Tag Archives: self esteem

Building client and counselor resilience

By Laurie Meyers December 26, 2018

Merriam-Webster offers two definitions for resilience. One is literal and drawn from physics: the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress. The second definition is a symbolic mirror of the first: an ability to recover from or adjust easily to misfortune or change.

In the past, many experts ascribed this ability to an innate quality that certain people possessed but others did not. More recently, however, researchers and mental health experts have concluded that resilience is multifaceted — something that is influenced by genetics, yes, but also something that can be built and enhanced over a lifetime (see sidebar, below).

“I believe we all have the capacity for [resilience],” says licensed professional counselor (LPC) Cara McCarty, “but it’s not something that’s earned or received without work. It’s not something that we just get for free. It’s something that you fight for, you have to work for, you have to earn.”

McCarty says that in the counseling profession, the idea of developing resilience — at its essence, the ability to rebound, bounce back and overcome — has most often been linked to trauma work. However, she believes it is something that counselors should be trying to nurture in all of their clients. Indeed, resilience is so central to McCarty’s counseling philosophy that she named her Oklahoma City practice Resilience Counseling.

McCarty says it was her initial work as a counseling intern with transgender clients that opened the door for her to see what she calls the “incredible power” of resilience. As she points out, transgender people are a minority even within the LGBTQ community, are marginalized by society and live every day in bodies that they don’t feel are their own. They often have co-occurring depression and anxiety and are pursuing a goal that often feels out of reach to them — to live fully as the gender with which they identify. Despite all of these challenges, they choose to keep going and pursue being themselves. This ability to endure in the face of existential obstacles led McCarty, who continues to work with transgender clients, to believe that resilience is the key to navigating all of life’s challenges.

LPC Karl Memmer has also based his practice on resilience. “I believe the concept of resilience captures the balance between the acceptance of the negative in our lives and the acknowledgment that we can all develop the skills necessary to overcome the adversities we all face,” he says. “Building resilience empowers individuals to take more control of their own lives, take responsibility for what they can and cannot control, and develop a greater sense of confidence in overcoming challenges. … I feel it is central to the practice of counseling as, ultimately, our jobs are not to take away the burdens of others but to help them organize the chaos in their own lives by listening objectively and helping them develop or enhance skills to more effectively take action and responsibility.”

Assessing and building resilience

What does resilience look like? McCarty says that in her experience, people with high levels of resilience are more “flexible,” meaning they are more easily able to adapt and adjust to life’s happenings as needed. This applies to everything from being inconvenienced by a simple mix-up in plans to being diagnosed with a serious medical condition or experiencing the sudden death of a loved one. People with high levels of resilience take in what has happened to them and ask, “What next?” she explains. Other people, such as those who struggle with anxiety, are less flexible, so they have to work harder at building their resilience.

McCarty isn’t aware of a scale or assessment tool to measure a person’s resilience. Rather, she says that she begins introducing the concept at intake. In her paperwork, she asks clients to describe past difficulties that they have overcome. “It gives me a window on how they view themselves,” McCarty says.

Clients sometimes leave this question blank because they don’t view their own challenges as serious or particularly difficult. In other instances, clients may perceive that they have failed to address the challenges in their lives. In either case, the responses give McCarty an opportunity to explain resilience to her clients, point out the ways in which they have already been resilient and discuss ways to continue building on that resilience.

“I think everything counts as a chance to be resilient, [such as] changing jobs or moving neighborhoods. It’s not just for major life events but for things that happen all the time,” she says.

McCarty’s aim is to help clients recognize that they are already using their personal strengths and attributes — such as grit, toughness and persistence — every day to do hard things on a smaller scale.

“For example, let’s say my client has been working on social anxiety and we’ve made a goal of attempting low-pressure conversation three times this week. My client reports they spoke to someone in the break room at work, they made small talk with their cashier and they interacted with someone while pumping gas,” McCarty says. “I might ask them how successful each of these were. Let’s say two out of three were positive. I might ask my client if they noticed a change in their anxiety with each interaction and if they felt the interactions got easier or harder. Assuming their anxiety was lower with each interaction and they felt more comfortable as a result, I would point out how their grit and persistence kept them moving forward.”

“In this example,” she continues, “even if the interactions were negative, the fact that the client kept trying shows grit and persistence and helps the client understand that it’s not about the result of the interaction, it’s about the attempt. The more attempts we make, the easier it is to keep going regardless of the result or outcome. Resilience is the culmination of this practice and work.”

Andrea Cooper, an LPC and licensed clinical professional counselor who works with Memmer at Resilience Counseling and Social Skills Center in the Richmond, Virginia, area, says that building resilience often begins with shoring up clients’ self-esteem. She asks clients to keep a thought record, which helps them monitor what they are feeling and how they are reacting to situations that they find difficult or unsettling. The goal is to uncover automatic thoughts tied to negative
self-perceptions.

“Someone who has ideas about contributing to a business meeting but doesn’t speak up may be listening to their own automatic thoughts,” Cooper says, “such as ‘No one will care. They will not think this is a very good idea. Who am I to speak up?’”

She explains that these negative self-messages are often an indication of false core beliefs, such as “I have nothing of value to contribute” or “I’m not smart enough.”

“Developing an awareness of that automatic thought trail gives the person an opportunity to interrupt their habitual response — not contributing — by choosing alternative statements to tell themselves, such as ‘I feel uncomfortable speaking up, and that’s an old habit. I have an idea worth sharing,’” Cooper continues.

The process may sound simple on paper, but disrupting negative automatic thoughts takes practice. “We generally start practicing with low-risk situations — such as contributing to a social encounter in the break room — so the client gains a sense of success with their new behavior,” Cooper says.

Memmer chips away at self-esteem issues that can hamper resilience by teaching clients to distinguish between thoughts, feelings and actions. One tool he uses to do this is a “thought pyramid.” He and the client start by drawing a pyramid on a piece of paper. The pyramid is divided into three sections: Thoughts are at the top, feelings are in the bottom left-hand side, and actions are assigned to the bottom right.

Memmer then asks clients for examples of thoughts — typically negative — that frequently pop up in their daily lives. Those thoughts — for example, “I’m a loser” — are recorded at the top of the pyramid. Next, emotions such as anxiety, sadness and hopelessness that accompany those thoughts are recorded in the bottom left space. Finally, Memmer and the client move to the bottom right-hand corner: actions.

Memmer asks clients what they typically do when they feel these negative emotions. They might respond by saying that they isolate themselves from their friends. Memmer then demonstrates how those actions are contributing to a negative feedback loop by asking clients how they feel when they isolate themselves. The answer (for example, “Like an undesirable loser”) lands them back at the top of the pyramid: their thoughts.

By using this exercise, Memmer is also highlighting that clients cannot change negative thought patterns just by “deciding” to feel or act differently. Rather, they must disrupt the cycle through identifying and reframing the negative thoughts.

As clients begin changing their negative beliefs, they often come to the realization that they cannot always control their daily stress and strife, but they can control how they react. This awareness allows them to feel more capable and empowered — more resilient, Memmer says.

Because Cooper believes that cultivating emotional and physical wellness enhances resilience, she encourages clients to take time between sessions to focus on mindfulness techniques such as guided meditation. Rather than asking clients to sit down and aim for 30 minutes of meditation on their own, she recommends that they use an app such as Headspace, which offers numerous guided meditations that focus on stress, anger, anxiety and other issues. Other meditations are geared toward helping listeners sleep better or develop stronger focus.

The important things in life

Cooper also believes that helping clients identify their values — what is most important to them — and evaluating how closely their lives conform to those core principles enhances resilience. She does this by listening to clients’ stories.

For example, a client might talk about being unhappy at work because he or she is supervised very closely by a manager and expected to provide continual incremental updates. This tells Cooper that the client is feeling smothered and values autonomy at work. The client can then work to change or improve the situation by setting boundaries in the current job or perhaps looking for a different position that offers more autonomy.

Cooper has also worked with numerous teachers who feel they are never really off the clock. Responding to parent phone calls and email inquiries extends their workdays well into the evening, leaving them little time to spend with their spouse, partner or children. When these clients identify family time as one of their primary values, Cooper helps them explore whether they can engage in more family activities on the weekends or whether they might benefit from improving their time-management skills.

“Once we can name [our] values, we’re more apt to seek them out and improve our quality of life,” she says.

Cooper asserts that being connected to others is also essential to building and maintaining resilience. “Connectedness is important [because] we are social beings and need some meaningful relationship to others,” she says. She adds that depression, isolation and loneliness often accompany each other.

Cooper points out that life phase changes are one common cause for social disconnectedness. Relocating for a new job or graduating from college or high school may be exciting life events, but they often result in the dissolution of previously established social circles. “We have to learn how to connect with new people,” she says.

One way that counselors can assist clients in building resilience is to help them find ways of establishing new connections. This might involve encouraging clients to explore their interests and engage in activities. “Do what you love and you are likely to encounter others who are like-minded,” Cooper advises. She adds that religious or spiritual connections and volunteer work can also lead to rewarding social contact.

In fact, resilience is not limited to the personal level. It is also manifested at the relationship level and the community level, says American Counseling Association member Matthew Fullen, an assistant professor at Virginia Tech who studies resilience in aging adults.

He explains that the counseling relationship itself can be a source of resilience for clients because of its supportive nature. It also helps demonstrate that resilience is developed with the help of relationships that lift people up and support them. Likewise, communities such as cultural or faith-based groups not only surround people with support but derive resilience
from their shared histories, traditions and experiences.

Fullen, a licensed professional clinical counselor in Ohio, believes that group therapy is particularly effective for building resilience precisely because of this community effect. As part of a study, Fullen ran a program at a day facility that offered support and rehabilitation for people 55 and older with disabilities that severely curtailed their functioning. The group spent a substantial amount of its time discussing resilience. Members not only shared times when they had been personally resilient but also pointed out examples of resiliency demonstrated by other group members.

“I remember someone saying, ‘Every day I have this physical therapy. It’s excruciating and it’s really hard, and there are times when I feel like I can’t take one more step. When that happens, I think about this group,’” Fullen recounts. He points out that the group member was able to call on the collective resilience of the group as a source of support and inspiration that increased the group member’s personal level of resilience.

Another incident had a particularly profound effect on the group, according to Fullen. One day, he asked group members to name someone who exemplified resilience to them. Fullen was expecting people to name family members or celebrities. Instead, a soft-spoken group member shyly raised her hand and said, “Judy. Judy is who I think of,” pointing to one of the people in the room. The woman explained that Judy came in daily for difficult physical therapy and never complained.

“I know she has a lot going on at home,” the woman continued. “Her kids are having problems, and it weighs on her, but she is still able to come in and be nice and helpful.”

It was a moment of revelation for everyone in the room, Fullen says, because it drove home the point that resilience isn’t something possessed only by people who are outwardly “successful.” It can also be embodied by those who are marginalized. In fact, participants in the group showed significantly increased levels of resilience at the end of Fullen’s study.

Counselor, heal thyself

As counselors attend to clients’ resilience, they must also make sure to build and maintain their own. “What we do as clinicians impacts others,” says ACA member Robert J. Wicks, an expert on secondary stress in clinicians and the author of books such as The Resilient Clinician, Bounce: Living the Resilient Life and Night Call: Embracing Compassion and Hope in a Troubled World.

“There is a Chinese proverb that says, ‘When the tide rises, the boats in the water do as well,’” he continues. “I think this is true, but as clinicians, that doesn’t mean that raising the psychological tide is easy.”

The primary risk to counselors’ resilience is bound up in an essential paradox: The seeds of therapeutic compassion and the seeds of secondary stress are the same. Therapy is performed through reaching out to others, but the pressure caused by the therapeutic connection puts practitioners at risk for compassion fatigue, Wicks explains.

Those in the helping professions need to recognize that no matter how prepared they are, the pain of those they serve is so omnipresent that it can catch practitioners off guard and drain them, he continues.

When working with physicians and nurses, Wicks gives them a reminder of their epidemiology studies: For every case of poisoning, there are at least a dozen cases of subclinical toxicity. The parallel to counseling? He believes that for every impaired clinician, there are a least a dozen cases of practitioners who are on the edge of compassion fatigue.

“The reality is that — and this is important — clinician impairment is most often a developmental process … not a cataclysmic event,” he asserts. He adds that clinicians must learn to recognize, and lean back, when their stress is high.

Wicks says that counselors can build and maintain their resiliency by:

  • Gaining skills in regulation of emotions
  • Decreasing maladaptive behavior patterns that result from poor self-awareness
  • Improving their ability to balance their personal and professional lives
  • Developing a willingness to honestly assess their own coping patterns
  • Taking responsibility for managing personality-based coping tendencies and attitudes that drive them
  • Uncovering disruptive maladaptive coping habits, including workaholism and other compulsions
  • Treating their body/mind/spirit with respect
  • Counteracting toxic emotions
  • Learning to self-nurture with healthy pleasures
  • Using positive interpersonal skills such as assertiveness, anger management and principled conflict negotiation
  • Employing realistic work and family balancing strategies

Wicks also stresses the importance of counselors regularly setting aside time to be alone and reflect. Practitioners may be able to give themselves this necessary breathing room by modifying their habits and practice style. For instance, Wicks suggests that practitioners make it a habit of arriving early to their offices so they have time to center themselves rather than rushing in with only minutes to spare. He also advises against counselors putting client sessions back-to-back, which can cause client issues and details to run together.

Setting aside this time can assist counselors in recognizing their own foibles, protecting their “inner fire” and accepting change and loss. “We all need time to adjust and grieve,” Wicks says.

Rodney Dieser, a professor of health, recreation and community services and affiliated faculty member in the Department of Clinical Mental Health Counseling at the University of Northern Iowa, has centered his research, practice and teaching on the importance of leisure to overall well-being. He is a proponent of sociologist Robert Stebbins’ “serious leisure perspective.” Dieser, a licensed mental health counselor, believes that leisure is an essential component of maintaining counselor resilience by helping to prevent burnout.

Summarizing Stebbins’ research, Dieser explains that leisure has three categories:

1) Serious leisure involves spending a large amount of time mastering certain skills as a hobby. An example would be learning to play an instrument over time and participating in the community orchestra.

2) Casual leisure is what most people think of as leisure. It requires little in the way of special training to enjoy. Examples include relaxing, going to a restaurant, reading, engaging in social conversations, resting on a hammock or going to the beach.

3) Project-based leisure involves taking on a project that is somewhat complicated but that doesn’t involve more “serious skills.” Examples include planning a family vacation, engaging in fundraising for a local community project or participating in other kinds of volunteer efforts.

Research has shown that leisure can relieve stress, provide healthy coping methods and offer protection from the negative health effects of extreme and prolonged stress, says Dieser, a member of ACA. With that in mind, Dieser has students in his introductory counseling classes design self-care plans that include one serious leisure, one casual leisure and one project-based leisure activity. 

“Leisure programs can minimize the impact of stress through enjoyable distractions that create psychological breathers or regrouping,” he explains. “Leisure pursuits serve as a source of protection against stress because they enable coping through social support and the application of self-determination. During a stressful event, groups of similar people or acquaintances, including [those based on leisure activities], can provide a source of relief, instill hope, serve as a catharsis in expressing feelings and help a person not to feel alone. Application of self-determination through leisure allows a person to feel they have some control in their lives when other parts of their lives are out of control. … [Finally], leisure experiences can create or restore a sense of optimism through pleasant experiences in the face of intense stress.”

Cooper reminds counselors that they are their own best instrument of practice when it comes to resilience. “Practice some of the things you try to teach clients,” she urges. “Take care of your physical health, take time for yourself [and] get enough sleep.”

 

****

 

The science of resilience

The American Psychological Association defines resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of threat.” According to the October 2012 Science article “The science of resilience: Implications for the prevention and treatment of depression,” genetics play an important part in people’s responses to stress and trauma, but there are also important psychosocial factors that contribute to resilience. These factors include:

  • Positive emotion and optimism
  • Loving caretakers and solid role models
  • A history of mastering challenges
  • Cognitive flexibility, including the ability to reframe adversity in a more positive light
  • The ability to regulate emotions
  • High coping self-efficacy
  • Strong social support
  • Disciplined focus on skill development
  • Altruism
  • Commitment to a valued cause or purpose
  • The capacity to extract meaning from adverse situations
  • Support from religion and spirituality
  • Attention to health and good cardiovascular fitness
  • The capacity to rapidly recover from stress

 

****

 

Additional resources

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

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Neurocounseling: Brain-Based Clinical Approaches, edited by Thomas A. Field, Laura K. Jones and Lori A. Russell-Chapin
  • Counselor Self-Care by Gerald Corey, Michelle Muratori, Jude T. Austin II and Julius A. Austin

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/self-care-resources)

  • Self-care Resources for Professional Counselors

 

****

 

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

Letters to the editorct@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.

Some thoughts on thoughts: The inner critic and self-talk

By Whitney Norris December 6, 2018

There’s no doubt about it: Words are powerful. As a professional counselor, I return to a few themes often because of their relevance to a wide variety of presenting issues and goals that clients bring to my office. Self-talk is among my five most-visited topics in therapy. Still, I have found that the subject usually isn’t treated with the deference it deserves. Its impact on our mental health and general wellness is significant and, in my opinion, well worth exploring with our clients — but always first within ourselves as counselors.

When I use the term self-talk, I’m referencing that voice in our heads — all the thoughts in our minds that sound like one or both sides of a conversation. The unmistakable reality is that we’re constantly talking to ourselves, regardless of whether we realize it. Much has been written on the topic using various terminology. One of my favorite terms used is inner critic. I appreciate this wording because of its intent to externalize our negative self-talk and help us refrain from mistakenly overidentifying with it. Regardless of the label used to describe our negative self-talk, however, key themes emerge in our understanding of its origins, impact and proposed remedies.

Origins, impact, remedies

Many different views exist about the origins of the nature of our internal dialogue. Peggy O’Mara, an author and editor whose work centers around children and motherhood, states simply, “The way we talk to our children becomes their inner voice.” Other authors and researchers also claim that our self-talk mirrors the way we were spoken to and dealt with as children. Geneen Roth explains that as children, we learned to internalize the messages our parents sent us, for better or for worse, as a survival strategy. For example, as children, it’s best that we internalize messages such as “Don’t run out into the street.” However, those messages that sound more like “You’re worthy of love and acceptance only when you accomplish something” don’t do us any favors, either as children or later as adults.

When I delve into this topic with clients, I usually tell the following story of an experience that forever shifted my view of the importance and impact of negative self-talk. It also served as the beginning of the end of my then-thriving inner critic.

While in graduate school, I was given the amazing opportunity to intern at a treatment center where, one evening, I was invited to observe an eating disorders group. During my first visit to the group, the group therapy agenda was set to include the reading of a letter that had been assigned to one of the group members the previous week. After discovering the extreme nature of a group member’s self-talk and its connection to her disordered eating, her therapist had asked her to write a letter to herself from her inner critic, just as she experienced it inside her head on a daily basis.

During the group therapy session, this woman was asked to pick the person in the group whose voice sounded most like her inner critic. The friend she chose was a champ, following through on what he was asked to do, which was read the letter aloud to her, knee-to-knee, in the tone in which it was clearly written. The scene was heartbreaking — not only watching the emotional reaction of the woman who was being read to and hearing the awful things written in that letter, but also watching the friend who was tearfully reading those words, of which he didn’t believe a single word.

Although years have passed since I witnessed that scene, I still can’t tell the story without tearing up. It was an incredibly powerful object lesson about what our unchecked negative self-talk can turn into and just how toxic it can be for all of us and for our relationships. I think most of us can relate to this on some level with a look in the mirror. I encourage you to take a moment and imagine yourself in this woman’s shoes. If others could see and hear your inner critic, how would that change the way you talk to yourself?

Now let’s take it a step further. Not only does this inner critic mirror something we likely have no desire or intention of reflecting, but it is also self-sustaining. Imagine that you have the most healthy, robust self-esteem of anyone you’ve ever known. Then you hire an assistant who is with you continuously and who never ceases to criticize you. Even with your world-class self-esteem, your assistant’s constant monologue about your work and your worth would eventually wear you down. Without anyone else there to defend you (which is the case when this is all playing out only in our heads), you would slowly move toward believing the negativity and criticism, regardless of whether it was true. Like a slow and steady gas leak, this toxicity would filter into the way you think, slowly poisoning your view of yourself and the world around you — likely without you even realizing it was happening.

In many respects, our self-talk is no different than this hypothetical “assistant.” Regardless of whether the messages are true, if we listen to them for long enough, we will eventually come to believe them. The more deeply we believe something, the more likely we are to see the world through that lens of self-fulfilling prophecy.

Brené Brown illustrates this beautifully in her 2017 book, Braving the Wilderness: “Stop walking through the world looking for confirmation that you don’t belong. You will always find it because you’ve made that your mission. Stop scouring people’s faces for evidence that you’re not enough. You will always find it because you’ve made that your goal. True belonging and self-worth are not goods; we don’t negotiate their value with the world.”

In his book The Four Agreements, Don Miguel Ruiz posits that our acceptance of someone else’s abuse is contingent on the severity of our abuse of ourselves. He claims that we will only leave an abusive situation when the abuser treats us worse than we treat ourselves. Regarding a solution to this pattern, Ruiz goes on to say, “We need a great deal of courage to challenge our own beliefs. Because even if we know we didn’t choose all these beliefs, it is also true that at some point we agreed to all of them. The agreement is so strong that even if we understand that it is not true, we feel the blame, the guilt and the shame that occurs if we go against these rules.”

The process of seeing, challenging and replacing these rules is often a core element of therapy. We can’t go back and unsend the messages we’ve received. However, as Ruiz alluded to, we can make the choice to face the blame, guilt and shame that solidify our loyalty to these imprisoning messages. If we never make ourselves aware of these internal beliefs, we will likely continue to shoulder their burden unknowingly and to our great detriment.

So, then, what is the solution? As with many truths, it’s simple but not necessarily easy. In her excellent book Women, Food and God: An Unexpected Path to Almost Everything, Roth explains it this way: “Freedom is hearing The Voice ramble and posture and lecture and not believing a word of it. … Listening to and engaging in the antics of The Voice keeps you outside yourself. It keeps you bound. Keeps you ashamed, anxious and panicked. No real or long-lasting change will occur as long as you are kneeling at the altar of The Voice.”

Roth cites “living as if” as the solution for silencing our inner critic — living as if we don’t believe a word of it. When helping clients move toward healthier self-talk, I take a similar approach:

1) Name the lies that your inner critic is known to speak to you (they can usually be boiled down to a few major themes).

2) Label them as lies (some form of “Is this standard true for me but no one else?” or “Can I imagine speaking this ‘truth’ to a child?” usually does the trick).

3) Treat them as lies regardless of how you feel in the moment.

Every time we act out of the truth rather than a lie we’ve been led to believe, that voice becomes a bit quieter until, eventually, it fades into the background. Sure, it takes practice, but starting down the path to a healthier internal world really can be that simple.

Positive self-talk

I started with the negative side of the coin because, unfortunately, I think many of us are more familiar with it than with the positive side. I do not, however, want to suggest that it is only the negativity of our self-talk that makes it so compelling. Our positive self-talk can be equally transformative and, quite frankly, much simpler.

Similar to the inner critic, positive self-talk as a concept garners a substantial amount of attention via many different perspectives and traditions: modern psychology, meditation, mantras, affirmations, etc. The most recent mainstream perspective aiming to increase focus on the significance of our internal world is positive psychology.

In his highly entertaining 2011 TED Talk, Shawn Achor, author of The Happiness Advantage, stated, “We’re finding it’s not necessarily the reality that shapes us, but the lens through which your brain views the world that shapes your reality.” He posits that, as the adage says, we should work smarter not harder. We’re better off spending our energy remaining positive in the present moment than striving for the next thing that promises to make us happy or successful (and probably won’t deliver).

In his work with businesses, Achor reports, “What we found is that only 25 percent of job successes are predicted by IQ; 75 percent of job successes are predicted by your optimism levels, your social support and your ability to see stress as a challenge instead of as a threat.”

Near the end of his talk, he gets more practical: “We’ve found there are ways that you can train your brain to be able to become more positive. In just a two-minute span of time done for 21 days in a row, we can actually rewire your brain, allowing your brain to actually work more optimistically and more successfully. We’ve done these things in research now in every company that I’ve worked with, getting them to write down three new things that they’re grateful for for 21 days in a row — three new things each day. And at the end of that, their brain starts to retain a pattern of scanning the world not for the negative, but for the positive first.”

If you’re anything like me, you are thinking, “Nope. Sorry, I just can’t believe it could be that easy. Something that affects so much of us so deeply can’t shift significantly with an intervention so simple.” I hear you, and I by no means want to oversimplify a profound topic such as self-talk. As I mentioned earlier, many different factors play into our self-talk, many of which are the stuff of therapy. However, I do believe that the jumping-off point can be as simple as a small consistent habit such as practicing gratitude.

This concept applies across the board, well beyond the scope of gratitude specifically. As Achor mentioned, a daily practice of noticing and acknowledging something shifts how we operate on a subconscious plane. We can change our thinking on a fundamental level, in whatever category, by sheer force of focus. That focus is changing our internal world over time in a way that can bring more lasting change than any amount of in-the-moment, conscious white-knuckling. As Kristen Neff aptly states in Self-Compassion: The Proven Power of Being Kind to Yourself, “Who is the only person in your life who is available 24/7 to provide you with care and kindness? You.”

One of the biggest real-life examples of this for me came from an experience during my college years. One day, a friend invited me to a weekly small group she had been attending for a while. She explained that the group wasn’t studying anything and didn’t have a specific agenda. Group members simply spent their time together talking about the ways they had seen God show up in their lives over the past week. Looking back, I’m sure I went to this group to prove that nothing good could come from warm-and-fuzzy share time without some intellectual bounty involved. What I found, though, surprised me. At no other time have I been more aware of daily divine intervention in my life as when I was attending this group. Do I believe now that God was moving more at that point in my life than at others? No, not at all. What was different was merely the fact that I was looking for it and paying attention. So, I found it.

For those who perhaps need a more research-based example, keep reading. This topic also rose to the surface while I was working at a residential treatment center soon after finishing graduate school. It was a small facility, and I was the rookie therapist, so, naturally, one afternoon I found myself scrubbing some graffiti off one of the bathroom walls next to my office. Apparently, I was using my outside voice while saying “I love my job” over and over to myself (sarcastically, in case that’s not evident).

At that point, one of my supervisors walked past and said, “Hey, you know that actually works, right?” After pausing a second to take in my more-than-slightly aggravated facial expression, he proceeded to tell me about an article he had read on a common practice of Navy SEALs. In doing some fact-checking, I found that Navy SEALs have used positive self-talk as a part of their training curriculum for years, resulting in significantly higher passing rates in their training program.

Eric Barker, in his book Barking Up the Wrong Tree: The Surprising Science Behind Why Everything You Know About Success Is (Mostly) Wrong, says we should pay close attention to what Navy research has shown us about the impact of self-talk: “A Navy study revealed a number of things that people with grit do — often unknowingly — that keep them going when things get hard. One of them comes up in the psychological research again and again: ‘positive self-talk.’ Yes, Navy SEALs need to be badass, but one of the keys to that is thinking like ‘The Little Engine That Could.’ In your head, you say between three hundred and a thousand words every minute to yourself. Those words can be positive or negative. It turns out that when these words are positive, they have a huge effect on your mental toughness, your ability to keep going. Subsequent studies of military personnel back this up. When the Navy started teaching BUD/S [Basic Underwater Demolition/SEAL] applicants to speak to themselves positively, combined with other mental tools, BUD/S passing rates increased from a quarter to a third.”

Simple steps

Let’s sum up some of the practical pieces of positive self-talk. As I mentioned earlier, elements of our internal world create barriers to the simplicity of what I presented here about changing our self-talk. This is where a wise, trusted friend or personal work with a therapist can help you navigate what gets in the way of harnessing the power of healthy self-talk.

When trying to help clients (or myself) understand how self-talk should best sound, I try a few different avenues, asking questions that challenge the internal beliefs that function as the cogs of the internal self-talk machine. If we force one gear (the negative) to stop turning and instead focus our efforts on movement of the positive gear, our mind will automatically begin moving in the direction of wellness.

Even our simplest intentional daily actions change our brains and the brains of our clients. It really is that simple.

 

****

 

Whitney Norris is a licensed professional counselor and somatic experiencing practitioner in Little Rock, Arkansas. In 2017, she co-founded Little Rock Counseling, where she practices as a trauma specialist. She also provides case consultations and private practice business coaching for professionals. Contact her through her website at whitneynorris.com.

 

Letters to the editor:  ct@counseling.org

 

*****

 

Related reading, from the Counseling Today archives:

A protocol for ‘should’ thoughts

Quieting the inner critic

 

 

****

 

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

Finding love in a ‘swipe left’ universe

By Bethany Bray November 28, 2018

When it comes to dating, it’s often said there are plenty of fish in the sea. But when you’re dangling a fishing pole in the seemingly vast ocean of online dating and not getting many nibbles, it can leave you with a seasick feeling. Or perhaps you’ve heard tales of other people connecting with really nice fish, but whenever you cast a line, all you seem to reel in are sharks and slippery eels.

Online dating can be a great way for people to meet those who are outside of their usual social circles and connect with potential partners whom they might never have crossed paths with otherwise. At the same time, getting to “happily ever after” can be an emotionally charged experience fraught with rejection and anxiety-provoking scenarios.

As with conventional dating, online dating carries with it the inherent risks of having bad dates and encountering hurtful behavior. But with online dating, the always-on nature of the technology allows users (perhaps encourages users is even more accurate) to check, recheck and overanalyze whether a potential match has viewed their profile, responded to a message or blocked the match entirely.

Yes, online dating carries the potential for disappointment and anxiety, acknowledges Rachel Dack, a licensed clinical professional counselor with a private practice in Bethesda, Maryland, who specializes in helping clients with dating, relationship and intimacy issues. However, she believes that online dating is a risk worth taking — if approached in a healthy way.

There are “normal highs and lows associated with online dating, and, unfortunately, many of those situations are unavoidable. … It’s helpful for counselors to understand that, oftentimes, online dating takes years [before finding the right relationship]. Helping clients with patience and setting realistic expectations is key,” says Dack, who writes and contributes relationship pointers for eHarmony and DatingAdvice.com. “Often, social media and pop culture can offer an unrealistic picture of it. It’s helpful to reframe a client’s view. It’s really important to normalize the online dating experience, including the good, the bad and the ugly.”

Fifteen percent of U.S. adults have used an online dating website or app, according to data from the Pew Research Center. Since 2013, usage of online dating has nearly tripled among adults ages 18-24 and doubled among those ages 55-64.

As online dating grows more widespread, it is also becoming more socially accepted. Pew reports that nearly half of all Americans know someone who uses online dating or has met a romantic partner online.

Online dating offers users opportunities to enter the dating pool at their own pace, pursuing and accepting as many messages and matches as they choose, notes Dack, a member of the American Counseling Association.

“It can be overwhelming to have as many choices as we have online, but at the same time, it’s an amazing opportunity to meet people,” she says. “Online dating can be a powerful tool for clients who are more shy or introverted and unlikely to approach new people in public. There can be a large sense of comfort found in starting communication [with a potential match] on a phone or computer and setting the pace for what communication looks like. You can get to know someone slowly, over time, instead of trying to approach someone and make decisions right away.”

 

Getting up to speed

The online dating market is a crowded one, with dozens of apps and programs available. Some require payment to join, and some are free. Some match users on the basis of sophisticated algorithms, whereas others allow users to “swipe” through profiles and choose only those that appeal to them. Certain apps are designed to allow only female users to make the first move of contacting another user. And yet others cater to LGBTQ consumers, those looking for matches of a certain religious faith or other demographics.

Although it isn’t necessary for counselors to know the nuances between all of these options, they should have a basic understanding of what online dating is and how it works so they can connect with clients who present with issues related to online dating in therapy sessions, says Mark J. Taliancich, a licensed professional counselor supervisor in New Orleans whose doctoral dissertation was on online dating. He suggests that counselors search for information online to bring themselves up to speed. Although scholarly research on the topic is limited, especially as it pertains to online dating’s connection to mental health, he says an internet search will yield plenty of consumer-focused reviews and news articles that detail the online dating experience and the pros and cons of different platforms. Should clients raise an issue specific to the online dating app they are using, Taliancich suggests having them talk through their experience in session.

Kathleen Smith, a licensed professional counselor in Washington, D.C., agrees. She says counselors should engage these clients by asking why they chose a particular app or platform and which features appealed to them. “It’s not the client’s job to teach you how it works, but also don’t just pretend that you understand,” Smith says. “Just having a basic knowledge can be important. [Online dating] is not just exchanging messages. Know which are the most-used apps and their features.”

Taliancich also stresses that counselors should drop any outdated or stereotypical assumptions they might harbor, such as the misconception that online dating is used only by people who are desperate or awkward and can’t find dates any other way.

“It’s similar to a multicultural issue, or working with a client who has an aspect of their culture that’s not familiar [to the counselor]. It requires doing a little research, a little homework. Realize that there’s a different process to each app,” says Taliancich, the clinical director of counseling solutions for the Catholic Charities Archdiocese of New Orleans. “Don’t go off of assumptions or things you’ve heard. It’s really easy to say ‘online dating is dangerous.’ But when you dig down into it, it’s as dangerous as traditional dating. … Two common criticisms of online dating are that it’s dangerous and people lie [about themselves]. I would argue [those things] can be true of traditional dating just as much.”

 

Diving in

The nature of online dating can exacerbate mental health issues, including struggles with anxiety, self-esteem and setting boundaries. For some clients, it can also dredge up feelings related to past experiences with rejection, abandonment, loss or trauma. For example, a lack of replies to messages could be especially damaging to a client who has issues with self-worth or rejection. Similarly, selecting photos for an online profile can bring up issues for those who struggle with their body image.

“Dating can be a very triggering and uncomfortable experience based on [individuals’] personal mindset about themselves,” Dack says. “A lot of negative feelings [about yourself] can be reinforced through online dating.” At the same time, she adds, “If you’re working to be your best, that’s what you will attract. [Clients’] attitudes about themselves and connecting to others are a major factor in meeting others and the dating process.”

Counselors can help clients work through past issues that spill over into their online dating experiences and prepare them for the challenges that can be a natural part of dating, Dack says. She emphasizes the need to offer both a compassionate and realistic approach.

“With rejection, reinforce that it’s a normal part of the dating experience and probably has nothing to do with them. But [for some clients], their past is going to make them believe that it has everything to do with them,” Dack says. “Hold space for the client to feel their emotions about the past and really grieve and work through it.”

“Online dating is setting you up to get rejected more frequently — remember that,” she adds. “It’s really hard for us to grasp the concept that not everybody is supposed to like us or will like us, and that comes [up] with online dating.”

Smith says she has similar conversations with her clients, the majority of whom are women in their 20s and 30s. She counsels clients that it’s more important to focus on themselves and becoming the person they want to be rather than on what they think a potential match might be looking for.

“The ability to step back and remember yourself versus being anxious about how to make a person not break up with you, that puts the focus on things that are easier and calmer,” says Smith, whose doctoral dissertation was on cellphone use and anxiety. “Help people recognize that dating, especially online dating, is an anxious process. It’s very risky, and you can only control 50 percent of the process. If your anxiety spikes during the process, it doesn’t necessarily mean something is wrong. You’re putting yourself out there and engaging with someone you don’t know who is allowed to reject you. It’s what you do to manage it and respond to it [that matters].”

 

Navigating the ups and downs

Counselors can help clients maintain a healthy perspective and remain true to themselves even as they navigate the sometimes-choppy waters of online dating. The following takeaways can provide some guidance.

Get to the why: One of the most helpful questions counselors can ask clients about online dating is why they chose to sign up in the first place. The answer can provide insights into the person’s goals, intent and motivations, says Taliancich, an adjunct professor in the master’s counseling program at the University of Holy Cross in New Orleans.

“It’s entirely possible to dive into online dating and never have to spend a night alone,” he says. “People can go on four, five or six dates a week, for whatever motivation. But it can be a way to escape something or not deal with another issue. There is a range of motivations, just as with traditional dating.”

At the same time, Taliancich stresses, counselors shouldn’t assume that every client makes a conscious choice to date online versus pursuing more traditional methods. For younger, more tech-savvy clients in particular, online dating may be the more accepted way to meet people. Others may simply feel it is the best option open to them for any number of reasons, such as there being no eligible matches in their immediate social circles.

Set a good pace: “Helping people get the right pace is a conversation I often have [with clients],” Smith says. “Make sure they focus on work and friends and the life they had before they started to date. Clients often focus on whether a relationship will work or not, but breaking it down into manageable steps can be helpful. People tend to be so terrified that they don’t [date] or are so obsessed that they turn dating into a full-time job and get burned out and frustrated. I have conversations with clients about taking breaks when they need to. There’s so much data, you can spend forever looking at it and go on tons of dates. It can be very overwhelming for people when they see so many potential matches and they forget themselves and what they’re looking for.”

Conduct a time check: It’s important to ask clients how much time they’re spending on online dating apps, Taliancich notes, because in many cases, they may not even realize the degree to which it is eating into other aspects of their life, such as schoolwork or connecting with friends. He explains that the apps draw people in with behavioral “rewards” for staying engaged, such as notifying them that a match has viewed their profile or the app has developed a batch of new matches for them to view.

Smith works with clients to monitor and create boundaries for the amount of time they spend focusing on online dating. This can be especially important for clients whose anxiety fluctuates according to the number of responses and attention they receive from matches. She recommends asking clients, “When does [online dating] get in the way? How can you direct yourself away from that when you need to?”

It can also be helpful to remind clients that they can turn their app notifications off entirely or change the settings so they don’t receive messages that are particularly triggering, such as when a match looks at their profile or blocks them, Smith notes.

“How [a client] engages with the apps and technology is such a good marker for their anxiety,” Smith says. “Ask them questions: ‘How often do you look at the app?’ Gauge how much of their time this is taking up. Are they dating reactively or thoughtfully? People might not own up to that at first, but if you ask, it may be surprising how much they are focusing on it.”

Know your client: Clients who have struggled with anxious or obsessive behaviors in the past may find it difficult to resist checking and rechecking a dating app for messages or new matches. A counselor who knows that a client is sensitive to rejection can help prepare that client to manage his or her reaction when the inevitable happens.

“If it’s someone you’ve been working with, you’ll know how likely they are to be compulsive or sucked into that experience,” says Taliancich, who met his wife through online dating. “People who feel invested by chatting with someone, they can take it a lot harder when they don’t get a response or [the match] stops replying. It feels a lot worse for them because the rejection feels a lot stronger — feeling that stab, over and over. Whereas people who don’t feel as invested in that initial part tend to navigate it a little easier because it doesn’t feel as much like a personal affront [to them].”

Similarly, Smith notes, clients who have a history of relying on relationships to regulate their moods may find it easy to fall into bad habits with online dating. “Your mood will ascend and descend based on dates, inevitably, but if your sense of self is coming from dating, it will be worse,” she says. “Have the client ask themselves, ‘If I’m not paying attention, what might happen? What do I need to be aware of, be mindful of? How can I be my best self?’”

Celebrate goals, not boyfriends or girlfriends: Clients may assume that success in online dating equates to finding a steady relationship. The reality, though, is that it simply won’t happen for everyone. Instead, Smith urges her clients to learn from each interaction and to celebrate each goal they reach.

“There’s also successes such as being able to go out on a date when they haven’t in a really long time. Celebrate that. Or have the goal that I’m going to do this [go on a date] and be OK the next day. And that’s great,” Smith says. “Having those clarifying experiences, even if they’re breakups, I would see as a victory. Next time, things will go more smoothly.”

Turn “failure” on its head: Smith recalls one client who began dating a match whom she really liked. However, he wouldn’t respond to her messages consistently, which “was driving her up the wall,” Smith says. Eventually, the client was able to talk calmly to him and explain what she needed, and the pair came to the mutual conclusion that the relationship wasn’t going to work out. Although some might have considered that a failure, Smith helped the client to see it as a success: She had learned for next time what she wanted and needed in a match.

Likewise, counselors can help their clients reframe some of the things they experience in online dating. “Everyone in life has to learn that rejection and disappointment is inevitable. You learn that in different ways, and dating is one way,” Smith explains. “If you can find humor in it, that can help. Set a goal of going on one terrible date or being rejected a couple of times. It can help to laugh at it a little. It makes it not so intimidating. You don’t necessarily have to get better at rejection, but know that it’s not a failure. Knowing that you can only control 50 percent of the process, it’s more about managing yourself than trying to control another person.”

Stay true to yourself: Smith sometimes suggests that clients create a list of “guiding principles” they can focus on during dating and refer back to when they start to feel anxious. The principles can be as simple as “be honest” or “be kind.” Other clients may need to add more specific benchmarks, such as, “Don’t check my dating app more than once each day.”

As Smith explains, the guiding principles can offer reassurance whenever clients have a bad date or other negative experience. “Focusing on what they can control in the dating process can help them calm down and feel less anxious,” she says. “Measure progress not on whether a person liked [you], but ‘Was I the person I wanted to be? Was I myself?’ If you’re doing that, then you’re doing what you’re supposed to be doing.”

Similarly, Dack works with clients, particularly those who struggle with anxiety, to create predate rituals that can help them focus on goals they have set. The rituals — perhaps listening to a favorite music playlist or repeating a positive affirmation — help them prepare and quiet down their predate jitters, she says.

Use role-play: Dack suggests that counselors use role-play exercises in session with clients to prepare them for interacting on dates. She asks clients some of the sensitive questions that might come up (for example, “How long was your longest relationship?”) and gives them feedback on their responses. This can help teach clients what levels of self-disclosure are appropriate when meeting a potential match and how to express themselves in healthy, genuine ways, she says. It can be particularly beneficial for clients who struggle with vulnerability or who view being vulnerable as a weakness.

Dack notes that questions about past relationships — or a lack thereof — can dredge up feelings of shame for those who view themselves as inexperienced. “We want to help them feel vulnerable and authentic while being confident about what they have to offer. With men in particular, there are societal expectations and poor dating advice telling them to portray themselves as super successful, masculine or strong. Sometimes, this can come off as sales-y or disingenuous,” she says. “I encourage my clients to be more open and real.”

“Remind clients that it’s important to be authentic and truthful, but there are layers to sharing,” she continues. “It’s important to share at an appropriate pace. [Find] balance in disclosure. Also, reading your date’s body language and responses is an important skill. My approach is very direct and feedback-oriented so [clients] can practice self-disclosure in a healthy way and learn what comes off as fake or manipulative.”

Be mature rather than anxious: Smith uses the word “mature” with clients to describe behaviors and reactions that are the opposite of anxious. This often comes up in conversations about online dating, she says. For example, when a match doesn’t text after a date or respond to messages right away, the client might be tempted to react in anxious ways: checking and rechecking the app, obsessing over the date’s social media accounts or barraging the person with follow-up messages.

With clients who find themselves overthinking aspects of the dating process, Smith says it can be helpful for a counselor to ask, “How would you know you are doing this as maturely as possible? How would you interact with this differently than you are now? What’s the mature way? What’s the anxious way, and how do you know the difference between the two?”

“Believe it or not,” she says, “there is a mature way to interact with these apps. The word ‘maturity’ helps people figure out a way to not let it take over their life or not make them want to throw their phone across the room. The more maturely you engage with it, the better the chance that you will match with someone who is mature and handling it well.”

Interrupt the negative spiral: Clients may approach online dating with negative assumptions that it won’t work out, especially if they harbor feelings of self-doubt or shame associated with being single, Dack says. Those feelings can be exacerbated when clients experience rejection or when they aren’t getting many responses from potential matches.

“They may be operating on a narrative that they’re not worthy,” Dack explains. “It can be very challenging to hold on to the belief that love will happen for you. That can be a very challenging belief to sit with. Feeling good about yourself and believing you have something to offer is a key part of dating success. But if it’s not going well, it’s hard to feel good about yourself. They may take the ups and downs personally.”

Counselors can equip clients to quell this negative cycle by teaching them how to use positive self-talk, Dack suggests. The intervention can help clients overwrite the negative thoughts and messaging that “can get particularly loud with bad dating experiences,” she says.

Dack works with clients to create positive affirmations that they can refer to whenever they’re feeling low. For instance, she says, counselors can help clients replace thoughts such as “I’m going to end up alone” or “I’m doomed in the love department” with messages such as “I am open and ready for love,” “I am committed to connecting with others,” “I am worthy of the type of relationship I’m looking for” and “I choose to accept and grow from my challenging relationships and breakups.”

In session, counselors can listen to clients’ language and point out cognitive distortions to help steer them away from negative thought patterns. For example, a client might remark “My dating life never goes right, so why bother?”

“They’re in an internal conflict because they really do want to date and find a satisfying relationship. It’s important to change any self-defeating narratives because these beliefs are going to make them feel worse,” Dack says. “Offer a realistic perspective while trying to step out of their self-narrative. If they say, ‘All men are jerks,’ break that down [with the client]. Look for exceptions and positives that can foster hope and clear out mental blocks.”

Helping clients focus on what they are able to control in the experience can also shift thinking away from the negative, Dack adds. For instance, they are not able to control whether a match responds to a message. However, they can pick and choose which dating apps they use,
what they say about themselves in their online dating profile and other aspects
of the process.

Accept some anxiety as natural: Counselors who understand online dating can help clients set realistic expectations about the process and prepare them for the reality that meeting new people and opening themselves to rejection is bound to involve some measure of anxiety, Dack says.

“With anxious clients, it’s important for counselors to understand that dating is basically exposing them to constant anxiety — everything from waiting to hear back from a date to showing up for a date and figuring out the frequency of communication,” Dack says. “It can be mentally exhausting, but it can also be really good. It’s hard, but it’s worth it. The anxiety about it is natural to living a full life. Anxiety is normal in dating, and it doesn’t have to keep you from dating. The more skill and intention that clients bring to their dating life, the better it goes.”

 

****

 

Contact the counselors interviewed for this article:

 

****

 

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

Letters to the editor: ct@counseling.org

 

****

 

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.

Life after traumatic brain injury: Lessons from a support group

By Judy A. Schmidt October 8, 2018

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

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

 

Effects of TBI

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

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

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

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

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

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

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

 

Psychosocial aspects of TBI

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

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

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

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

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

 

Lessons learned

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

****

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

 

****

 

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.

Spinoza was right: Four steps to recovery from addiction

By James Rose August 21, 2018

The 17th-century Dutch philosopher Benedict Spinoza wrote that “when a man is a prey to his emotions, he is not his own master, but lies at the mercy of fortune.” He named this condition “human bondage.”

In my view, there is no greater form of human bondage among us now than drug addiction. Addiction is a form of self-imposed bondage that binds people as firmly as if they were held in chains. People who are addicted are being held in a form of bondage that is rooted in their own emotions.

In my three years of working with people in recovery from addiction, I have seen a clear pattern emerge. Individuals who begin recovery by detoxifying from their drug of choice soon feel a rush of hard emotions. These hard emotions are the ones they have been suppressing with their drug use.

From there, successful recovery follows a few distinct steps:

1) Patients name the emotions they are feeling.

2) They identify the story they have been telling themselves about the people, events or circumstances that are at the root of those hard emotions.

3) They examine the meaning of the story they have been telling themselves and consciously challenge that meaning.

4) They find a way to change the meaning of their story.

Because emotions flow from the stories we tell ourselves, patients in addiction recovery can then begin to change the emotions they feel, including the hard emotions that led to their drug use.

Let’s examine these four steps to recovery in detail.

1) Identify the hard emotions that arise. People vary significantly in their ability to discuss emotions. In general, women tend to be better at expressing their emotions than are men. Among people who abuse substances, both men and women typically struggle with expressing emotions. Not knowing how to handle strong emotions, and needing to numb them out, is often at the root of their use.

I often begin group counseling sessions by asking patients to name various emotions. It is a warm-up exercise to get them thinking about the range of emotions that exist and whether they are feeling them at that moment. Among the emotions frequently listed are loneliness, sadness, abandonment, depression, anger and hurt. Often, I will fill a chalkboard with their emotion words and then ask the participants to pick out a few words that apply to them. By giving patients a broad panoply of emotion words to choose from, they often find it easier to name their own emotions.

2) Identify the people, events or circumstances from which those hard feelings arose. For one young man, it was seeing his father, whom he considered his “rock,” suffer from diabetes and have his foot and part of his leg amputated. This was followed two years later by his father’s death. For a young woman, it was the death of her mother and the simultaneous abandonment by her boyfriend. For another young man, it was the emotional coldness of his father, which compelled him to threaten to commit suicide to get his father’s attention.

A sense of abandonment — and, in particular, abandonment in one form or another by a parent — plays a large part in many people’s addictions. A parent might be physically absent, either through death or divorce, or a parent might be physically present but emotionally absent. This can be the result of a parent who is simply emotionally distant by nature or a parent who is emotionally absent because they are involved in some form of addiction to drugs, alcohol, work, sex, gambling, pornography or other things.

Children by nature model themselves after their parents. Sometimes children are unaware of this modeling behavior. One client hated that his father struggled with alcoholism. So much so that this client had promised himself he would never drink alcohol, and he kept his promise. Instead, he used heroin. He had simply replaced one addiction with another, becoming as emotionally unavailable to others as his father had been to him. One common element among all addictions is that they make a person emotionally unavailable to others around them.

Sometimes I use the analogy of fun-house mirrors — those mirrors they sometimes have at carnivals that distort people’s images. As children, we try to get a clear picture of who we are by the image we see reflected in the eyes of our parents. If a child is fortunate enough to have mature, healthy parents, that child is more likely to gain a reasonably accurate self-image from their parents and have a secure emotional foundation from which to face life.

But if a child’s parents are unhealthy or immature, then the self-image the child receives from those parents is more likely to be distorted or flawed. These children may go through life with the unsettled sense that there is something wrong with them. The grown child then lacks a basis for determining what his or her self-image should be.

That sense of not being able to see oneself clearly can create a lasting pain in a child’s heart, and addictive behaviors are more likely to develop in an effort to numb out that pain. As counselors, our work can involve “reparenting” our clients by providing a clear self-reflection of who they truly are — an image these clients might never have received from their actual parents.

There is also a hidden stigma involved in situations in which children have the opportunity to become better than their parents. Sometimes this stigma is called invisible loyalty. For example, if a child comes from a family where drinking is normal behavior, the child risks breaking a family norm — and thus becoming “better” than his or her parents — by not drinking. That is a step toward independence that not everyone is willing to take.

3) Challenge the story you are telling yourself. Often, the event or circumstance involved in the triggering event creates a terrible blow to the person’s self-esteem. For example, the client whose father walked out on the family when the client was 5 was taught in the most unmistakable terms that he was worthless. The woman whose mother died and whose boyfriend left her shortly thereafter simultaneously suffered both grief and abandonment — abandonment at a moment in her life when she most needed someone she could turn to and trust to help her deal with her grief. The young man who lost his father to diabetes felt cast adrift without the man who had represented stability in his life.

Our emotions follow our narrative. If the stories we tell ourselves are ones of loss, abandonment and aimlessness, our feelings will be ones of worthlessness. It is that feeling of worthlessness at the core of our being that is often at the root of addiction. Addiction is a way of trying to numb out those unbearable feelings. If our narrative tells us that all is lost, then there is nothing much to do but to numb out our pain and drag ourselves through life as best we can.

Our feelings are predictions of what to expect, based on our past experience. If our past experience has been full of sorrow and loss, we will come to expect more sorrow and loss in our lives. We will approach the potential of something joyful happening in our lives with dread, lacing it with the expectation that, sooner or later, things will turn out badly. If close relationships turn into abandonment and loss, we might create self-fulfilling expectations by not entering into new relationships with openness.

And yet, it is human nature to want to have close relationships. One young man with whom I worked desperately wanted to feel some sort of emotional connection with his father. To all appearances, his father was a good man and a good father, but he was incapable of showing warmth and caring to his son on an emotional level. The son’s drug use was an attempt to self-medicate the pain he felt at the lack of that important connection in his life.

It reached a point where the son called his father and said he had a knife in his hands and was ready to slit his wrists because he was so desperate for his father to show some level of care and concern for him. The father responded; the son did not commit suicide. He told his father of his drug use, and the son agreed to go into recovery. The son had received a message of worthlessness from his father, and he found that message too painful to live with. He forced his father’s hand to show caring.

In recovery, the young man gained an understanding of how deeply he felt the sense of emotional abandonment by his father. Once he gained an understanding of that emotion, he was ready to pursue the fourth step.

4) Change the way you tell your story. For that young man, recovery meant telling his story differently. Instead of telling himself that his father’s coldness meant he was worthless, he came to understand that his father’s coldness was his father’s nature — the product of his father’s own difficult upbringing. The son learned that he was capable of finding the sort of emotional connection he craved with his mother, his siblings, his friends and his new companions in Alcoholics Anonymous (AA).

He came to accept that he would never change his father, but he learned that he could change himself so that he could find the emotional gratification he longed for from others. He had previously believed that he needed to be like his father — cold and emotionless. Once he changed his story and gave himself permission to truly feel the emotions he was experiencing, he could share those feelings with others and find the sort of emotional connections that he craved. Once those emotional longings were satisfied, his need to numb out his more painful emotions evaporated.

Changing one’s story is fundamentally an act of building self-esteem. Self-esteem is built in a number of ways. It comes from allowing oneself to feel one’s emotions, from avoiding all-or-nothing thinking and from recognizing that life events most often consist of shades of gray. Finding the strength to express one’s true self among others, and to experience that self as different from other people and to develop enough detachment to become comfortable with those differences, is also essential.

For some people, and particularly those who had difficulty with their parents while growing up, spirituality may provide the context for seeing themselves differently. This is the concept behind the step in AA to surrender to a higher power, however that higher power may be understood. Seeing oneself as a child of God may provide a corrective lens for those who grew up with the fun-house mirrors and were never able to gain a true picture of themselves through the eyes of their parents.

I once spoke at a Christian-based recovery center where I offered that sort of corrective vision to the patients by slightly changing the word order of a familiar Scripture reading. I told the audience, “If you want to know who you are, consider these words from the Gospel of Matthew. ‘You are blessed, you who are poor in spirit, because yours is the kingdom of heaven. You are blessed who mourn, for you shall be comforted. You are blessed who are meek, for you shall inherit the earth,’” and so on through the remaining Beatitudes. And then I said, “You are a child of God, because why else would Jesus have taught us to pray to God as ‘Our Father?’”

Learning to see oneself differently, and changing one’s story in a way that builds self-esteem, is the fundamental act of recovery. Guiding patients through the growth of creating a healthy sense of self-esteem is at the core of my work as a counselor. People are not only recovering from the habit of substance abuse. They are recovering their lost selves.

Spinoza wrote, “The more clearly you understand yourself and your emotions, the more you become a lover of what is.” Examining emotions with patients and helping them to see themselves as they truly are is the royal road to helping those in recovery. It is the path that leads them to self-knowledge and self-esteem. Ultimately, it is the path out of the trap of human bondage.

 

****

James Rose, a national certified counselor and graduate professional counselor, is a recent graduate of Loyola University Maryland and works in addictions treatment at Ashley Addiction Services. Contact him at jrrose@loyola.edu.

 

****

 

Read more by James Rose, from the Counseling Today archives: “Stepping into recovery

 

Related reading, also from Counseling Today: “Grief, loss and substance abuse

 

****

 

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.