead, they need to gradually build up from focusing on daily frustration before moving into deeper trauma with their mindfulness practices. She prepares her clients to move from small mindfulness exercises to more difficult ones to help them eventually uncover and process their “greatest trauma” or “most difficult relationship.”

People who are triggered by meditation or mindfulness are different from those who refuse to use mindfulness or are critical of the practice, Forbes adds. For those who are hesitant but otherwise suited for mindfulness, it’s the counselor’s job to get their clients “over that hump.” But having a caring supporting therapist is more important than mindfulness, he says.

No quick fixes

Although mindfulness has many benefits, such as helping reduce stress, it has some downsides as well. The time spent on mindfulness during Hoge and colleagues’ study (45 minutes a day plus a 2.5-hour class per week) is more than most people can devote. But that does not mean one should completely skip mindfulness if they don’t have 45 minutes a day to spare.

Carey says that any amount of time geared toward mindfulness is a net positive. She often recommends clients set an alarm on their phone to chime throughout the day to remind them to stop and engage in some form of mindfulness practice, such as doing breathing exercises for a few seconds. Even just noticing the way it feels to walk from one place to another can be a mindful act, she adds.

Taking short breaks to practice mindfulness in this way can help to break up racing thoughts and make mindfulness “accessible to even the busiest person on the planet,” Carey says.

But mindfulness can’t always work on its own and it is not a substitute for therapy, Forbes stresses. “My position is that the traditional approaches of mindfulness in counseling, either with individual or groups, are necessary but not sufficient. Both in their work with clients and in their own personal and professional development, counselors need to go beyond the individualistic, intrapsychic and adjustment practices that characterize much of counseling — and mindfulness — and take a more integral approach,” he says. “Both counseling and mindfulness can help people make aspects of themselves objects of their own awareness, so let’s expand that awareness to include as many perspectives as possible.”

The counselors interviewed for this article all agree that mindfulness has become mass marketed as a “quick fix” for problems. Viewing mindfulness as a commodity can also shift the blame of failure onto individual workers, Yuan says, which overlooks systemic issues of companies having unrealistic and unhealthy expectations of their workers.

“We live in a very individualistic, competitive society where people are conditioned to blame themselves for their failure, where they blame themselves for almost anything,” Forbes says. With “any problem you end up solely looking within without looking at the sources.”

That isn’t to say that mindfulness is a negative thing, but people can’t expect it to get rid of the underlying problem. Using mindfulness to calm one’s anxiety can be helpful, he notes, but it doesn’t solve the source of anxiety (such as an unhealthy work environment or financial stress).

This tendency to view mindfulness practices as a quick fix plays out in other areas outside of counseling as well, Mikita adds. For example, she says it’s common in yoga classes for people to skip out on the “shavasana,” or corpse pose, which is an important aspect of yoga that helps ground people at the end of the class.

Mindfulness is also something people need to continually practice throughout their lives. At no point will a person “outgrow” the need for mindfulness, Killian notes. In fact, he often reminds his clients that mindfulness is not something to achieve.

“Mindfulness isn’t something you’re going to practice for a couple of weeks and then you’re done,” he says. “It’s an ongoing thing. It’s kind of a new way of thinking. There isn’t ever going to be a time when you don’t have to do it anymore. It’s always going to be something you’re working on and progressing, and it’s always going to be evolving for each individual in their own unique way.”

Samantha Cooper is a staff writer for Counseling Today. Contact her at scooper@counseling.org.

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.

Past, present or future: Where do you usually live?

By Madhuri Govindu June 10, 2022

Your monkey mind wants to live in either the painful past or the anxious future. It doesn’t like to stay in or savor the present moment.

This mental habit of ruminating over what has happened or what will happen can make life a miserable journey. Many people are unable to control their mental chatter and continue to suffer. But there’s hope if you can learn to tame your mind to stay in the present moment.

Life happens here and now

Life exists in this present moment. Not in the past or future as most of us are accustomed to. As a mental health counseling student, living in the present moment has been my anchor in a life filled with unexpected ups and downs. Undoubtedly, living in the “now” has served as a saving grace for me as we all continue to battle the darkest days of our current realities.

When I was younger, I couldn’t understand why “the past” would be a crucial part of someone’s life. I constantly pondered why adults ruminated about things that happened decades ago. This quest to understand people’s mindsets led me to quit my corporate job as a training and development manager with Accenture, a multinational company in India. Thereafter, I pursued my passion for counseling psychology, which brought me to the United States in 2018. Currently, I am a graduate student at Penn West University (Edinboro University of Pennsylvania) and will graduate with a mental health counseling degree in 2023.

Early on, I wanted to build a platform that would help those struggling with issues such as depression, anger, fear, past trauma, bullying and an inability to find a solid direction in life. Soulful Conversations, an in-person platform, allowed people to have heart-to-heart discussions and helped thousands of individuals cope with past traumas and future anxieties. This journey taught me that living in or thinking too much about the past is nothing but a disease — one that afflicts millions of people today.

Ruminating over what happened, why it happened and “how could it happen to me?” has become an irresistible habit for many individuals. Through the Soulful Conversations community, I started to understand better the workings of the human mind. For the first time, I questioned my audience: “Ask your mind, what is its next thought?” Interestingly, the moment you ask your mind this question, it goes blank, as if it has been put under a spotlight and its auto-running mode has been caught.

After trying this technique, my audience found a sense of relief to experience a much-needed pause in their uninterrupted mental activities. As people created even a 10-second gap between their reckless past and future thoughts, they found immense respite in their inner stillness. They discovered deep peace within that emanated from shutting the endless chatter of their untamed monkey minds.

Are you in the present moment?

As a counselor, it is vital to be aware that living in the present moment can help us reduce stress, stay more focused and better understand the repetitive patterns in our lives caused by our compulsive habits. When you are in the present moment, you are not waiting for the next moment to be fulfilling or happy. This is because you are not unhappy in the “now,” subject to unpleasant clingy thoughts from the past, empathy fatigue or any other distraction.

You are now more present with your family and friends. You are livelier, content and stress-free because you refuse to entertain past experiences or future anxieties related to health, money, family, work, etc. It may be helpful to have a phone wallpaper featuring the NOW clock or a gemstone that reminds you that everything you are experiencing exists only in the present. Don’t forget: Memories are just thoughts in your mind, quite similar to your thoughts about the future.

Gratitude changes everything

Many times, we carry stressful work situations or unsatisfactory client encounters with us in our minds. We repeatedly replay them in our minds to analyze and dissect how that meeting could have been better. Often, this stress spills into our personal space as well. We carry these feelings of resentment while we are spending time with family members and friends.

We forget that we have the right to “choose and appreciate” whatever the present moment brings to us. So instead of ruminating about past and future worries, we can choose to drop all fears and swim in the magic of the present moment. With practice, the ability to stay in the present moment can be mastered.

The present moment brings an opportunity to offer gratitude, which makes life more livable and joyful. Gratia, the Latin word for gratitude, means grace or gratefulness, and even a small act of thanking the present moment — appreciating what you see, feel, hear and sense around you — deepens that awareness. This helps you leave the perennial stream of unconscious mental chatter, which is eventually the root cause of myriad problems.

Tame the monkey mind

The monkey mind can hop in and hop off from one branch to another within seconds. It can scuba dive into the ocean of sorrow and bring you back into the sky of happiness in a matter of

Stephen Tafra/Unsplash.com

seconds. As counselors, we must try to bring ourselves to the present moment and erode the old conditioning by doing simple things consciously.

These activities can retrain our monkey minds to see the beauty in the present moment. The racing mind is like a galloping horse without any direction. It feels as if the mind is unstoppable, and you are helpless because you simply have no idea how to tame the unruly mind. In such situations, the easiest way to bring your mind to the present moment is to bring your attention back to your breath. Ask yourself, “Am I breathing consciously?” This question helps you to step outside the compulsiveness of identifying yourself with your thoughts.

So how do we build awareness? How do we become aware of our mindless mental chatter? Some of the simple ways such as chewing food slowly, washing hands consciously, taking occasional deep breaths, and setting alarms for present-moment reminders can be very helpful. Furthermore, the regular practice of meditation can help counselors in de-weeding the garden of their minds.

Even 20 minutes of meditation can help us observe everything the mind holds on to and help us see the workings of the mind more clearly. We can then navigate through the mind’s workings and ensure that we do not attach to any of the weeds that slowly creep into the subconscious mind. Hence, a regular practice of de-weeding through meditation is important.

Suffering and counselors

No one is immune to suffering in this world, not even counselors. Like all humans, they have their own professional and personal challenges to deal with. Also, navigating from one client to another, counselors often help others deal with afflictions such as addictions, trauma, posttraumatic stress disorder and so much more. Counselors try their best to help their clients, but this leaves them with very little time for their own recovery and self-care.

However, the good aspect is that counselors are well equipped to understand the unnecessary problems and conflicts created by the mind. So if we can leave the client stories behind, meditate for five minutes before each session, and then step into the next one, a lot of our projections will disappear. It is important to note that the moment you realize that you are not living in the present moment, you are immediately transported back to the present moment. Isn’t that wonderful?

We must understand that the countless voices in our heads will never be silent. At times, it even annoys us, and this inner dialogue makes us miss most of life’s present moments because we are never in the NOW. So, realize that you are not the voice in your head — you are the conscious being who has the power to observe this voice and still not believe in it.

Mind full or mindfulness?

One mindful step at a time can help us embrace inner peace. I personally have trained my mind over the last two years to consciously bring it back to the present moment. As counselors, our work involves welcoming clients from diverse cultural backgrounds and helping them hold their inner peace. This doesn’t leave us with a lot of buffer time to recover, rejuvenate and refocus on the next client.

Hence, it is extremely important for counselors to focus on their mental movements and understand if there is an underlying stillness. A simple practice of five-minute meditation can help counselors embrace the present moment between sessions. The art of practicing self-observation to identify your intrinsic motivations, projections and deflections can help counselors go into tiny mindful retreats and hold their inner peace.

Judgment detox

If counselors can continue to observe their own minds in a nonjudgmental way, then they will be more effective in their profession. The present-moment awareness practice can help in increasing focus and alertness, having a relaxed state of mind, being more mindful with clients and not getting distracted easily.

Being fully aware of the counselor-client relationship can lead to building deeper connections, being more efficient as a counselor, embracing self-compassion and living a fulfilling professional life. What’s more? It will be easier for counselors to bounce back from intense sessions as they continue to deepen their present-moment practice. Random mind wandering is common, and being aware of how often your mind wanders and leaves the present moment is a great indicator of your happiness and mental well-being.

How often have you found yourself unhappy while having sex, exercising, watching your favorite show on Netflix or taking a warm shower? It is the presence of thoughts, drifting mind and past woes or future anxieties that jeopardize your present-moment happiness. A moment of pause, deep breathing in that pause, and being aware of the pause can soothe your nervous system immensely.

With consistent practice, there will be a significant reduction in your thoughts and a more focused approach at work, and an absence of worry and rumination can help you become happier. Another interesting creative approach is using mandalas, which are visual diagrams that can help one become more mindful of the present moment. These intricate patterns allow one to dive deeper into the drawing and deepen one’s relationship with the present moment.

Conclusion

I hope counselors will feel more conscious of their mental chatter and be more confident in helping themselves with some of the present-moment techniques that I have shared. It is fulfilling to know that we deserve to take mental breaks, focus on self-care and refuse to succumb to the cessation of endless mental activities.

In one of my Soulful Conversation sessions, I had mentioned, “Don’t take the time, effort, patience and mental health of counselors for granted. We sacrifice a lot to maintain a peaceful and positive demeanor while underplaying some of our inner challenges. We believe in our own ability to impact the lives of others in a positive way and create a culture of wellness by touching the lives of others mindfully, one day at a time.”

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Madhuri Govindu is a counseling psychology graduate student at Edinboro University of Pennsylvania. Her work was featured in The New Indian Express in 2018 when she began to invite individuals from all walks of life to embrace the present moment through her open social change platform titled Soulful Conversations. Contact her at madhurigovindu23@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 counselor’s journey to healing from chronic pain

By Douglas Guiffrida July 8, 2020

From 2005-2007, I suffered from excruciating back and leg pain. My pain was so bad that I was unable to sit for nearly a year. The only time I would sit was to drive myself to work, and the pain during that drive was so intense that there were several times I had to crawl out of my car once I arrived.

An MRI revealed a herniated disc, so I began a series of medical interventions that included seeing two chiropractors (a second after the first failed to help), two different types of physical therapists with two different approaches, and an acupuncturist, and receiving three cortisone shots, to name just a few of my treatments. Although I occasionally experienced relief, it never lasted long, and my pain got worse. I reluctantly decided to undergo back surgery.

To help deal with my pain as I awaited surgery, I began exploring nontraditional approaches and came across a book by Dr. John Sarno called Healing Back Pain: The Mind-Body Connection. In the book, Sarno, a physician, outlined a radical approach to curing back pain that he had developed through observing his own chronic pain patients for decades. He theorized that pain such as mine was caused not by structural abnormalities or injuries but rather by oxygen deprivation and faulty neuropathways in the brain. Furthermore, Sarno argued that the brain can actually create physical pain as a means of protecting people from experiencing painful emotions such as anger, rage and guilt. He labeled this condition tension myositis syndrome (TMS).

Learning about my pain

This isn’t to suggest that chronic pain is not real or is “all in your head.” On the contrary, Sarno believed that TMS pain was real and could be excruciating. However, because chronic pain is often not caused by structural abnormalities, Sarno argued, it could not be cured by focusing solely on the body. In other words, surgery, manipulations, injections, stretches and so on cannot cure the pain because the pain originates in the mind, not the body. Even for me, a licensed mental health counselor, this theory sounded crazy at first. After all, I had an MRI that proved I had a bulging disk.

At the same time, there was also something that resonated with me about Sarno’s ideas. First, he described how people with TMS tended to have shifting pain that could manifest in different ways and move to other areas of the body. This could include experiencing migraines, heartburn and other digestive issues, knee and shoulder pain, and so on. These were all things I had suffered from since I was a child, but none was occurring now that I had back pain.

Second, Sarno outlined how people with TMS often experienced more severe pain under times of stress and how that pain could diminish during less stressful times. This was certainly true for me. At the time, I was working very hard to earn tenure as a professor at the University of Rochester, and my wife and I were raising two small children. It was among the most stressful times in my life. I also noticed that my pain would sometimes subside during less stressful times such as vacations.

Third, Sarno outlined a series of personality characteristics that are consistent with people who suffer from TMS. Not only do TMS patients tend to ignore their own emotional reactions, but they are incredibly hard on themselves (i.e., they are perfectionistic, highly driven, tend not to seek out help, etc.). These personality characteristics fit me perfectly. Furthermore, Sarno argued that an MRI would reveal structural abnormality in almost all patients over the age of 30 — but most people don’t experience any pain as a result. In other words, if Sarno was to be believed, my herniated disk wasn’t the cause of my pain; rather, it was my personality.

I decided that Sarno’s approach was worth a try, so I delayed back surgery, stopped physical therapy and seeing chiropractors, and began working on my emotions. I found a therapist who worked from a psychoanalytic approach designed to help clients uncover repressed emotions, and I began therapy. I also began engaging in psychoeducation, behavioral interventions and mindfulness (which I will describe in more detail later).

Miraculously, after just a few weeks of practicing this integrative mind-body intervention, I was free of pain. Not only was I able to avoid back surgery, but I was able to heal a number of other chronic health issues with which I had suffered for years. To this day, my back remains pain free, and I am able to engage in physical activity without any restrictions.

In 2017, I began advanced training and research in mind-body therapies, and later that year, I opened a private practice focused on helping clients who are in chronic pain. Since then, I have helped dozens of people overcome a variety of chronic pain conditions, including back, neck, shoulder, knee and hip pain; fibromyalgia; migraines; and chronic nerve pain. Like me, most of my clients suffered for years and were not able to find cures from mainstream medical approaches. Several of them were on disability from work or school but have now resumed normal life activities.

In this article, I provide an overview of the mind-body counseling approach I use with clients who are in chronic pain and provide suggestions to counselors interested in integrating this approach into their work.

Integrating a mind-body approach

When I began my own healing journey, few resources about this intervention existed beyond Sarno’s books. Thankfully, things have changed. The advent of social media has allowed the hundreds of people healed by Sarno to share their stories (many presented in the documentary All the Rage), and a growing body of research now supports the efficacy of Sarno’s ideas.

This increased awareness and popularity have led to numerous options for professional counselors to receive additional training in this modality. Although I highly recommend that counselors pursue this additional training through workshops and clinical supervision, many of the mind-body counseling interventions are consistent with skills that counselors already possess.

To begin, counselors must carefully screen clients to ensure they are appropriate for the intervention. Most importantly, clients must be screened by their physicians for serious medical conditions such as cancer, heart disease or broken bones that require medical attention and cannot be cured by mind-body counseling. Second, as with all counseling interventions, the mind-body approach is most helpful to those who believe in it, are familiar with the process, and are committed. While most clients arrive with some skepticism (like I did), those who are completely closed to the idea (e.g., clients who attend only to appease someone else) are not likely to be helped and can often become frustrated with the process. In addition to posting information about my approach on my website, I also conduct extensive phone consultations with prospective clients to explain the approach in detail and assess their potential fit.

Once clients are screened, several counseling interventions can be used in ways that effectively integrate Sarno’s strategies. These interventions include:

Psychoeducation about the nature of chronic pain
Behavioral techniques to build confidence and reduce fear
Mindfulness to help clients become more comfortable with uncomfortable physical and emotional sensations
Intensive short-term dynamic psychotherapy (ISTDP) to allow clients to become aware of and express painful emotions
Social support from other mind-body clients

Psychoeducation

The first step in integrating this mind-body approach to healing chronic pain is to provide clients with psychoeducation regarding the relationship between their minds and their pain. In addition to Sarno’s books, a number of other recent books by mind-body experts such as Howard Schubiner, Allan Abbass, Nicole Sachs, David Clark, Steve Ozanich and spine surgeon David Hanscom review scientific evidence that supports and extends Sarno’s ideas about mind-body connections to many forms of chronic pain. These resources expose clients to research that shows:

1) Most people with healthy (i.e., pain-free) backs, knees, shoulders and hips show structural abnormalities that should cause pain, supporting the notion that human bodies naturally change with age in ways that look structurally problematic but do not cause pain.

2) There are relationships between childhood trauma and physical health, including many forms of chronic pain.

3) fMRI research has established links in neuropathways responsible for physical and emotional pain.

4) There are strong relationships between chronic pain and the inability to be aware of, experience and express painful emotions such as anger and guilt.

Familiarizing clients with research showing that their pain is not likely of a structural origin, which is contrary to what they have been told by other health care providers, and providing them a path for recovery can instill hope and reduce fear. This process alone can begin to reverse the fear-pain-fear cycle that can activate and reinforce pain neuropathways in the brain.

Behavioral therapy

At the same time clients are learning about mind-body connections to chronic pain, counselors should also begin engaging them in behaviorist interventions designed to reduce fear and encourage reengagement in their normal activities. Well-meaning health care providers frequently instruct people with chronic pain to discontinue physical activities that they enjoy in order to allow their bodies to heal. This is great advice for injuries such as broken bones or sprained ligaments but extremely problematic for mind-body ailments. Several health care professionals told me to swim laps instead of playing basketball. After several weeks of swimming (which I hated), a chiropractor then told me that swimming was the worst thing I could do for my back because of all the twisting and bending involved. He instructed me to disengage from all activity. In reality, the less activity I engaged in, the more depressed and hopeless I felt, and the worse my pain became.

As clients become educated about mind-body connections to their pain, they are encouraged to gently reengage in physical activity without fear of harm the next day. Counselors can facilitate this process by encouraging clients to engage in daily affirmations to reduce their fears of physical activity. This could include declarative statements such as “I am strong, and my body is capable of engaging in this activity” or “There is nothing structurally wrong with me, so doing this can’t hurt me.”

Clients should also be instructed to chart their progress as they reengage in life activities. Often, clients can become discouraged and feel hopeless when minor setbacks occur. Logs that indicate their overall progress over time can help clients sustain optimism during these setbacks.

Counselors should also encourage clients with chronic pain to engage in somatic tracking. These clients often arrive at counseling having already devoted extensive time to seeking potential relationships between their pain levels and physical activities (e.g., exercise, household chores) or the foods they eat. This process can become incredibly frustrating because many of the activities or foods they once associated with their pain often are disproved over time. Counselors integrating this mind-body approach should instead encourage clients to document relationships between their physical pain and their emotional states.

A very common example is that people suffering from chronic pain can experience reductions in pain during less stressful times in their lives such as vacations. Traditional structural models of pain often seek to correlate these improvements to things such as nice weather, changing humidity levels or even the quality of the mattress at the hotel. However, counselors operating from a mind-body approach should encourage clients to document their emotional states when feeling free from pain. This same process is used when pain increases.

For example, pain that went away during vacation often returns or becomes even worse when the client returns home. It is tempting to attribute this increase in pain to uncomfortable travel conditions (e.g., car or airplane seats) or weather changes. However, clients should be encouraged instead to explore problematic interpersonal issues to which they may be returning at home. Sometimes these answers can be very clear; other times, the answers are hidden from view, especially when they involve traumatic events or emotions that clients feel guilty about having toward others. In these cases, ISTDP is central in uncovering hidden emotions related to pain flare-ups.

Counselors can also help clients consider, without judgment or fear, the secondary gain that their pain potentially provides them, particularly regarding what their pain gets them out of doing or feeling. Chronic pain often requires people to become confined to their homes and, therefore, to miss out on potentially stressful interpersonal encounters. These can include social events that they may be dreading, conflicts with colleagues or family members, or even having to provide care for children, partners or aging parents.

Understandably, clients are often resistant to exploring these possible relationships because it may feel like they are being blamed for their pain or accused of it all being in their heads. Counselors need to continually reassure their clients that mind-body pain is real and not “created” on purpose. In fact, it is often a result of people trying to subconsciously protect others from their feelings toward them.

Counselors should encourage clients to create logs of what they miss out on during severe pain flare-ups. This may reveal correlations between their pain and their hidden (but potentially powerful) feelings of fear, anger and guilt. Sometimes, the patterns that emerge, although difficult to recognize initially, can become too prevailing for clients to ignore. Once these patterns are identified, ISTDP can be particularly useful in assisting clients with unpacking and understanding the complex relationships between their pain and their hidden emotions toward others.

Mindfulness-based therapy

Mindfulness-based stress reduction, first introduced into Western medicine by Jon Kabat-Zinn, has been used for over 30 years to treat chronic pain. While research indicates that mindfulness shows only moderate effects in alleviating chronic physical pain, the approach has proved highly effective in improving psychological symptoms associated with chronic pain, such as depression and anxiety, and reducing physical limitations associated with the pain.

From my experience, mindfulness is also extremely useful in helping clients become more comfortable with uncomfortable emotions. This can greatly enhance the effectiveness of the behavioral approaches mentioned previously as well as emotional-focused therapies such as ISTDP.

A detailed description of mindfulness is beyond the scope of this article. Counselors interested in effectively implementing this mind-body approach should seek training in mindfulness and mindfulness-based therapy. However, even counselors without training in mindfulness can encourage their clients to participate in mindfulness workshops and to develop regular mindfulness practices outside of their counseling sessions.

ISTDP

While Sarno argued that many people could heal themselves through psychoeducation and behavioral approaches alone, he also realized that some people (like me) needed psychotherapy to assist them with recognizing, experiencing and expressing repressed painful emotions that might be causing pain. Specifically, Sarno advocated that people with chronic pain engage in ISTDP, which is an attachment-based, emotion-focused somatic therapy developed by psychiatrist Habib Davanloo.

Through extensive research over several decades, Davanloo identified a series of core defenses some people have developed, often since childhood, to block uncomfortable feelings and repress traumatic experiences. While these defenses can often be adaptive when people are children, Davanloo found that they create tremendous emotional and physical suffering later in life.

Chronic pain, from an ISTDP perspective, is an unconscious attempt to protect (or distract) people from experiencing uncomfortable emotions and harmful impulses toward others, particularly loved ones, as well as the guilt they carry for harboring these negative feelings and impulses. Counselors conducting ISTDP therapy help clients notice strategies (or defenses) that they have developed to prevent themselves from becoming close to others and experiencing emotions toward them. Counselors also integrate experiential techniques that help clients become aware of, experience and express these painful, repressed emotions toward others and to recognize and even act out potentially threatening impulses associated with these painful feelings.

This process of skillfully pressuring and challenging client defenses can result in what Davanloo referred to as an “unlocking” of repressed emotions, where defenses are loosened and waves of painful feelings are experienced consciously. When partially or fully experienced in therapy, an unlocking can result in dramatic improvements in both physical and psychological well-being.

ISTDP is a complex and powerful approach to therapy that requires years of supervised training to implement. Even after completing extensive reading on ISTDP, attending numerous conferences and workshops, and participating for several years in a core training group and individual supervision with an expert ISTDP practitioner, I still feel like a novice. Even so, leading mind-body physicians such as Sarno and Schubiner have suggested that all health care professionals, including those without formal training in ISTDP, should integrate aspects of this approach into their mind-body practice. Specifically, they advocate for people in chronic pain to journal about their feelings toward others and to engage in meditations designed to help them connect their emotions to their bodies.

More information about ISTDP, including how to integrate elements of the approach into health care practice, can be found in Abbass and Schubiner’s book Hidden From View: A Clinician’s Guide to Psychophysiologic Disorders.

Social support

When I began this process as a client 15 years ago, I remember feeling very alone in my journey. The few attempts I made to discuss these ideas with health care providers, or even friends and family members, were usually met with skeptical or condescending looks and remarks. Now, having counseled many others, I have learned the power of social support in the success of this process. A consistent comment I hear from clients in my pain groups is how integral the support they receive from their fellow group members is to their success.

Engaging in pain groups may not be possible for everyone, but a number of online communities are available through Facebook and other social media platforms that can provide opportunities for clients with chronic pain to connect with others like them. There are also several podcasts, including The Mind and Fitness Podcast, hosted by former chronic pain sufferers who share their own and others’ success stories overcoming various forms of chronic pain through the mind-body process. These stories usually detail their struggles with chronic pain; their frustrations with health care professionals who performed costly and unnecessary tests and medical procedures; their mind-body healing journeys, including how they overcame setbacks; and their quality of life since becoming free of chronic pain.

Such connections provide clients not only with role models, but with continual support from others. This can enhance the effectiveness of the intervention, especially during times of struggle. There is even an app called Curable that is specifically designed to provide people in chronic pain with resources, activities and social support in ways consistent with Sarno’s approach.

Summary and conclusions

The integrative mind-body approach outlined in this article is a powerful and underutilized approach to helping clients heal from chronic pain. The approach is particularly well suited to clients who have been cleared of serious health conditions and who have exhausted traditional medical interventions with no relief.

While many of the intervention strategies align well with traditional counseling approaches, counselors who are interested in specializing in this work should engage in professional development by attending mind-body trainings and workshops and participating in an ISTDP core training group. Among the ISTDP master clinicians who offer core training are Allan Abbass, Patricia Coughlin, Marvin Skorman and Jon Frederickson. Counselors may also consider enrolling in the University of Rochester’s advanced certificate program in mind-body healing and wellness (see tinyurl.com/Mind-BodyCert). It is the first program of its kind to provide advanced-level training in this type of mind-body intervention.

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Douglas Guiffrida is professor, counseling program director, and director of the mind-body healing and wellness program at the Warner Graduate School of Education and Human Development at the University of Rochester. He is a licensed mental health counselor and a national certified counselor. To learn about his private practice or to contact him, visit DouglasGuiffrida.com.

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

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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.

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.