Tag Archives: shame

Bringing pornography use out of the shadows

By Bethany Bray November 30, 2021

Dana Kirkpatrick, a licensed professional counselor (LPC) and certified sex therapist (CST) and supervisor in Pennsylvania, is only half joking when she says she “specializes in talking about really uncomfortable things — and business is booming.”

She often supports clients as they delve into what is and isn’t working in their sex lives and how that intertwines with mental health, relationships and other aspects of life. Those discussions frequently include open and honest conversations about pornography, Kirkpatrick says.

Pornography use, like many other topics related to sexuality, can tie into other concerns that individuals and couples bring to counseling. Clients’ attitudes and beliefs regarding pornography are typically internalized based on social, cultural and moral influences. It is up to practitioners to raise the topic and create a nonjudgmental space for clients to explore the role pornography might play in their own sexuality and relationships, says Kirkpatrick, an American Counseling Association member and owner of the counseling practice Calm Pittsburgh.

This is unexplored territory for most clients, she points out, especially for couples, many of whom have never spoken out loud to each other about their use of or views on pornography. It is a complicated topic that can involve feelings of shame, hurt or embarrassment, and individuals often don’t know how to begin to talk about it.

“The important thing is [for counselors] to prompt that dialogue,” notes Robert Zeglin, a licensed mental health counselor and CST in Florida who is the founding editor of the Journal of Counseling Sexology & Sexual Wellness. “[A client] may think their partner is watching porn for one reason, but they may be wrong, entirely wrong — and they need to talk that through. … It’s a very powerful thing when people are openly allowed to talk through these things: Why am I so opposed to porn? Or why am I drawn to it? It’s really powerful to facilitate and be a part of that [exploration].”

Unrealistic expectations and assumptions

Kirkpatrick says pornography can shape a person’s sexuality much like romantic comedies do. Both set people up with unrealistic expectations concerning sex, attraction and romance, she explains.

“If [the film] Pretty Woman was your first view of romance, then that’s what you see as romance,” Kirkpatrick says. “It’s the same for porn or 50 Shades of Grey. If that’s what you see first, it’s an expectation. Both scenarios create delusions of grandeur that set you up for failure.”

“Just as with romantic comedies, we know they’re actors, but [pornography] can still lead to unrealistic expectations,” she notes. 

Pornography use can have negative effects on clients’ sexual wellness when it is used as a substitute for or an addition to sex education during a client’s formative years or when it is consumed without the intentional mindset that pornography is fictitious, with actors who are performing in scenes and stories that are created, curated and edited by a full crew of professionals.

Zeglin, an associate professor and program director for clinical mental health counseling at the University of North Florida in Jacksonville, refers to this tendency to view pornography as factual or real as “bad porn literacy.” Clients who have this mindset can struggle with body image issues and negative thought patterns as they compare their bodies to the above average (and often augmented) bodies they see portrayed in pornography, he explains.

“Body shame is a common theme when talking about pornography [with clients],” Zeglin says. “Just as not everyone looks like the cast of [the TV drama] Grey’s Anatomy, we need to emphasize that [pornography] is entertainment. There are so many bad expectations that can leak into sex and body expectation.”

Similarly, clients can harbor unrealistic expectations about what sex is or should be, Kirkpatrick adds. This can especially be true for people who started viewing pornography at a young age. Young adults may expect their partners to do certain things and respond in the same way that they’ve witnessed on screen, she notes.

Aydrelle Collins, an LPC who specializes in Black sexuality at her Dallas practice, Melanin Sex Therapy, says that pornography is where many of her clients first learned about sex or saw other people be sexual. In addition to body image issues, this can lead to a narrow or incomplete understanding of sexuality, she says.

In pornography, “the focus is on the orgasm, and if there’s not one [in real life], it can lead to disappointment,” Collins says. “That robs people of being in the moment of sex, the full experience, and can lead to the assumption that they have to have performance-type sex.”

Pornography use can also lead to misconceptions about what a partner may want in sexual situations. For example, a pizza delivery person in a pornography scene may knock on the door ready and willing to have sex with the resident, but is that realistic or accurate? Of course not, Kirkpatrick says. Counselors can help clients talk through and clear up any assumptions they’ve internalized that may be leading to frustrations or challenges in their relationships or sexual wellness.

Zeglin, an ACA member, also emphasizes that counselors can offer psychoeducation for clients who harbor unhealthy expectations or assumptions gleaned from pornography. One important message, he says, is the reality that sex is often just OK, with some really great and really disappointing experiences thrown into the mix.

Clients’ lives and relationships can also be negatively affected by pornography when it is used compulsively. If a counselor hears a client talk about their pornography usage with language that might indicate a dependence or addiction — including viewing it at inappropriate times, such as when they’re at work or school — further assessment or specialized treatment may be needed. (For more on the nuances of helping clients who use pornography compulsively, see the articles “Six steps for addressing behavioral addictions in clinical work” and “Addicted to sex?”)

Broaching and breaking unhealthy cycles 

Laura Morse, an LPC and CST in private practice in Lancaster, Pennsylvania, says her clients bring up the topic of pornography almost daily, most frequently through questions related to the theme of “Am I normal?” Clients often wonder if what they are watching and the amount of time they spend watching is “OK” or “normal”; others question whether they should be watching it at all, Morse says.

“As clinicians, we work with clients who may be struggling with unpacking the messages they receive about sex — messages which can have negative impacts on their own sexuality and their relationships,” says Morse, an ACA member and Gottman-trained couples therapist. “It’s essential that we use evidence-based tools to evaluate what role pornography serves in our clients’ lives and assess what concerns they may have about their usage. Is it impacting time away from work? [Causing them to] spend too much money? [Resulting in] loss of interest in sexual desire with their partner? All of these assessment questions help inform treatment planning.”

Morse and Collins both recommend the PLISSIT model (developed by Jack Annon in the 1970s) for prompting discussions to assess clients’ thoughts on and relationship with pornography. The model’s acronym represents its four intervention levels: permission, limited information, specific suggestions and intensive therapy. Breaking discussion into these ascending levels helps practitioners decide whether they need to continue or intensify conversations with a client and match the individual(s) with an intervention that meets their level of need. 

The model’s first level can help broach sexuality-related subjects in an open way, as the practitioner invites and gives the client(s) permission to talk about and explore issues they might have previously considered taboo, including pornography, Morse says.

Feelings of shame regarding pornography use — either self-described in individual clients or shaming language used toward a partner in couples counseling — can also indicate that a counselor needs to facilitate discussion about the topic, Zeglin says. This can include the need to unpack the assumption that because one partner views pornography, it means they don’t find their partner attractive anymore, he notes. When left unprocessed, these emotions can lead to an unhealthy cycle.

“Because of that shame, they start to hide the porn use, [and] secret-keeping and hiding things is never good for relationships,” Zeglin says. “It creates a cycle, and it’s a pretty common manifestation within couples [where one or both partners] have an overall values system that porn is taboo.”

In addition to feelings of blame, shame and embarrassment, Collins says that pornography use can lead to a disconnect between couples. This is especially so for couples who have never talked about the subject together.

“It can create a disconnect in the relationship, in multiple layers. It’s not just the porn, but everything surrounding it and the shame that can come up,” says Collins, who is fully trained but not yet certified as a CST. “It can show up as resentment, lack of sex and connection, or arguments. It can be a spiral where one person is caught watching porn and they’re not having [frequent] sex already, and then that person is shamed [by their partner]. It causes them to retreat and furthers the lack of intimacy.”

Hurt feelings surrounding pornography use are often magnified when a couple isn’t having sex regularly or as frequently as one or both partners would like, Collins adds. Blame can become intensified if one partner feels the other is choosing pornography over sex within their relationship.

In these cases, a counselor can help clients talk through not only their feelings regarding pornography but also the many complicated layers that can accompany those feelings. This can include trust issues, Collins notes.

“You don’t trust [your partner] if you feel like you’ve been misled or lied to or shamed or ridiculed for something that you feel is normal and natural and everyone does it. Once that trust gets broken, there comes a disconnect,” Collins says. “We all bring our own messages that we’ve received about sex and sexuality into relationships, and that’s the biggest underlying thing. Sex brings up a lot of feelings of uncomfortableness if you haven’t had a chance to explore your own feelings about sexuality. … We all have attitudes and biases, including around porn. We all have different feelings about what’s healthy and not healthy, whether it’s OK to watch, and how much is OK to watch.”

Collins has worked with couples who have differing views on the consumption of pornography and admits that it can be a sensitive subject to broach. She emphasizes that practitioners should validate each partner’s views about pornography and focus on repairing the disconnect between partners by helping them process their underlying emotions.

To foster discussion in sessions, Collins often creates a “sexual health plan” with couples to outline what they’d like their sex life to look like together and the role that pornography will or will not play in it.

“In cases like these, I explore clients’ views on porn watching and what that means for their relationship,” Collins says. “These conversations can be difficult to facilitate, and working with this dynamic [when partners have differing views on pornography] can be a tender topic for couples. My advice to counselors working with couples is [to] focus on the underlying emotional hurt that is there. What are their goals for their relationship? The best thing a counselor can do to facilitate these discussions is to check their own views and bias around porn in order not to take sides.”

Unpacking the complicated layers that can surround clients’ pornography use may also include talking or asking about physical problems that are affecting clients’ sex lives and debunking misunderstandings or assumptions they may have regarding their or their partner’s sexual challenges.

Collins emphasizes there is no confirmed connection between the consumption of pornography and physical problems such as delayed ejaculation or erectile dysfunction. However, client assumptions regarding this topic can lead to an unhealthy cycle, she notes.

“Many people have the misconception that masturbating or watching too much pornography can desensitize people and cause them to not be able to perform or get an erection for sex,” Collins explains. “And those assumptions can exacerbate the problem if you have those [physical] problems already.”

The counselor’s role 

Kirkpatrick notes that when working with couples who are processing their feelings regarding pornography and its effects on their relationship, a helpful first step is to invite both partners to describe what they feel pornography is. Each person will have a different definition, and couples will benefit from understanding each other’s boundaries, she says. Is it acceptable to look at Playboy magazine? Browse the website Pornhub? Watch the TV show Game of Thrones? Visit interactive mediums where the user communicates with another person (such as virtual reality or video chat)?

“Help the partners define what their beliefs are [regarding] pornography use — good or bad — and what feelings they are having presently related to [their] pornography use. The key is finding the partners’ definition of their feelings and validating those feelings,” Kirkpatrick explains. “Then [counselors] can help them work on where their views come from and if they are being kind to themselves. Do they feel betrayed? Confused? Left out? Jealous? Once we can identify what that feeling is, then we can address it.”

Kirkpatrick also suggests that counselors include a range of questions about client sexuality, including pornography use and masturbation habits, during intake. This information will provide the practitioner with more context, and it lets the client know that the counselor is interested in and open to discussing these often-taboo subjects.

The counselors interviewed for this article agree that when unpacking the topic of pornography (both with individual clients and couples), a practitioner’s role is to serve as a neutral facilitator, prompting clients to explore the values, emotions and thoughts they hold regarding its use. With couples, this includes making equal time for each partner to explain their likes, dislikes and range of feelings.

Counselors should remain neutral — “without putting their thumb on either side of the scale” — while facilitating these conversations, Zeglin stresses. This mediator role includes the exploration of differences between couples and the differences that individuals hold within themselves on the topic.

“Have frank conversations about [the client’s] comfort levels and interest, [saying,] ‘Tell me a little bit about your values about sexual stimuli and porn. Is there anything that would get in the way of enjoying that?’ It’s the same as [addressing] anything that would put them outside of their comfort zone,” Zeglin says. “We need to give time and space to all voices, all the complex and dynamic parts of the people in the room.”

If pornography has led to conflict, feelings of betrayal or other hurtful emotions between partners, it may be appropriate to have them agree to temporarily pause their pornography consumption while they unpack their feelings and thoughts during this phase of therapy, Kirkpatrick says.

Because pornography consumption is an intense subject, clients may feel more comfortable talking about it if the counselor offers to look in another direction or turn their camera off in sessions held via telebehavioral health, she adds.

Inviting clients to frame their conversations about pornography through the lens of “this is what I’m into” empowers clients and allows them to present their thoughts in an open, positive way, Kirkpatrick says. In couples counseling, this approach can also spark questions, further dialogue between partners and, in some cases, reveal that the couple shares similar interests.

Kirkpatrick advises counselors to create an open and safe place for clients to talk about pornography use because it helps take away the power of shame that often accompanies the topic. She sometimes uses a “yes, no, maybe” chart that lists a variety of sexual interests, including different types of intercourse, use of vibrators, pornography and other preferences, to encourage open discussion between couples. Each partner fills out their own chart, selecting “yes,” “no” or “maybe” for each item. Afterward, couples have an avenue to talk about things honestly with each other (both inside and outside of counseling sessions). This tool can also help with overcoming shyness, Kirkpatrick says, and reveal sexual interests that both partners share, including ones they may not have known about or considered previously.

Kirkpatrick also sometimes suggests that clients use the app MojoUpgrade, which has a similar quiz to help couples explore and spark discussion about sexual interests and desires. The app shows only items for which both partners have responded “yes,” which can also help with overcoming shyness, Kirkpatrick says. 

In couples counseling, the clinician should ensure that conversations about pornography remain respectful and refrain from assigning blame or shame toward either partner, Collins says. Society often views pornography in black-and-white terms of either all good or all bad, but it’s more complex than that. A counselor can help clients understand that it’s natural to have multifaceted feelings on the topic.

“The truth is you can put up boundaries for what you want, but you need to get there without shaming your partner,” Collins says. “Have clients really flesh out what their narrative is around sex. If they feel like porn is not the best thing for their partner to watch, explore why that is without shaming their partner. [Prompt] conversation about what they are getting out of watching porn: Is it fantasy or being curious, etc.? Everyone is allowed to have their own feelings about what is healthy and boundaries on what they want out of sexuality.”

Collins notes that using a narrative focus can be helpful in this realm. Prompting clients to explore their sexual narrative frames the conversation in an empowering way and allows them to talk through and reject stereotypes and internalized messages that they no longer feel are helpful or accurate, Collins says.

An important aspect of this work includes asking clients questions about their sexual history. Collins does a sexual genogram with clients to find out where they first learned about sex, who they have discussed sexual issues with and other details. Asking questions about when and how they began to view pornography can also give the counselor and client(s) more context on factors that influence how they feel about and interact with pornography currently.

“I go line by line, unpacking everything they’ve ever taken in about sex, and assess how that impacts how they view sex now and how they view themselves as a sexual being,” Collins says. “[This allows them to] leave the things that no longer suit them and find the things that help them define their sexuality. … Our role as therapists is to help clients [find] their own narrative — not what they’ve been told or our narrative, but what works for them.”

Allowing clients to “be present and accept that they are sexual creatures” leads to empowerment and stronger confidence and decision-making, she adds.

Back to basics 

Zeglin advises practitioners who are helping clients process their feelings and thoughts on pornography to “take the sex out of it.” Instead, counselors should draw upon the same toolbox of methods they would use to help a client who is wrestling with a nonsexual dilemma.

“Anything that distracts from the relationship can impact it negatively; it’s not the porn per se,” Zeglin says. “It’s just like anything — it’s really the use of it and not the thing itself that can cause problems.”

In fact, research has shown that the level of dopamine released by the brain when a person watches pornography is the same as when a person does other things they enjoy or find pleasurable, he adds.

pio3/Shutterstock.com

Zeglin finds that Gestalt theory is a helpful lens to use as he prompts clients to explore and “give voice” to the parts of themselves that are in competition. For example, perhaps a client is conflicted because they want their partner to be happy, but they also feel that their partner must think they are ugly because their partner chooses to watch pornography. Or maybe a client is drawn to pornography because it entertains them or brings them pleasure, but they also feel guilt and shame for watching it. 

“If you take the sex out of it, it becomes a counseling 101 values conflict,” Zeglin says.

Perhaps a counselor is working with a couple experiencing a common scenario: One person is watching pornography and is compelled to hide it, and the other partner finds out and is hurt. By taking the sex out of it, Zeglin says, counselors can flip this conversation and ask, what if the person had set a goal to lose weight and the partner found them sneaking Oreo cookies? In both scenarios, the practitioner and clients would need to explore the couple’s lack of communication, the sense of broken trust, and other thoughts and feelings related to the behavior, he explains.

“Don’t make the problem the porn. Focus on the relationship. Sex is so moralized that we get distracted by that sometimes,” says Zeglin, a co-founder and past president of the Association of Counseling Sexology and Sexual Wellness, an organizational affiliate of ACA. “Counselors already have the tools to address it, but it just feels different because sex is involved.”

When it’s a good thing

Adult couples who have talked through their feelings and preferences and are accepting of pornography may find that viewing certain things together can enhance their sexual relationship. The counselors interviewed for this article noted that some clients (consenting adults) on their caseloads have benefited from incorporating pornography into their sex lives as a way to explore new things together. This can happen organically, such as when couples come up with the idea on their own, or when a counselor suggests it (when appropriate) as a bonding exercise for a couple outside of session.

“First, you have to make sure it’s accepted by the couple and culturally appropriate,” says Kirkpatrick, who co-presented a session, “Sex Positivity: Increasing Competencies in Addressing Sexuality Issues in Counseling” at the 2021 ACA Virtual Conference Experience. “There are body-positive sites, or sites with [instructional-style videos on] things to try. It’s using it as a tool, not a replacement. It should be something to enhance your sex life, not replace your sex life.”

Kirkpatrick has a list of sex-positive websites she offers to clients who express an interest in watching pornography together. It can be a means to grow together and learn what each partner does and does not like, she says. It can also be a way for couples who have a low sex drive or sexual desire to begin thinking about sex before becoming intimate together. Depending on a couple’s interests and comfort level, Kirkpatrick’s sex-positive recommendations can include pornography that involves writing (such as erotic fiction), photographs or images, or videos.

Collins agrees that pornography can be a helpful tool for some clients. Couples who have trouble with physical issues, such as erectile dysfunction, can use it to find and explore other avenues of sexuality that may work better for them, she notes.

“A lot of people figure out what turns them on by watching porn,” Collins says. “It can be a way to educate, watch together and … explore fantasy, broaden your sexuality or get out of a rut. It can give people options, room to explore, and open up dialogue and conversation around sex.”

It can also be a way for couples to bond and even laugh, Zeglin adds. “Couples need to explore both mentally and physically, and things change over the life span. Desires change, bodies change as we age. Just like anything, porn can serve as an opportunity to see what strikes your fancy,” he says. “Or you can giggle together about how unrealistic it is [and] how bad the dialogue is.”

Counselor competency

Professional counselors must always assume a nonjudgmental lens when working with clients, especially ones who are wrestling with thoughts and feelings about the complex and sometimes uncomfortable topic of pornography. The professionals interviewed for this article agree that counselors have a responsibility not only to leave their personal feelings out of the equation but also to seek training, continuing education or consultation when they don’t understand or know how to best treat a client’s questions or conflicts regarding pornography.

“We [counselors] are licensed as health providers, and we have to remember that what is and isn’t healthy is different than what is or isn’t personally important to us,” Zeglin says.

Collins agrees, noting that the last thing she wants to do is add another voice to a client’s understanding of a topic that is already heavily influenced by cultural, societal and other factors.

“I want them to find their own voice,” Collins says. “We [counselors] need to be checking our own biases and our own narratives around sex so that we are not imposing what we feel about sex and porn [on clients]. When our stuff comes into a session, it takes away from the work that we are doing with the client. Sometimes, with sex, [practitioners] tend to forget that.”

Practitioners also shouldn’t make assumptions about clients’ views on pornography. For example, clients who come from conservative religious or cultural backgrounds may not automatically be opposed to pornography use, whereas clients who come from more liberal backgrounds won’t necessarily embrace it, Kirkpatrick points out. In addition, clients will have a range of feelings about pornography that won’t necessarily fall into binary categories of “pro-pornography” or “anti-pornography,” she says.

Kirkpatrick urges counselors not to feel that they should refer a client whenever sexual wellness issues arise in counseling work. Instead, she encourages counselors to seek training, supervision or consultation with a local sex therapist. Counselors and CSTs can also co-treat clients, when appropriate, she notes. (Find a local CST and continuing education offerings at the American Association of Sexuality Educators, Counselors and Therapists website, aasect.org.)

Counselors who find they are interested in facilitating dialogues about pornography should consider seeking certification as a sex therapist, she adds.

“Don’t automatically refer. We need more people to be able to talk about this comfortably,” Kirkpatrick stresses. “Also, ask the client. I learn more from my clients than anyone else. … They are the experts in their sexuality because it’s so complicated. They are the experts on themselves.”

 

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Pornography use during the COVID-19 pandemic

As the COVID-19 pandemic began to stretch across the globe, causing millions of people to stay home, many individuals and organizations predicted or assumed that the isolation, loneliness and boredom would result in an increase in pornography consumption. 

In spring 2020, Pornhub announced that the online platform’s “premium” content would temporarily be free to users who were on lockdown because of COVID-19. As a result, the company reported a 38%-61% increase in web traffic from regions that had lockdowns and restrictive stay-at-home orders. This usage was above and beyond the more than 1 million daily unique web visits that Pornhub reported in 2019.

However, a study published recently in the Archives of Sexual Behavior polled more than 2,000 men and women in February, May, August and October 2020 and found that pornography consumption among American adults decreased overall in 2020.

In May, immediately following the United States’ first wave of pandemic-related restrictions, there was a small increase in the number of people who said they had viewed pornography in the past month, but less so than in the baseline data, which indicated that 38% of participants — 59% of men and 21% of women — reported using pornography at least once per month.

“Among those who reported use in May 2020, only 14% reported increases in use since the start of the pandemic, and their use returned to levels similar to all other users by August 2020,” wrote the study’s co-authors. “In general, pornography use trended downward over the pandemic, for both men and women. Problematic [compulsive or uncontrolled] pornography use trended downward for men and remained low and unchanged in women. Collectively, these results suggest that many fears about pornography use during pandemic-related lockdowns were largely not supported by available data.”

 

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

Money on the mind

By Laurie Meyers April 7, 2021

Money is the dirty little secret of American society. The unspoken social contract is that, like Voldemort, it shall not be named. We may joke about winning the lottery, but we don’t reveal the strained financial circumstances that underlie that pipe dream. Modern life is not cheap. Unfortunately, many workplaces and professions do not reflect this reality. Could we be making more money? Who knows? Many companies forbid their employees to discuss salaries with co-workers.

Meanwhile, our consumerist culture makes it easy for money to fly out of our wallets and onto our credit cards. Financial experts (some of whom sound a bit like scolds) urge us to maximize our contributions to our retirement plans and have savings sufficient to sustain us for six months or more of unemployment. These are worthy goals, but most Americans find them challenging to achieve.

A 2019 survey by the personal finance company Bankrate found that approximately 28% of Americans had no emergency savings and only 18% had enough to live on for six months. And a 2019 report by the U.S. Federal Reserve revealed that 25% of nonretired workers possessed no retirement savings at all. Surveys show that a large share of Americans — including those who earn higher salaries — live paycheck to paycheck. Many people get by with the help of a credit card — or three or four. A recent poll by CreditCards.com showed that almost half of Americans (47%) currently carry credit card debt. And even though being in hock to credit card companies is so common, carrying that kind of debt is still associated with a lack of financial responsibility. 

Just set a budget! Track your spending! Stop buying that daily Starbucks latte!

It’s not the latte. And the one-size-fits-all financial advice on offer by cable talking heads and in best-selling books doesn’t typically work. Not just because people’s financial obligations are different, but because managing money isn’t only about the numbers. The way we spend — and save — is tightly entwined with emotion and driven by learned behaviors and beliefs whose existence we are frequently unaware of, according to experts who study neuroeconomics. These factors can prevent us from effectively managing our money.

The mental health consequences of financial difficulties can be significant. Even before the recession caused by the COVID-19 pandemic, Americans frequently rated financial worries as one of their top sources of stress. This past October, the fourth in a special pandemic-oriented series of “Stress in America” surveys from the American Psychological Association revealed that nearly 2 in 3 adults (64%) said money was a significant source of stress in their lives.

Financial difficulties can cause stress and depression. Stress and depression make it harder to tackle money problems. It becomes a vicious cycle — particularly for those who are already living with mental health problems.

Enter financial therapy, which the Financial Therapy Association (FTA) defines as “a process informed by both therapeutic and financial competencies that helps people think, feel, communicate and behave differently with money to improve overall well-being through evidence-based practice and interventions.”

Financial therapists primarily come from the mental health, coaching and financial fields. Some of them are mental health professionals who realized that money plays an important role in overall well-being and decided to become trained to offer financial therapy in addition to their regular practice. Others are financial professionals who realized that they needed to be able to handle the emotional aspects of money and received additional behavioral training or, in some cases, became licensed mental health practitioners.

All of the sources Counseling Today spoke to for this article are licensed counselors who offer financial therapy to existing clients who express interest or as a stand-alone service. They use a variety of tools to help clients understand their internal money narratives, identify behavioral patterns, and process the emotions that are getting in the way of setting and working toward their financial goals.

The field developed out of a body of research on neuroeconomics. Psychologists Ted Klontz and Brad Klontz and financial planner Rick Kahler are widely considered the “grandfathers” of financial therapy.

Early lessons learned

Research by Klontz, Kahler and Klontz suggests that people begin developing money beliefs — and potential future problems — in childhood. These attitudes are often developed through experience and observation rather than parental instruction.

That’s because many families don’t talk about money, notes American Counseling Association member Elaine Korngold, a licensed professional counselor in Portland, Oregon. Children grow up in families not knowing how much money their parents make, how much (or how little) different jobs pay, and what level of income is necessary to cover basics such as rent/mortgage, utilities and food — let alone how to set up and follow a budget, she says.

Although parents usually talk about and teach their children essential life skills such as driving, anything to do with money is often kept secret, says Korngold, who worked in the financial sector before she became a counselor. This not only leaves children uninformed and unprepared but also reinforces the societal perception of money as a taboo topic. As a result, many adults who struggle to manage their finances simply don’t know how to seek help or are too ashamed to ask for it, she says.

But even when parents don’t explicitly teach their children about money, they are still imparting lessons, says Kathy Haines, an LPC in Marietta, Georgia, who is training to become a certified financial therapist through FTA.

An integral part of Haines’ financial therapy process is exploring the financial beliefs held by a client’s family of origin. Haines, an ACA member, asks questions regarding whether money was ever discussed, who managed finances in the family and how. “Were there fights about money?” Haines asks. “Spoken or unspoken messages such as don’t have credit debt? Work hard so that you can take care of yourself?”

Similarly, Korngold asks clients about the spending behaviors they observed growing up. Did it seem like the family was always just making it until payday, or was there any financial cushion? If the family found itself with more money than usual, what did they do with it? Put it in the bank? Take a vacation? Buy a TV?

Jennifer Dunkle, an LPC in Fort Collins, Colorado, whose specialties include financial therapy, asks her clients to write their “money story” by answering a variety of questions: What are your earliest memories concerning money? What did you learn from your family about money? Specifically, what did you learn from your father? From your mother? What experiences did you have with money as a young adult?

These messages and experiences contribute to what Klontz, Kahler and Klontz call “money scripts” — unconscious beliefs that shape our financial behavior.

Money narratives

Dunkle, like many financial therapists, also gives clients the Klontz Money Script Inventory (KMSI) assessment.

“Most adult money scripts are based on earlier life experiences,” she says. “In order to make lasting changes to budgeting, spending, savings and investing plans, it is very helpful to learn more about our underlying beliefs and values in regard to money.”

The most common money scripts include beliefs such as:

  • More money will make things better.
  • Money is bad.
  • I don’t deserve money.
  • I deserve to spend money.
  • There will never be enough money.
  • There will always be enough money.
  • Money is unimportant.
  • Money will give my life meaning.
  • It’s not nice or necessary to talk about money.
  • If you are good, the universe will supply all your needs.

Dunkle explains that Klontz, Kahler and Klontz group money scripts into the following types:

  • Money avoidance: Avoiding dealing with money and rejecting personal responsibility for one’s financial health.
  • Money worship: Believing that a financial windfall or increased income will be the solution to all of one’s problems; being focused on the inward value of the accumulation of money.
  • Money status: Being overly concerned with the idea that self-worth equals net worth; believing that money conveys status; wanting to always have the next new, big-ticket item; and being interested in the outward display of one’s wealth to others.
  • Money vigilance: Being watchful, alert and concerned about one’s finances. Those who are money vigilant are much less likely to avoid their financial matters, overspend, gamble and engage in financial enabling.

Klontz, Kahler and Klontz say that the scripts themselves are not “good” or “bad.” Rather, they are simply indicators of behavioral influences.

“For example, someone who has the belief that ‘I deserve to spend money’ might run up a lot of credit card debt despite not being able to actually afford their purchases,” Dunkle explains. “The script, ‘It is not nice or necessary to talk about money’ could lead to money secrets between spouses. Believing that ‘If you are good, the universe will supply all of your needs” may result in not doing adequate planning and saving for retirement.’”

Working toward change

Dunkle uses motivational interviewing to help clients recognize the adverse effects their financial habits are having on their lives.

“The goal of motivational interviewing in financial therapy is to elicit ‘change talk’ by using the skills of open-ended questions, affirming, reflective listening and summarizing,” she explains. “When clients hear themselves talk about potential changes, they start to believe that change is indeed possible. For example: ‘Getting my finances under control would help me sleep so much better at night.’”

To facilitate the process, Dunkle might ask someone who is money avoidant an open-ended question such as, “What is that like for you, seeing those unopened credit card statements pile up on your desk?”

For someone whose script is money worship, she might make an affirming observation such as, “It sounds as though working 70 hours a week in order to earn more income is really starting to get to you. It’s no wonder that you feel worn out.”

With a money status case, Dunkle says she could listen and reflect back by stating, “What I hear you saying is that you believe that your value in the family comes from showing your relatives how much you earn and how much you own, not from who you are as a person.”

For a client whose script is money vigilance, she might observe and summarize with a statement such as, “Wow, it sounds as though you feel exhausted, thinking that you need to check your accounts every night before you can relax and go to sleep.”

Haines also uses the KMSI as one of her tools for uncovering the narratives that drive clients’ financial behaviors. She breaks down narratives into thoughts about skills or situations and core beliefs about worth.

“Step one for both is to become aware of those narratives,” Haines says. “This can be difficult because they run so quickly in the background that we often don’t even know they are informing our behavior. Slowing down and becoming curious about our own thoughts and beliefs can be difficult, but [it] is a necessary first step.”

Haines asks clients to write down their thoughts — which she reminds them are not facts. When reviewing their collection of thoughts and beliefs with them, she asks clients to consider the following questions:

  • “What leads me to believe this is true? Is it from my own personal experience or maybe from some other influential person in my life who has told me this?”
  • “Is it always true? Is there evidence to the contrary?”
  • “If I can’t see evidence of it being true, can I hold the possibility that it’s not true?”
  • “If there is evidence of it not being true, how are those instances different, and how can I intentionally bring more of that?”

For example, many clients believe that they will never be able to manage money, Haines says. “I would ask, ‘What leads you to believe this is true? Are there instances where you have made good financial decisions that align with your values and what you want? What was different about those times? What prevents you from doing more of that? Are there skills that you need to learn? Do you need to ask for help? Is there fear involved?’”

“Once we go deep into the genesis and meaning of the narrative, it can go in any direction,” Haines says.

When a client’s narrative is about worthiness or “deserving” something (such as money or a higher paying job), Haines uses a similar, but less structured, process. “I usually ask those clients to slow down, take a few breaths, close their eyes and ask internally, ‘Whose voice is this?’ Is it yours, or is it someone else’s?” Haines notes that it is almost always someone else’s voice, such as a parent or caregiver or another figure who holds meaning for the client into adulthood.

“We then will unpack whatever comes up,” she says. “I might suggest that those who gave [the client] the message of unworthiness around something — either directly or indirectly — were struggling with their own sense of self and meaning in the world and [it] has absolutely nothing to do with my client.”

“I often will use the visual of newborns in a hospital nursery,” Haines continues. “Are some of those newborns born worthy and others unworthy? This helps them to see that feeling unworthy of something is just an internal narrative, not an absolute truth. I might ask, ‘What will it take for you to feel worthy? How will you know when you are worthy? Think of someone you care deeply about. Now decide when and what they are worthy of.’ That usually feels really uncomfortable for them [the client]. Then I reflect back that’s exactly what they are doing to themselves.”

Haines adds another common belief about money and success is that people who are rich are greedy and achieved that higher position because they didn’t care what they had to do to get there. “In essence, not having integrity,” she continues. “I have seen this a lot. An individual feels strongly about honesty, integrity and not being greedy. They want to succeed, but the people in the positions they want don’t seem to personify integrity. So, the position is out of alignment with their values, and their behavior will not support moving up. We then work on how they can create their own visual of how to be in that position from a place that aligns with their own values.”

Where does the money go?

Overspending is a problem that financial therapists see frequently. Clients show up at Haines’ office wondering why they are always in debt despite making an adequate salary. She helps clients identify what kinds of things they are purchasing and why.

“I’ve had clients who wanted to participate in getting together with friends, perhaps for dinner and drinks, concerts, plays, etc.,” Haines says. “They couldn’t really afford to do these things, but as humans, our need for belonging is so strong that we will do almost anything to fit in. I try to help my clients identify what they get out of these activities. It may be good conversation, advice, laughing together, intellectual stimulation or just not feeling lonely. We then brainstorm other ways to get these needs met, but without having to spend money they don’t have.”

“For instance,” she continues, “instead of expensive dinners, they could meet for coffee and have the same connection and conversation without the cost. If it’s intellectual conversation, maybe starting a book club. One idea that came up was to meet at a park and bring a lunch. The atmosphere is better than a restaurant, and it doesn’t cost anything.”

A possible downside is if the clients’ friends don’t want to make those changes. Then comes the difficult decision of whether the client will commit to living within their means and risk losing the relationship(s) or continue to overspend and remain in the safety of the relationship. This adds another layer of exploration about whether those relationships are, in fact, healthy and reciprocal, Haines says, but the overarching theme remains identifying what those dinners or other expensive activities are providing to clients and how some of those needs might be met in other ways.

“I will add that knowing and having a visual of the ‘why’ [the necessity] of changing financial behavior is always present,” Haines says. “Coming back to that assists with getting over the hurdles of change.”

“Keeping up with the Joneses” is another common spending impetus. Society encourages competition, such as having a nice car just because “everyone else” drives a nice car. But Haines asks clients if that really fits their core values.

“If you value a nice car and if you have one, that’s great, but if you buy a nice car because everyone in the neighborhood has a nice car, that’s going to create turmoil,” she says. For Haines, financial therapy is all about helping clients achieve what they want, not what other people think they should want.

ACA member Edward Kizer, an LPC whose specialties include financial therapy, says many of his clients are aware that they are engaging in compulsive shopping as a method of self-soothing or self-care. He teaches them simple techniques such as belly breathing to reduce their anxiety and also asks clients to think about what shopping gives them.

“If I’m expressing a need through retail therapy, what is that, and how can I feed that?” he asks. “What feeds you? Is it being creative? Is it the outdoors? How do [you] get back to nurturing yourself?”

Impulsivity is a significant driving factor in compulsive spending, says licensed professional clinical counselor Denise Kautzer, who is also a certified public accountant and specializes in financial therapy. She has clients track their spending and encourages them to follow the “24-hour rule,” which involves waiting for 24 hours after seeing something that they want to buy. In the end, they may still end up purchasing the item after giving it more consideration, but adopting this approach cuts down on impulse buys, she says. In addition, because spending often makes people feel good, at least temporarily, Kautzer helps clients identify other things that bring them joy.

Seeing the whole picture

Clients can’t manage their money if they don’t know where it’s going — or where it’s needed. Part of the financial therapy process is identifying expenses and assets: money in and money out.

Brian Farr, an LPC in Portland, Oregon, whose specialties include financial therapy, introduces what he calls a “snapshot” in the first session. “It’s a simple expenses and income and debt worksheet, not a budget or spending plan. Just a snapshot of what a typical month looks like,” he says. “It’s to help introduce them to the reality of their household finances.” Farr’s clients tell him this exercise helps give them clarity and motivation.

Like the other financial therapists Counseling Today spoke to for this article, Farr does not see himself or offer himself to clients as a financial planner. Instead, he helps clients understand their finances and develop a system to help them meet their goals.

“The freedom around money is coming up with some method that makes it visible,” Farr says. Once clients have that picture, he helps them be realistic about what they can and cannot do. That involves identifying how much money comes in and then giving each dollar a “job.”

He finds the youneedabudget.com website useful because it offers helpful videos and allows people to categorize not just their everyday expenses, but also infrequent but large expenses such as holiday gifts, a pet’s yearly checkup at the vet or car maintenance. Clients can then look at the money coming in and evaluate where it needs to go.

“If 60% already has a job to do, stop thinking that it’s yours to do with what you want,” Farr tells clients. He advises them that when they know how much of their money is discretionary, then they can make more realistic choices.

Asking clients about financial health

Many counselors don’t like asking about money. In fact, several of the professionals interviewed for this article noted that counselors often fall under the “avoidant” category when it comes to money scripts. But financial therapists say that it’s essential for counselors to be aware of money stress.

“We all have money stress,” Haines says. “I don’t know a person who doesn’t have money stress at some point in their lives. … It affects everybody.”

Counselors need not create an elaborate process to uncover a client’s money worries, Haines says. “It could be as simple as putting a question on your intake form such as: Are there financial concerns that are impacting you?”

Haines also urges counselors to listen for nuggets of information, such as clients mentioning that they hate opening their mailbox because it’s always full of bills. “You can just ask the question, ‘What impact does that have on you?’” she says. Money troubles are something that most people don’t talk about, even with their friends, so counselors can serve as that trusted person clients share those fears with, Haines emphasizes.

Haines and Kautzer both say that one of the most critical parts of their work as financial therapists is giving people hope.

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@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.

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.

Procrastination: An emotional struggle

By Lindsey Phillips October 24, 2019

Procrastination is a common issue — one that people often equate with simply being “lazy” or having poor time-management skills. But there is often more to the story.

William McCown, associate dean of the College of Business and Social Sciences and professor of psychology at the University of Louisiana at Monroe, cites a case example of a man in his mid-30s with a degree in chemical engineering who was procrastinating about applying to graduate school. The client reported just not being able to “get it together.” Through therapy, however, the man discovered that he had an emotional block. His parents supported his choice to get another degree, but their own lack of formal schooling often led them to make detractive comments, such as the father stating that when his children thought they were as smart as him, he would just die. The client came to realize that comments such as these sometimes incited him to self-sabotage his career.

According to Joseph Ferrari, a psychology professor at DePaul University in Chicago, “Everyone procrastinates, but not everyone is a procrastinator.” His research indicates that as many as 20% of adults worldwide are true procrastinators, meaning that they procrastinate chronically in ways that negatively affect their daily lives and produce shame or guilt.

According to McCown, a pioneer in the study of procrastination and co-author (along with Ferrari and Judith Johnson) of Procrastination and Task Avoidance: Theory, Research, and Treatment, procrastination becomes problematic when it runs counter to one’s own desires. “We all put things off,” he notes. “But when we put off things that are really in our best interest to complete and we do it habitually, then that’s more than just a bad habit or a lifestyle issue.”

McCown finds that clients with chronic procrastination often come to counseling for other presenting concerns such as marital problems, depression, work performance issues, substance use, attention-deficit/hyperactivity disorder (ADHD) and anxiety. He has noticed, however, that younger generations are starting to seek counseling explicitly to work on procrastination.

McCown says that among Gen Xers and particularly among baby boomers, tremendous stigma existed around procrastination. But that largely changed with the Great Recession, he contends, because people realized that having a procrastination problem hurt them at work — a luxury they could no longer afford.

Managing emotions, not time

A growing body of research suggests that procrastination is a problem of emotion regulation, not time management. Julia Baum, a licensed mental health counselor (LMHC) in private practice in Brooklyn, New York, agrees. “Poor time management is a symptom of the emotional problem. It’s not the problem itself,” she says.

Nathaniel Cilley, an LMHC in private practice in New York City, also finds that chronic procrastination is often a sign of an underlying, unresolved emotional problem. People’s emotional triggers influence how they feel, which in turn influences how they behave, he explains. However, clients may incorrectly assume that procrastination is their only problem and not connect it to an underlying emotional issue, he says.

People procrastinate for various reasons, including an aversion to a task, a fear of failure, frustration, self-doubt and anxiety. That is why assessment is so important, says Rachel Eddins, a licensed professional counselor and American Counseling Association member who runs a group counseling practice in Houston. “There’s not one answer to what procrastination is because [there are] so many things that lead to it,” she says.

Procrastination can also show up in conjunction with various mental health issues — ADHD, eating disorders, perfectionism, anxiety, depression — because it is an avoidance strategy, Eddins says. “Avoidance strategies create psychological pain, so then that leads to anxiety, to depression, and to all these other things that people are calling and seeking counseling for,” she explains.

Sometimes, procrastination may even mask itself initially as another mental health issue. For example, overeating in itself is a procrastination strategy, Eddins says. She points out that if certain people have a hard task they are avoiding, they may head to the refrigerator for a snack as a way of regulating the discomfort.

If a client comes to counseling because he or she is binge eating and procrastinating on tasks, then the counselor first has to determine the root cause of these actions, Eddins says. For example, perhaps the client isn’t scheduling enough breaks, and the stress and anxiety are leading to binge eating. Perhaps food acts as stimulation and provides the client with a way to focus, so counselors might need to explore possible connections to ADHD. Maybe the client is rebelling against harsh judgment, or perhaps the root cause is related to the client experiencing depression and feeling unworthy.

One approach Eddins recommends for finding the root cause is the downward arrow technique, which involves taking the questioning deeper and deeper until the counselor uncovers the client’s underlying emotion. For example, if a client is avoiding cleaning his or her house, the counselor could ask, “What does it mean to have a messy house?” The client might respond, “It means I can’t invite people over.” The counselor would follow up by asking, “What does that mean?” These questions continue until the client and counselor get to the issue’s root cause — such as the client not feeling worthy.

Eddins and Cilley both find imaginal exposure helpful for accessing clients’ actual memories and experiences and discovering the underlying cause of procrastination. For instance, if a client is procrastinating over writing an article, Cilley may have the client imagine sitting at his or her desk and staring at the blank computer screen. Cilley would ask, “What’s going on in this moment? Where are we? What is around you? How are you feeling emotionally at the thought of writing this article?” The client might respond that he or she feels anxious about it, which means the underlying cause is emotional.

“Imagination is really great with drumming up emotions,” Cilley notes. “The emotion starts to come into the session when [clients visualize what they are avoiding].”

Addressing irrational thoughts

“You can do all the time-management skills in the world with someone, but if you haven’t addressed the underlying irrational beliefs fueling the anxiety, which is why they’re procrastinating, they’re not going to do [the task they are avoiding],” notes Cilley, an ACA member who specializes in anxiety disorders.

As described by Cilley, the four core irrational beliefs of rational emotive behavior therapy (REBT) are:

  • Demands (“should” and “must” statements such as “I should go to the gym four times a week”)
  • Awfulizing (imagining a situation as bad as it can be)
  • Low frustration tolerance, which is sometimes referred to as “I-can’t-stand-it-itis” (belief that the struggle is unbearable)
  • Self-downing (defining oneself on the basis of a single aspect or outcome, such as thinking, “If I mess up one work project, then I am a failure”)

“When we’re having procrastination problems, a lot of times we awfulize about the task and have abysmally low frustration tolerance about the energy required to do it,” observes Cilley, a certified REBT therapist and supervisor and an associate fellow at the Albert Ellis Institute. “And we disproportionately access how bad it would be to do it or to be put through it and minimize our ability to withstand or cope with it.” Put simply, sometimes when people think something will be too difficult, they don’t do it.

Another common reason people procrastinate is a fear that they could fail, and they interpret failure to mean that something is inherently wrong with them, Cilley says.

For example, imagine a client who comes to counseling because he procrastinates responding to work emails out of fear that he will answer it incorrectly and his co-workers will realize he is a failure. To first identify the root cause, Cilley would ask a series of open-ended questions to the client’s statements regarding procrastination: I am avoiding responding to emails at work. What would it mean if you responded to the emails? I’m afraid I would do it incorrectly. What if you did respond incorrectly? My boss would think I’m an idiot. What would that mean to you? That I’m no good at my job. I’m a bad employee.

A self-label of “bad employee” causes the client to filter everything through that lens, including minimizing the good that he does, Cilley points out. In addition, the man will act as if he is a “bad employee,” which reinforces this label and makes him more prone to procrastination, Cilley says.

One technique that Cilley uses with clients to challenge unhealthy thinking and break the vicious cycle is the circle exercise. He draws a big circle, and at the top he writes the client’s name. At the bottom, he writes the negative thought in quotes — “I’m a bad employee.” Then, he places six plus signs and six minus signs inside the circle and asks the client to think of six things that he or she does poorly at work. The client might respond, “I procrastinate on tasks, I show up late, I make mistakes when I respond to emails” and so on. Next, Cilley has the client name six things that he or she does well. For example, the client could say, “I care about the work I do, I stay late if needed, and my co-workers can depend on me.”

If clients respond by saying that they don’t have any positive qualities at work, then Cilley will ask them to think about what positive things another co-worker would say about them (even if the clients don’t believe the statements themselves).

Next, Cilley circles one of the statements in the minus category and asks the client if this one negative statement erases the other six positive statements. To emphasize the flawed logic, he may also ask if one positive trait causes all of the negative ones to go away and makes someone a “perfect” employee.

This exercise challenges black-and-white thinking and helps clients separate their identities from their actions or the task they messed up on, such as sending an incorrect email, Cilley explains.

Even after clients identify their irrational beliefs and create rational coping statements (positive beliefs used to replace the negative and irrational ones), they still may not believe the rational ones. When this happens, Cilley uses an emotiveness exercise he refers to as “fake it till you make it.” He asks clients to read the rational beliefs out loud 10 times with conviction — as if they were Academy Award-winning actors and actresses who wholeheartedly endorse and embrace the beliefs.

If clients are going to rebut thoughts such as “I am a failure” and “I can’t do anything right,” then a monotone voice won’t help them change their thoughts or calm down, Cilley notes. “Anyone can go up on stage and read a speech,” he says. “The emotion and conviction behind your voice is what moves the audience, and that’s what we have to do to ourselves when we’re trying to convince ourselves of the rational beliefs.”

Even though clients may not initially believe what they are saying, by the eighth or ninth time they repeat it, they are finally internalizing the beliefs, Cilley says. On the 10th time — when clients are starting to actually believe what they are saying — he records them repeating the rational beliefs. Clients are then instructed to listen to this recording three times per day throughout the week as a way of talking themselves into doing whatever they have been procrastinating over, he says.

Cilley has also used role-play to help clients put stock in more rational thoughts. He does this by adopting the client’s irrational belief (e.g., “I am a failure” or “I am unworthy”) and then asks the client to try to convince him of more rational thoughts. By doing this, the clients start to convince themselves. Even though clients often laugh at this exercise, Cilley has found it to be one of the quickest ways to change clients’ irrational thoughts.

REBT and other short-term therapy techniques are not just effective but also efficient for clients who procrastinate, notes Baum, a rational emotive and cognitive behavior therapist and supervisor, as well as an associate fellow at the Albert Ellis Institute. With procrastination, clients often want to see results quickly, she says. They want to finish the work project, clean their house or get to the gym next week, not next year. REBT helps clients quickly “take responsibility for their behavior and recognize that they have agency to change it,” Baum emphasizes.

Learning to tolerate discomfort

Often, people procrastinate to avoid discomfort, Eddins notes. This discomfort comes in many forms. Maybe it’s procrastinating on beginning a complex task at work out of fear of failure, or avoiding having a difficult conversation with a friend.

The first step is helping clients become aware of the discomfort they are avoiding, Eddins says. “When we suppress our feelings, that’s when the procrastination and avoidance habits emerge,” she adds.

Eddins often uses the “name it to tame it” technique. She will first ask clients what they are feeling when thinking about the task they are avoiding. Clients may not have a word for this discomfort, so she will ask them to identify what they are feeling physically, such as a tightness in their chests.

Baum, a member of the New York Mental Health Counselors Association who specializes in helping creative professionals and entrepreneurs overcome procrastination, helps clients learn to cope with feelings of discomfort through imaginal exposure. First, Baum teaches clients coping skills such as breathing exercises to use when they experience discomfort. She also helps them identify, challenge and replace irrational thoughts that contribute to emotional distress and self-defeating behaviors. Then, she asks them to imagine walking through the scenario they have been avoiding.

For example, a man procrastinates about going to the gym because he feels ashamed of being out of shape. The client thinks to himself, “I’m out of shape. I won’t fit in at the gym. I’m no good because I let myself go.” These thoughts and his fear of others judging him prevent him from going to the gym despite the health benefits.

To address this emotional problem, Baum would have the client imagine walking into the gym and getting on the treadmill as others stare at him. During this exercise, she would guide the client to breathe slowly to keep his body calm and have him practice rational thinking, such as accepting himself unconditionally regardless of the shape he is in or what others may think. This will help him overcome his shame and productively work toward a healthy fitness routine.

Eddins also uses a mindfulness-based technique called “surfing the urge” to help clients. She instructs clients to stop when they feel the urge to procrastinate and ask themselves what the urge feels like in their bodies and what thoughts are going through their heads. For instance, clients may notice having an urge to get up and grab a snack rather than work on their task. This technique helps them learn to sit with their discomfort and face the urge rather than distracting themselves from it or trying to change it, she explains.

The power of rewards and consequences

Cilley finds rewards and consequences a useful motivational tool for those clients who are good at identifying irrational beliefs and who already possess coping and emotion-regulation skills yet are still procrastinating when faced with certain tasks (or even their therapy homework). For example, clients could reward themselves by watching their favorite show on Netflix after they complete the task. The ability to watch the show could also become a consequence — they would withhold watching the show until they complete the task.

Counselors may need to help clients determine appropriate rewards. McCown, a clinical psychologist at the Family Solutions Counseling Center in Monroe, Louisiana, finds that clients sometimes want to use grandiose rewards that really aren’t helpful motivators. For example, a client may decide that he or she will take a trip to Europe after finishing writing a novel. McCown notes that the likelihood of this motivating the client to make progress on the novel isn’t as strong as if the client used smaller rewards, such as going out with a friend or taking a walk to celebrate completing 300 words of their novel.

If clients are having trouble enforcing rewards or consequences themselves, counselors can become the enforcers — but only as a last resort, Cilley says. For example, Cilley had a client who was procrastinating when it came to taking steps toward starting a side business because he feared he would do it imperfectly, and that would make him a “failure.” After learning how to identify his irrational thoughts and how to regulate his emotions, the client still needed one final push to start his business. The client was a gamer, so both he and Cilley agreed that if he didn’t start his business that week, Cilley would change the client’s PlayStation 4 password so that he couldn’t play video games until after the business was launched.

“You want to make sure you have a good working alliance with the client and that they feel safe to be vulnerable and that [you] can laugh about this [with them] because it’s kind of unorthodox. But sometimes that’s what works for some people. They need that accountability,” Cilley says. “Just laughing about how silly the consequence is in therapy can make it more of a fun challenge.”

Giving yourself permission

Eddins finds that shame is a big factor with people who procrastinate. “Somehow we learned that shame [is] a way of motivating — ‘If I’m just hard on myself, then maybe I’ll get it done’ — and that for sure backfires and leads to procrastination,” she says.

For some people, their inner critic is shaming them constantly with “should” statements (e.g., “I should work out four times a week”). Procrastination is their way of rebelling against this harsh judgment, Eddins explains.

Self-compassion is one way to address critical thoughts and shaming, Eddins says. For example, the critical inner voice that declares a client lazy if he or she doesn’t go to the gym could be changed to use more motivating statements such as “It feels good when I go outside and move my body.”

In addition, if critical thoughts start to surface when clients are trying to complete a task, they can use a self-compassionate voice to remind themselves that they will feel better after they take a break, Eddins advises. In fact, the act of giving oneself permission to take a break, practice some self-care, and rest and relax can sometimes break the cycle of procrastination, Eddins says.

A 2010 study found that students who forgave themselves for procrastinating when studying for a first exam were less likely to procrastinate when studying for the next one. The researchers concluded that self-forgiveness allows people to move past the maladaptive behavior and not be burdened by the guilt of their past actions.

At the same time, Eddins advises counselors to be careful with the technique of giving permission. Clients with black-and-white thinking may interpret that as the counselor telling them it is OK to be “lazy.” Instead, she recommends that counselors use this strategy within a context that the client will accept.

Eddins had a client who put off meal planning each week because it was stressful. When Eddins asked why it was stressful, she discovered the client was preparing up to three different meals each night to accommodate each family member’s personal preferences. Eddins knew that if she told this client to give herself permission to cook only one meal each night, the client would engage in black-and-white thinking: “Well, that would make me a bad mom.”

So, instead, Eddins said, “No wonder you are exhausted. You are trying to do everything for everyone else but not for yourself. This doesn’t work for you. You have permission to take care of yourself and do what works for you. And that does not make you a bad mother.”

Strategies for success

Procrastination does offer momentary relief and reward, which only reinforces the behavior and continues the cycle of avoidance, Eddins notes. So, the more times that an individual avoids a task, the more difficult it becomes to stop the cycle of procrastination.

In counseling, clients can learn strategies that are more effective than avoidance. One therapeutic technique that Eddins likes involves breaking tasks into smaller ones that are realistic and obtainable. For instance, an individual who hasn’t formally engaged in exercise in the past year might be tempted to set a goal of working out four times a week. This person has created an ideal “should,” but because the goal is overwhelming, he or she is likely to continue avoiding exercising, Eddins points out.

Should this happen, Eddins might explore why the client is procrastinating on the goal: “Tell me about the last time you worked out. When was that?”

When the client responds that it was a year ago, Eddins would suggest establishing a smaller goal to ensure success and build motivation. For example, the client could start by exercising one day a week for 10 minutes and build from there.

“I want [clients] to take the smallest possible step because I want to [help them] build success,” Eddins says. “That is actually reinforcing in the brain because … it gives you that sort of reward and that success, and then that allows people to achieve the goal.”

McCown points out that “the rehabilitation of a severe procrastinator is almost like working with a severely depressed person: Once they are able to … do anything, they will feel better about themselves, and they’ll have more self-efficacy.” That’s why it is important to get these clients to succeed at some task, even if it is a small and relatively meaningless one such as going to the grocery store or getting the car washed, he says.

Counselors can also help clients who procrastinate to create specific — rather than generic — goals, Eddins says. For example, a goal of “meal planning” would become “planning four meals for dinner on Sunday afternoon.” The counselor can then collaborate with these clients to identify the specific actions they will need to take to meet that goal: What typically happens on Sunday afternoons? What could get in the way of this task? How can you make time on Sunday afternoons? What do you need to prepare in advance? What steps will you take to complete this task?

Some clients, especially those with perfectionist tendencies, may resist setting a small goal or task because they don’t see it as “good enough” or as an effective way of achieving their larger goal, Eddins says. In these cases, counselors may need to address the client’s black-and-white thinking and the role it can play in procrastination, she adds.

Counselors can also help clients identify optimal times to complete tasks that they have been procrastinating on, Eddins says. For instance, clients might tell themselves they will complete an unpleasant task right after getting home from work. But if the counselor knows the client doesn’t like his or her job and will likely need some time to decompress after getting home, the counselor can point that fact out and note that it increases the likelihood of the client avoiding the task, she says.

Shifting clients’ focus to what they will do — rather than what they won’t do — is another way to motivate clients, Eddins says. For example, counselors can encourage clients to think along the lines of “I’m going to come home, get a glass of water, put on my tennis shoes, go out for a 10-minute walk, and then come home and fix dinner” rather than “I’m not going to sit on the couch this evening and watch television.” Trying to avoid procrastination or its underlying emotional root makes procrastination more active and powerful in one’s mind, Eddins points out.

All of these strategies can aid clients in addressing the deeper emotional problems connected to their procrastination. McCown stresses that procrastination won’t go away by itself. “Joe Ferrari phrases it quite beautifully: ‘It’s not about time.’ It’s often something deeper,” McCown says, “and I think counselors are in a great role to figure out whether it’s just simply a bad habit or whether it’s something a little more serious.”

 

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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.

Challenging the inevitability of inherited mental illness

By Lindsey Phillips August 29, 2019

With a family history that famously includes depression, addiction, eating disorders and seven suicides — including her grandfather Ernest Hemingway and her sister Margaux — actress and writer Mariel Hemingway doesn’t try to deny that mental health issues run in her family. She repeatedly shares her family history to advocate for mental health and to help others affected by mental illness feel less alone.

And, of course, they aren’t alone. Mental health issues are prevalent in many families, making it natural for some individuals to wonder or worry about the inherited risks of developing mental health problems. Take the common mental health issue of depression, for example. The Stanford University School of Medicine estimates that about 10% of people in the United States will experience major depression at some point during their lifetime. People with a family history of depression have a two to three times greater risk of developing depression than does the average person, however.

A 2014 meta-analysis of 33 studies (all published by December 2012) examined the familial health risk of severe mental illness. The results, published in the journal Schizophrenia Bulletin, found that offspring of parents with schizophrenia, bipolar disorder or major depressive disorder had a 1 in 3 chance of developing one of those illnesses by adulthood — more than twice the risk for the control offspring of parents without severe mental illness.

Jennifer Behm, a licensed professional counselor (LPC) at MindSpring Counseling and Consultation in Virginia, finds that clients who are worried about family mental health history often come to counseling already feeling defeated. These clients tend to think there is little or nothing they can do about it because it “runs in the family,” she says.

Theresa Shuck is an LPC at Baeten Counseling and Consultation Team and part of the genetics team at a community hospital in Wisconsin. She says family mental health history can be a touchy subject for many clients because of the stigma and shame associated with it. In her practice, she has noticed that individuals often do not disclose family history out of their own fear. “Then, when a younger generation person develops the illness and the family history comes out, there’s a lot of blame and anger about why the family didn’t tell them, how they would have wanted to know that, and how they could have done something about it,” she notes.

Sarra Everett, an LPC in private practice in Georgia, says she has clients whose families have kept their history of mental illness a secret to protect the family image. “So much of what feeds mental illness and takes it to an extreme is shame. Feeling like there’s something wrong with you or not knowing what is wrong with you, feeling alone and isolated,” Everett says. Talking openly and honestly about family mental health history with a counselor can serve to destigmatize mental health problems and help people stop feeling ashamed about that history, she emphasizes.

Is mental illness hereditary?

Some diseases such as cystic fibrosis and Huntington’s disease are caused by a single defective gene and are thus easily predicted by a genetic test. Mental illness, however, is not so cut and dry. A combination of genetic changes and environmental factors determines if someone will develop a disorder.

In her 2012 VISTAS article “Rogers Revisited: The Genetic Impact of the Counseling Relationship,” Behm notes that research in cellular biology has shown that about 5% of diseases are genetically determined, whereas the remaining 95% are environmentally based.

The history of the so-called “depression gene” perfectly illustrates the complexity of psychiatric genetics. In the 1990s, researchers showed that people with shorter alleles of the 5-HTTLPR (a serotonin transporter gene) had a higher chance of developing depression. However, in 2003, another study found that the effects of this gene were moderated by a gene-by-environment interaction, which means the genotype would result in depression if people were subjected to specific environmental conditions (i.e., stressful life events). More recently, two studies have disproved the statistical evidence for a relation between this genotype and depression and a gene-by-environment interaction with this genotype.

Even so, researchers keeps searching for disorders that are more likely to “run in the family.” A 2013 study by the Cross-Disorder Group of the Psychiatric Genomic Consortium found that five major mental disorders — autism, attention deficit/hyperactivity disorder (ADHD), bipolar disorder, major depressive disorder and schizophrenia — appear to share some common genetic risk factors.

In 2018, a Bustle article listed 10 mental health issues “that are more likely to run in families”: schizophrenia, anxiety disorders, depression, bipolar disorder, obsessive-compulsive disorder (OCD), ADHD, eating disorders, postpartum depression, addictions and phobias.

Adding to the complexity, Kathryn Douthit, a professor in the counseling and human development program at the University of Rochester, points out that studies on mental disorders are done on categories such as major depression and anxiety that are often based on descriptive terms, not biological markers. The cluster of symptoms produces a “disorder” that may have multiple causes — ones not caused by the same particular genes, she explains.

Thus, thinking about mental health as being purely genetic is problematic, she says. In other words, people don’t simply “inherit” mental illness. A number of biological and environmental factors are at play in gene expression.

Regardless of the genetic link, family history does serve as an indicator of possible risk for certain mental health issues, so counselors need to ask about it. As a genetic counselor, Shuck, a member of the American Counseling Association, admits that she may handle family history intake differently. Genetic counseling, as defined by the National Society of Genetic Counselors, is “the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease.” It blends education and counseling, including discussing one’s emotional reactions (e.g., guilt, shame) to the cause of an illness and strategies to improve and protect one’s mental health.

Thus, Shuck’s own interests often lead her to ask follow-up questions about family history rather than sticking to a general question about whether anyone in a client’s family struggles with a certain disorder. If, for example, she learns a client has a family history of depression, she may ask, “Who has depression, or who do you think has depression?” After the client names the family members, Shuck might say, “Tell me about your experiences with those family members. How much has their mental health gotten in the way? How aware were you of their mental health?”

These questions serve as a natural segue to discussing how some disorders have a stronger predisposition in families, so it is good to be aware and mindful of them, she explains. Discussing family history in this way helps to normalize it, she adds.   

Everett, who specializes in psychotherapy for adults who were raised by parents with mental illness, initially avoids asking too many questions. Instead, she lets the conversation unfold, and if a client mentions alcohol use, she’ll ask if any of the client’s family members drink alcohol. Inserting those questions into the discussion often opens up a productive conversation about family mental health history, she says.

Environmental factors

Mental disorders are “really not at all about genetic testing where you’re testing genes or blood samples because there are no specific genetic tests that can predict or rule out whether someone may develop mental illness,” Shuck notes. “That’s not how mental illness works.”

Shuck says that having a family history of mental illness can be thought of along the same lines as having a family history of high blood pressure or diabetes. Yes, having a family history does increase one’s risk for a particular health issue, but it is not destiny, she stresses.

For that reason, when someone with a family history of mental disorders walks into counseling, it is important to educate them that mental health is more than just biology and genetics, Shuck says. In fact, genetics, environment, lifestyle and self-care (or lack thereof) all work together to determine if someone will develop a mental disorder, she explains.

One of Shuck’s favorite visual tools to help illustrate this for clients is the mental illness jar analogy (from Holly Peay and Jehannine Austin’s How to Talk With Families About Genetics and Psychiatric Illness). Shuck tells clients to imagine a glass jar with marbles in it. The marbles represent the genes (genetic factors) they receive from both sides of their family. The marbles also represent one’s susceptibility to mental illness; some people have two marbles in their jar, while others have a few handfuls of marbles.

Next, Shuck explains how one’s lifestyle and environment also fill the jar. To illustrate this point, she has clients imagine adding leaves, grass, pebbles and twigs (representing environmental factors) until the jar is at capacity. “We only develop mental illness if the jar overflows,” she says.

Behm, an ACA member, also uses a simple analogy (from developmental biologist Bruce Lipton) to help explain this complex issue to clients. She tells clients to think of a gene as an overhead light in a room. When they walk into the room, that light (or gene) is present but inactive. They have to change their environment by walking over and flipping on a switch to activate the light.

As Everett points out, “Our experiences, drug use, traumas, these things can turn genes on, especially at a young age.” On the other hand, if someone with a pervasive family history of mental disorders had caregivers who were aware and sought help, the child could grow up to be relatively well-adjusted and healthy in terms of mental health, she says.

In utero epigenetics is another area that illustrates how environment affects our genes and mental health, Douthit notes. The Dutch Hongerwinter (hunger winter) offers an example. In 1944-1945, people living in a Nazi-occupied part of the Netherlands endured starvation and brutal cold because they were cut off from food and fuel supplies. Scientists followed a group who were in utero during this period and found that the harsh environment caused changes in gene expression that resulted in their developing physical and mental health problems across the life span. In particular, they experienced higher rates of depression, anxiety disorders, schizophrenia, schizotypal disorder and various dementias.

Why is this important to the work of counselors? If, Douthit says, counselors are aware of an environmental risk to young children, such as the altered gene expression coming from the chronic stress and trauma associated with poverty, then they can work with parents and use appropriate therapeutic techniques such as touch therapy interventions in young infants and child-parent psychotherapy to reverse the impact of the harmful
gene expression.

Behm uses the Rogerian approach of unconditional positive regard and “prizing” the client (showing clients they are worth striving for) to create a different environment for clients — one that is ripe for change.

Counseling interventions that change clients’ behaviors and thoughts long term have the potential to also change brain structure and help clients learn new ways of doing and being, Behm continues. “It’s the external factors that are making people anxious or depressed,” she says. “If you get yourself out of that situation, your experience can be different. If you can’t get yourself out of it, the way you perceive it — how you make meaning of it — makes it different in your brain.”

The hope of epigenetics

Historically, genes have been considered sovereign, but genetics don’t tell the entire story, Behm points out. For her, epigenetics is a hopeful way to approach the issue of familial mental illness.

Epigenetics contains the Greek prefix epi, which means “on top of,” “above” or “outside of.” Thus, epigenetics includes the factors outside of the genes. This term can describe a wide range of biological mechanisms that switch genes on and off (evoking the prior analogy of the overhead light). Epigenetics focuses on the expression of one’s genes — what is shaped by environmental influences and life experiences such as chronic
stress or trauma.

Douthit has written and presented on the relationship between counseling and psychiatric genetics, including her 2006 article “The Convergence of Counseling and Psychiatric Genetics: An Essential Role for Counselors” in the Journal of Counseling & Development and a 2015 article on epigenetics for the “Neurocounseling: Bridging Brain and Behavior” column in Counseling Today. In her chapter on the biology of marginality in the 2017 ACA book Neurocounseling: Brain-Based Clinical Approaches, she explains epigenetics as the way that aspects of the environment control how genes are expressed. Epigenetic changes can help people adapt to new and challenging environments, she adds.

This is where counseling comes in. Clients often come to counseling after they have struggled on their own for a while, Behm notes. The repetition of their reactions to their external environment has resulted in a certain neuropathway being created, she explains.

Clients are inundated with messages of diseases being genetic or heritable, but they rarely hear the counternarrative that they can make changes in their lives that will provide relief from their struggle, Behm notes. “Through consistent application of these changes, [clients] can change the structure and function of [their] brain,” she adds. This process is known as neuroplasticity.

Behm explains neuroplasticity to her clients by literally connecting the dots for them. She puts a bunch of dots on a blank piece of paper to represent neurons in the brain. Then, for simplicity, she connects two dots with a line to represent the neuropathway that develops when someone acts or thinks the same way repeatedly. She then asks, “What do you think will happen if I continue to connect these two dots over and over?” Clients acknowledge that this action will wear a hole in the paper. To which she responds, “When I create a hole, then I don’t have to look at the paper to connect the dots. I can do it automatically without looking because I have created a groove. That’s a neuropathway. That’s a habit.”

Even though clients often come in to counseling with unhealthy or undesirable habits (such as responding to an event in an anxious way), Behm provides them with hope. She explains how counseling can help them create new neuropathways, which she illustrates by connecting the original dot on the paper with a new dot.

Of course, the real process is not as simple as connecting one dot to another, but the illustration helps clients grasp that they can choose another path and establish a new way of being and doing, Behm says. The realization of this choice provides clients — including those with family histories of mental illness — a sense of freedom, hope and empowerment, she adds.

At the same time, Behm reminds clients of the power exerted by previously well-worn neuropathways and reassures them that continuing down an old pathway is normal. If that happens, she advises clients to journal about the experience, recording their thoughts and feelings about making the undesirable choice and what they wish they had done or thought differently.

“The very act of writing that out strengthens the [new] neuropathway,” she explains. “Not only did you pause and think about it … you wrote about it. That strengthened it as well.”

In addition, professional clinical counselors can help bring clients’ subconscious thoughts to consciousness. By doing this, clients can process harmful thoughts, make meaning out of the situation, and create a new narrative, Behm explains. The healthy thoughts from the new narrative can positively affect genes, she says.

Protective factors

When patients are confronted with a physical health risk such as diabetes or high blood pressure, they are typically encouraged by health professionals to adjust their behavior in response. Shuck, a member of the National Society of Genetic Counselors and its psychiatric disorders special interest group, approaches her clients’ increased risk of mental health problems in a similar fashion: by helping them change their behaviors.

Returning to the mental illness jar analogy, Shuck informs clients that they can increase the size of their jars by adding rings to the top so that the “contents” (the genetic and environmental factors) don’t spill over. These “rings” are protective factors that help improve one’s mental health, Shuck explains. “Sleep, exercise, social connection, psychotherapy, physical health maintenance — all of those protective factors that we have control of and we can do something about — [are] what make the jar have more capacity,” she says. “And so, it doesn’t really matter how many marbles we’re born with; it’s also important what else gets put in the jar and how many protective factors we add to it to increase the capacity.”

Techniques that involve a calming sympathetic-parasympathetic shift (as proposed by Herbert Benson, a pioneer of mind-body medicine) may also be effective, Douthit asserts. Activities such as meditation, knitting, therapeutic massage, creative arts, being in nature, and breathwork help cause this shift and calm the nervous system, she explains. Some of these techniques can involve basic behavioral changes that help clients “become aware of when [they’re] becoming agitated and to be able to recognize that and pull back from it and get engaged in things that are going to help [them] feel more baseline calm,”
she explains.

In addition, counseling can help clients relearn a better response or coping strategy for their respective environmental situations, Behm says. For example, a client might have grown up watching a parent respond to external events in an anxious way and subconsciously learned this was an appropriate response. In the safe setting of counseling, this client can learn new, healthy coping methods and, through repetition (which is one way that change happens), create new neuropathways.

At the same time, Shuck and Douthit caution counselors against implying that as long as clients do all the rights things — get appropriate sleep, maintain good hygiene, eat healthy foods, exercise, reduce stress, see a therapist, maintain a medicine regime — that they won’t struggle, won’t develop a mental disorder, or can ignore symptoms of psychosis.

“You can do all of the right things and still develop depression. It doesn’t mean that somebody’s doing something wrong. … It just means there happened to have been more marbles in the jar in the first place,” Shuck says. “It’s [about] giving people the idea that there’s some mastery over some of these factors, that they’re not just sitting helplessly waiting for their destiny to occur.”

Shuck often translates this message to other areas of health care. For example, someone with a family history of diabetes may or may not develop it eventually, but the person can engage in protective factors such as maintaining a healthy body weight and diet, going to the doctor, and getting screened to help minimize the risk. “If we normalize [mental health] and make it very much a part of what we do with our physical health, it’s really not so different,” she says.

Bridging the gap

Shuck started off her career strictly as a genetic counselor. As she made referrals for her genetics clients and those dealing with perinatal loss to see mental health therapists, however, several clients came back to her saying the psychotherapist wasn’t a good fit. Over time, this happened consistently.

This experience opened Shuck’s eyes to the existing gap between the medical and therapeutic professions for people who have chronic medical or genetic conditions. Medical training isn’t typically part of the counseling curriculum, often because there isn’t room or a need for such specialized training, she points out.

Shuck decided to become part of the solution by obtaining another master’s degree, this time in professional counseling. She now works as a genetic counselor and as a psychotherapist at separate agencies. She says some clients are drawn to her because of her science background and her knowledge of the health care setting.

Behm also notes a disconnect between genetics and counseling. “I see these two distinct pillars: One is the pillar of genetic determinism, and the other is the pillar of epigenetics. And with respect to case conceptualization and treatment, there aren’t many places where the two are communicating,” she says.

Douthit, a former biologist and immunologist, acknowledges that some genetic questions such as the life decisions related to psychiatric genetics are outside the scope of practice for professional clinical counselors. However, helping clients to change their unhealthy behaviors and though patterns, deal with family discord or their own reactions (e.g., grief, loss, anxiety) to genetically mediated diseases, and create a sympathetic-parasympathetic shift are all areas within counselors’ realm of expertise, she points out.

An interprofessional approach is also beneficial when addressing familial mental health disorders. If Behm finds herself “stuck” with a client, she will conduct motivational interviewing and then often include a referral to a medical doctor or other medical professional. For example, she points out, depression can be related to a vitamin D deficiency. She has had clients whose vitamin D levels were dangerously low, and after she referred them to a medical doctor to fix the vitamin deficiency, their therapeutic work improved as well.

Another example is the association between addiction and an amino acid deficiency. Behm notes that consulting with a physician who can test and treat this type of deficiency has been shown to reduce clients’ desires to use substances. Even though counselors are not physicians, knowing when to make physicians a part of the treatment team can help improve client outcomes,
she says. 

Another way to bridge the gap between psychotherapy and the science of genetics is to make mental health a natural part of the dialogue about one’s overall health. “Mental illness lives in the organ of the brain, but we somehow don’t equate the brain as an organ that’s of equality with our kidneys, heart or liver,” Shuck says. When there is a dysfunction in the brain, clients deserve the opportunity to make their brains work better because that is important for their overall well-being,
she asserts.

Facing one’s fears

Having a family history of mental illness may result in fear — fear of developing a disorder, fear of passing a disorder on to a child, fear of being a bad parent or spouse because of a disorder.

“Fear is paralyzing,” Shuck notes. “When people are fearful of something … they don’t talk about it and they don’t do anything about it.” The aim in counseling is to help clients move away from feeling afraid — like they’re waiting for the disorder to “happen” — to feeling more in control, she explains.

Some clients have confessed to Everett that they have doubts about whether they want or should have children for several reasons. For instance, they fear passing on a mental health disorder, had a negative childhood themselves because of a parent who suffered from an untreated disorder, or currently struggle with their own mental health. For these clients, Everett explains that having a mental health issue or a family history of mental illness doesn’t mean that they will go on to neglect or abuse their children. “With parents who have the support and are willing to be open and ask for help … [mental illness] can be a part of their life but doesn’t have to completely devastate their children or family,” she says.

Shuck reminds clients who fear that their children could inherit a mental illness that most of the factors that determine whether people develop a mental disorder are nongenetic. In addition, she tells clients their experience with their own mental health is the best tool to help their child if concerns arise because they already know what signs to look for and how to get help.

Even if a child comes from a family with a history of mental illness, the child’s environment will be different from the previous generations, so the manifestations of mental illness could be less or more severe or might not appear at all, Douthit adds.

The potential risk of mental illness may also produce anger in some clients, but as Shuck points out, this can sometimes serve as motivation. One of her clients has a family history that includes substance abuse, addiction, hoarding, anxiety, bipolar disorder, OCD, depression and suicide. The client also experienced mental health problems and had a genetic disorder, but unlike her family, she advocated for herself. When Shuck asked her why she was different from the rest of her family, the client confessed she was angry that she had grown up with family members who wouldn’t admit that they had a mental illness and instead used unhealthy behaviors such as drinking to cope. She knew she wanted a different life for herself and her future children.

Defining their own destiny

Everett doesn’t focus too heavily on client genetics because she can’t do anything about them. Instead, her goal is to encourage clients to believe that they can change and get better themselves. She wants clients to move past their defeated positions and realize that a family history of mental illness doesn’t have to define them.

Likewise, Behm thinks counselors should instill hope and optimism into sessions and carry those things for clients until they are able to carry them for themselves. To do this, counselors should be well-versed in the science of epigenetics and unafraid of clients’ family histories, she says. Practitioners must believe that counseling can truly make a difference and should attempt to grow in their understanding of how the process can alter a client’s genes, she adds.

From the first session, Behm is building hope. She has found that activities that connect the mind and body can calm clients quickly and make them optimistic about future sessions. For example, she may have clients engage in diaphragmatic breathing and ask them what they want to take into their bodies. If their answer is a calming feeling, she tells them to imagine calm traveling into every single cell of their bodies when they breath in. Alternately, clients can imagine inhaling a color that represents calm. Next, Behm asks clients what they want to let go of — stress or anxiety, for example — and has them imagine that leaving the body as they exhale.

Hope and optimism played a large role in how Mariel Hemingway approached her family’s history of mental illness. She recognized that her history made her more vulnerable. Determined not to become another tragic story, Hemingway exerted control over her environment, thoughts and behaviors. Today, she continues to eat well, exercise, meditate and practice stress reduction.

Hemingway’s story illustrates the complexity of familial history and serves as a good model for counselors and clients, Douthit says. “Whether it’s genetic or not, it’s being passed along from generation to generation,” Douthit says. “And that could be through behaviors. It could be through other environmental issues. It could be any number of modifications that occur when genes are expressed.”

Shuck says she often hears other mental health professionals place too great an emphasis on the inheritance of mental illness. A family history of mental illness alone does not determine one’s destiny, she says. Instead, counselors and clients should focus on the things they do have control over, such as environmental factors and lifestyle.

“We have to emphasize wellness [and protective factors] much more than the idea that ‘it’s in my family, so it’s going to happen to me,’” she says. “We have to look at those things we can do as an individual to enhance those aspects of our well-being to make [the capacity of the mental illness] jar bigger.”

 

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

Letters to the editor: ct@counseling.org

 

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