Tag Archives: shame

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.”

 

****

 

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

 

****

 

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.”

 

****

 

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

 

****

 

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.

Taming impulses

By Lindsey Phillips August 5, 2019

About five years ago, a young client walked reluctantly into Jennifer Skinner’s office. In addition to impulse-control issues, the 10-year-old had been diagnosed with attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), struggled with issues around being adopted, and had medical concerns. This long list meant the boy was often being told what to do and felt powerless.

Shortly after the boy’s parents dropped him off, he walked out of Skinner’s office and headed toward his house a few blocks away. Skinner, a licensed professional counselor (LPC) at Kettle Moraine Counseling in Wisconsin, quickly followed. She told him she wasn’t going to stop him from going home, but she was going to make sure he got there safely. Hearing this, the boy circled back to Skinner’s office and locked her out. Skinner stayed calm, and eventually he let her back in.

According to prevalence data cited by Psych Central, 10.5% of Americans have an impulse-control disorder. Even so, Skinner, a licensed professional school counselor who works with students with self-esteem, impulse-control and other social-emotional issues, says that impulsiveness is often poorly understood or is not on people’s radar. She rarely has clients present and tell her they are impulsive.

Similarly, Laura Galinis, an LPC in private practice in Georgia, affirms that when she uses the term impulsivity to describe her work with clients, she is frequently met with blank stares.

Impulsiveness comes from an internal place in which individuals either react without thought or can’t stop themselves from doing the impulsive behavior, says Skinner, a member of the American Counseling Association. Sometimes, if these individuals don’t yell or lash out, they will be left feeling unsatisfied, she adds.

Edward F. Hudspeth, an associate dean of counseling at Southern New Hampshire University, acknowledges that “some impulsivity is just a natural part of growing up [and] learning from situations.” It becomes a problem, however, when repeated consequences and societal pressures have no impact on the person’s impulsive behavior. “Basically,” adds Hudspeth, a member of ACA, “you’re saying that everyone around you and even consequences are of no value to change [your] behavior. It’s just, ‘I’m going to be impulsive,’ and nothing seems to stop this.”

According to Galinis, impulsivity is an inclusive term that describes the ways that people disconnect from themselves, their relationships and their reality. The majority of her clients come in because they are having relationship problems or because someone suggested they seek help. She finds that “the deeper root is not really feeling present when you make decisions.” To her, this means that impulsive behavior can take several forms, including sleeping with lots of people indiscriminately or drinking or spending more than one wants to.

Because impulsivity can be broadly defined, Galinis recommends asking clients what they mean when they say they struggle with impulsivity. She also suggests questions that will help counselors determine whether a client’s impulsivity has gone too far:

  • Has the client been unsuccessful in attempts to fix the impulsive behavior?
  • What consequences is the client facing because of impulse-control issues?
  • Is the client’s impulsive behavior causing problems in relationships, with finances or with work?
  • Does the client’s impulsivity stem from not setting parameters, or is the client disassociated and being prompted to engage in behaviors he or she may not want to do?
  • Is there a pattern with the client’s impulsivity? Does it show up in just one relationship or across the board?

Impulsivity across the life span

Impulse-control disorders are often first diagnosed in childhood, but as Hudspeth points out, they can occur across the life span.

Children with impulse-control issues will often act on impulsive desires because their prefrontal cortex, which regulates impulse control, has yet to fully develop, explains Hudspeth, who is both an LPC and a registered pharmacist. In adults, he finds that impulsive behavior shifts in terms of its intensity. For example, impulsive behaviors that showed as verbal outbursts and some physical aggression as a child would develop into something more disruptive and destructive as an adult, he says.

Galinis, whose specialty areas include impulsivity and trauma, agrees that some people remain impulsive into adulthood unless treated. Impulse-control issues just look different across age ranges, she says. Often, adults can hide or delay the consequences of impulsive behavior because they are more independent, typically coordinating their own schedules, funding their own lifestyles and so on, she says. Teenagers, on the other hand, may be referred to counseling because they are spending too much time on their phones in school. But with adults, the impulsivity progresses beyond simple phone addiction to behaviors that cause relationship issues, such as an impulse to watch pornography or to spend money online.

Shifting societal norms for young adults have created a different developmental stage, known as emerging adulthood, for people ages 18-26, says Hudspeth, co-author of a chapter on impulse-control disorders and interventions for college students in the book College Student Mental Health Counseling: A Developmental Approach. He explains that members of this age group aren’t at the same level of brain development that they would have been 30 years ago. That’s in part because they no longer feel pressured to instantly get a job in their early 20s and start a family, he says. Instead, they often have a period of exploration before emerging as adults.

“Add that to impulsivity, and you get a lot of chaos and a lot of strange behaviors,” Hudspeth continues. “They’re adults. They have adult rights. They can consent to things. They can do things without the approval of someone else, so it presents the opportunity for a lot more riskiness and impulsivity.” For example, it’s not uncommon for these young adults to engage in impulsive behaviors such as taking a last-minute vacation while trying to hold down a job.

Hudspeth, president-elect of the Association for Creativity in Counseling, a division of ACA, points out that impulse-control disorders have morphed over the past three versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), so diagnosing and treating impulsivity can be challenging. In 2013, the DSM-5 published a new chapter on “Disruptive, Impulse-Control and Conduct Disorders.” Intermittent explosive disorder, pyromania, kleptomania, conduct disorders and ODD were included under that heading. At the same time, disorders such as gambling, sexual addiction and trichotillomania were moved out of the impulsive category. 

The new DSM-5 chapter attempts to limit the misconception that impulsivity is only a childhood issue by bringing in the developmental perspective and detailing that these disorders can also show up in different forms in adolescence and adulthood, Hudspeth says. In fact, while doing research for a book chapter in Treating Disruptive Disorders: A Guide to Psychological, Pharmacological and Combined Therapies, Hudspeth found that intermittent explosive disorder is often underdiagnosed and misdiagnosed because it was previously included in a chapter on childhood disorders in the DSM.

Counseling professionals need to be aware that impulse-control disorders can occur across the life span and not just during a particular developmental phase, he says.

Symptom or disorder?

For counselors, the challenge is not necessarily determining whether a client is impulsive but rather figuring out if impulsivity is the main presenting issue or a symptom of other issues such as substance use, ADHD or trauma, Hudspeth says. For this reason, the initial intake and assessment are crucial with regard to impulsivity. Hudspeth advises counselors to look beyond clients’ observable impulsive behaviors to try to figure out what is initiating those behaviors. Why and in what situations are clients being impulsive?

Skinner says it is common to see dual diagnosis with impulse issues. For example, ODD, conduct disorders, eating disorders, addiction and ADHD all have impulse control as a symptom.

Galinis finds that trauma is often an underlying cause of impulsivity. In fact, she says she has yet to see a client struggling with impulsivity who doesn’t also have some trauma attached to it.

Hudspeth concurs: “Trauma and abuse will make a person very hypervigilant and impulsive, and if it’s just treated as an impulse-control disorder, you’re never getting to the core issue.” He advises counselors to ask clients whether a history of trauma, abuse or neglect is connected to their impulsive behavior, either directly or indirectly. If there is, then counselors should approach impulsivity from a different perspective than they would if it were just part of ODD, ADHD or another disorder.

In addition, Hudspeth suggests asking clients the following questions: What is their developmental history? What was their temperament as a child (e.g., easy to soothe, difficulty eating or sleeping)? Where does the impulsive behavior occur (e.g., at school, at home, in the community, everywhere)? Is the person generally well-controlled but then suddenly explode? Does the person make spur-of-the-moment decisions such as taking a weeklong vacation at the drop of a hat?

Because inadequate sleep can make it more difficult to manage impulses, counselors should also ask clients about their sleeping habits, Skinner adds.

It also can be beneficial, if given consent by the client, to speak with others who are around the client on a regular basis, Hudspeth says. All of these situational factors can help counselors determine how best to treat the impulsive behavior, he explains.

Contextual factors such as culture, gender and socioeconomic status also can play a role. Hudspeth points out that every culture perceives and deals with impulsivity differently, so counselors need to consider these factors too. For example, are clients being impulsive because they feel they may never have that experience again or because they’ve never had that experience before and thus don’t have a tool in their toolbox to deal with it? “If it’s an experience that you don’t have on a regular basis and your brain hasn’t collected enough evidence on how to deal with it, then you [may be] impulsive,” Hudspeth observes.

Some recent studies suggest that living in poverty can lead people to opt for short-term rather than long-term rewards. For example, the well-known marshmallow experiment (in which a child’s ability to delay gratification of eating a marshmallow predicted better life outcomes) has recently been challenged by Tyler Watts, Greg Duncan and Haonan Quan’s 2018 study that aligns one’s social and economic background with the ability to delay gratification.

Factors such as trauma, depression and poverty can all affect people’s abilities to regulate their impulses and can make it difficult for them to see the world outside of themselves, Skinner adds.

Thus, to get a better sense of clients’ skills for handing their impulses, counselors should ask how they respond in new or unfamiliar situations, Hudspeth says.

Hudspeth also warns counselors not to latch on to the initial report or diagnosis too quickly when it comes to impulse-control issues. “There’s a lot more behind it than just the symptoms that somebody has reported,” he explains. “It takes a thorough comprehensive intake with assessment and then the willingness to more or less change as you know more.” He advises counselors to consider the first 90 days with the client as a continual period of assessment in which the diagnosis could change as the counselor learns more.

The shame of impulsivity

With impulse-control disorders, the client’s distress can adversely affect the well-being and safety of others and even violate others’ rights (through aggression or destruction of property, for example).

Impulse control “is one of those disorders that could be considered to be both internal and external,” Hudspeth says. “Internally, you’re not stopping yourself from doing something that’s impulsive. Externally, you’re affecting others. You’re in their space. You may be disruptive. You may be yelling. The origins are internal, but how it displays and who it affects is the individual and everybody around them.”

People who struggle with impulsivity often act without thinking and frequently lament their actions almost immediately afterward, which means their lives might be filled with regret, Skinner says. That consistent presence of regret can turn into shame, she adds.

In fact, one huge warning sign that clients’ impulsivity is getting out of hand is when they try to keep their impulsive behaviors a secret, Galinis points out. Even clients with whom she is familiar will sometimes mention impulsive behaviors they have been hiding from her, especially if they involve vulnerable topics such as sexual behavior or addiction. This secrecy results from the sense of shame these clients feel over their behavior and lack of impulse control, she says.

When clients mention being anxious or having uncomfortable emotions, counselors should check in to see how they are handling those emotions, Galinis advises. Asking how clients are coping often opens a door into the unhealthy and impulsive ways they are attempting to manage those feelings, she adds.

With her younger clients who have trouble identifying and communicating their feelings, Skinner likes to read books such as Bryan Smith’s What Were You Thinking? Learning to Control Your Impulses, about a boy whose impulsivity often gets him in trouble. Eventually, the boy learns to control his impulses by thinking about the possible consequences of his actions.

“Reading stories with clients, especially with children, takes the focus off of them, helps them realize they’re not the only person who is struggling with [impulsivity], and shows them possible solutions,” she says.

Engaging emotions and the senses

Impulse control “is not often based in logic,” Galinis says. “It is an emotional experience that drives the behavior, so we need to be able to incorporate the emotions into it because logic is going to fall short every time.” Counselors can’t simply tell people to stop being impulsive. Instead, she explains, they have to help clients understand their emotions and connect them to their behaviors.

“Sometimes we will act on an emotion before we even realize that we are having that emotion,” Skinner notes. For instance, a child might instinctively yell when a teacher enforces limits on the child. Children don’t necessarily know how to handle their feelings when someone makes them mad, so they just react, Skinner explains.

Thus, a large part of her work with clients involves helping them understand their emotions. “Just being able to name your emotions takes … the reactive part of the brain offline and allows your executive functioning to come into play more, and as soon as your executive functioning is coming into play, you’re going to have a better response to the situation,” Skinner says.

She often uses the Disney-Pixar movie Inside Out to explain to younger clients how each emotion has a purpose. “Emotions don’t just happen out of the blue,” she says. “They happen because we have a need that needs to be met.”

To help clients develop a habitual awareness of their emotions, Galinis has clients pick a number on the clock in her office. Then, she tells them that every time they see that number anywhere throughout the course of their day, they should check in on how they are feeling in the moment.

Skinner also gets creative to help clients better understand and name their emotions. For instance, she asks clients to play feelings charades (in which they name and act out all of the feelings they can think of). She also has clients look through magazines and find different emotions on people’s faces. Sometimes, she has clients make up stories about why the person in the magazine feels that way. “That [exercise] helps develop empathy and perspective taking, and both of those things are really important in treating impulse-control disorders,” she says.

Skinner also advises parents and caregivers to continue these exercises at home by pausing when reading stories or watching television to discuss characters’ emotions. She recommends asking questions such as “What do you think this person is feeling right now?” and “Why is the person feeling this way?”

She explains that guiding clients to develop a broad, robust vocabulary about their emotions will help them learn over time to act, not just react, when they are feeling impulsive.

Slowing the process down

Because impulsivity is a quick response, Galinis’ goal is to help clients slow down. She wants clients to connect to their feelings without flooding their emotions, she says. To help clients achieve this balance, she often uses somatic experiencing, which aims to regulate or reset the nervous system by releasing the energy accumulated during stressful events.

For example, if a client is talking about an event that was triggering during the week, Galinis may stop the client upon noticing that he or she is getting agitated and ask what the client is feeling in the body. If the client responds, “My hands are clenched,” she will direct the client to hold that feeling and then ask what the clients wants to do. The client may say, “I want to punch something.” Then, with Galinis’ help, the client will follow through with the punch in slow motion. According to Galinis, this technique helps clients get “unstuck” so they can fully process their impulse and the emotions in their body.

Galinis also has clients create a timeline of feelings and actions surrounding an impulsive behavior. For example, she may have clients walk her through what they noticed from the moment they woke up until the moment they impulsively started watching pornography, even though they hadn’t planned to or didn’t want to. As they talk through this event, she will ask what they notice in their body. Is their heart rate elevated? Does their stomach feel swirly?

If clients notice a change in their body, Galinis tells them to hold on to the uncomfortable feeling for a minute rather than immediately trying to get rid of it or run away from it. This process helps clients build up distress tolerance so that when they’re feeling uncomfortable, they are less likely to feel the need to escape and act impulsively, she explains.

Like Galinis, Skinner uses behavioral sequencing to help clients connect their thoughts, feelings and actions. She asks clients: What is the problem? What happened before you acted out? What happened and what were you feeling during the impulsive behavior? What was the outcome? “Through that process, we try to figure out offramps from that one trajectory that they are on,” she says.

Skinner also finds mindfulness useful with impulse-control disorders because it helps clients understand what is happening in the body. She recommends the 5-4-3-2-1 grounding technique, which engages the senses to help clients get back to the present. With this technique, counselors tell clients to take a deep breath and name five things they see, four things they feel, three things they hear, two things they smell and one thing they taste.

Skinner says meditation is one of her favorite tools for addressing impulsivity because it calms the nervous system down, which allows clients to make better choices instead of just reacting.

Galinis keeps tactile sensory objects such as stress balls, stuffed animals and a cozy blanket in the counseling room to make clients feel more comfortable and to help them calm their body down. Sometimes she even lets clients take a calming stone or an essential oil home with them because it serves as a tangible reminder of what they are working toward and aids them in finding that sense of calm they experienced in her office.

Learning control through play

Impulsive behaviors can frequently impede on the rights and safety of others. This means that many clients who enter counseling for impulsivity might not be there of their own accord. In fact, Skinner says that 95% of the time, her child and adolescent clients are seeing her at someone else’s suggestion.

Understanding that these clients may be reluctant participants in counseling, she uses creative counseling techniques such as games and role-playing. Any activity “where kids have to really stop and think about what their body is doing and pay attention to their surroundings is really helpful and fun” for them, she says. Games also help take the focus off of the client and their “problem,” she adds.

Skinner particularly likes to use the therapeutic board game Stop, Relax & Think with clients who struggle with impulse control. The objective of the game is to help impulsive children think before they act. Players move through the Feelings, Stop, Relax and Think stations on the board, collecting chips along the way.

With the feeling cards, clients name how they would feel in different situations. For example, if the card says, “Your brother hits you,” the client might respond, “I would be angry and want to hit him back.” The cards support clients in better understanding not only their own feelings but also the other players’ feelings, which helps them develop perspective taking, Skinner says.

When players land on a stop sign space, they have to perform an action such as patting their head and rubbing their stomach — which, as Skinner points out, requires a lot of concentration — until another player says, “Stop.” If the player stops immediately, then he or she gets a chip.

Skinner loves that clients can judge counselors when landing on this space. Children, especially ones with ODD, often feel powerless, she points out, and this stopping activity allows them to feel empowered in a safe, healthy way. Sometimes Skinner will purposely fail to stop in time. She wants clients to know that she’s not perfect and doesn’t expect them to be either. It also allows her to model appropriate behavior when someone is frustrated or makes a mistake. 

The relax spaces on the board help clients learn how to calm their bodies. The space may instruct them to take three slow breaths, think about white clouds, or say “I am calm” three times. With the think cards, players come up with ways to handle different scenarios (such as a friend breaking their favorite toy) and earn a token if it is a good plan.

Skinner also uses games such as Uno and Parcheesi to help clients learn how to wait their turn and practice impulse control. In addition, she recommends basic childhood games such as Mother May I; Red Light, Green Light; Simon Says; and Follow the Leader. She says counselors can even stage relay races in which children have to walk carefully while balancing a marshmallow on a spoon. These types of games also work well for group counseling sessions, she adds.

Hudspeth, editor of the International Journal of Play Therapy and The Journal of Counselor Preparation and Supervision, agrees that games are a great way to help child and adolescent clients learn to focus and grasp that there is a sequence of events they must follow to get what they want. Take darts, for example. “Just throwing the dart at the wall is not going to get you points,” he says. “Taking time to aim at the place that’s going to get you the most points is more likely to get you to the place of winning the game.” 

When sessions become impulsive

Sometime clients’ impulsive behaviors spill into the counseling session. When this happens, Skinner reminds counselors to be calm, ignore the bad behavior and reward the positive behavior.

When Skinner worked as a clinical intern at an outpatient clinic with youth who experienced trauma, she had clients whose impulsive and aggressive behavior resulted in overturned chairs and tables and smashed lamps in the office. When this happened in group settings, she would get the other kids out of the room and then make sure the child having the impulsive reaction stayed safe. Other than that, she would show no reaction to the outburst and praised the child when he or she calmed down and regained control.

Control is a big part of impulsivity, Hudspeth points out. For this reason, he uses play therapy, which provides clients with a sense of control but allows counselors to set limits and model appropriate behavior in a safe, trusting environment. For example, with children with impulsive behaviors, Hudspeth would tell them they were allowed to do anything in the playroom as long as they didn’t hurt themselves. This statement might not have been one hundred percent true, he says, but it helped the children feel a sense of control. Then, if a child picked up a Nerf gun and shot darts at him, he would respond, “I am not for shooting, and if you choose to shoot me, you choose not to play with that toy.” After setting this limit, he would offer the client an alternative (and more appropriate) behavior such as shooting the wall.

Skinner and Hudspeth both point out that counselors might also have to train parents to use this method at home to help their children make progress with the impulsive behavior. Often, people assume that children understand what is happening during the impulsive moment, so they may yell or remove children from the situation without giving them a reason, Hudspeth says. “By setting the limit and giving them the alternative and then telling them what the consequence is, you’ve spelled it all out,” he explains. “There’s nothing left to wonder about as a child.”

One realization Skinner had was that clients with impulse-control issues, and especially those with ODD and conduct disorder, could trigger her own impulsive and angry reactions. She acknowledges that sometimes it is difficult as a counselor to hear what certain clients are doing to other people or how they are reacting. In fact, she admits once making a snarky comment to an adult client who was rolling his eyes and being defiant throughout a session. Skinner says she instantly felt terrible and knew that her comment wasn’t helpful to the counseling process.

The experience taught Skinner that she has to temper her own impulses and focus on giving clients what they need in session. She says she also learned that she needs to take a moment between sessions to calm down and prepare for the next one. Even if all she has available is 30 seconds, she closes her door, takes a deep breath and centers herself.

It’s quite possible that counselors will face challenging moments with clients who struggle with impulse control. Five years later, Skinner is still working with the client who stormed out of the counseling session determined to walk home, only to turn around and lock her out of her own office. Thankfully, he has come a long way since that first meeting

Challenging sessions still occur in which the client comes in and won’t say a word. Skinner simply responds, “That’s OK. I guess this is going to be a quiet one. Let me know if you want to do anything.” Sometimes, the client will say that he wants to play a game.

“But within that space, he has learned how to control himself a little bit,” she says. “He has learned that he has some control over his life. He has found his voice … and he’s been able to assert himself with adults in a calmer and more appropriate way.”

 

 

****

 

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

 

****

 

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.

Addressing intimate partner violence with clients

By Bethany Bray June 24, 2019

Licensed mental health counselor Ryan G. Carlson had just earned his master’s degree when he began working on a grant-funded project to provide relationship education to couples in the Orlando, Florida, area. Overseeing the intake process as local couples came into the university-based research center to participate, he quickly learned two things: Domestic violence “is very prevalent — much more prevalent than I realized — and it’s complicated,” says Carlson, an associate professor of counselor education at the University of South Carolina. “Every case was a little bit different than the next.”

The National Coalition Against Domestic Violence reports that on average, nearly 20 people per minute are physically abused by an intimate partner in the United States. On a typical day, domestic violence hotlines across the country receive more than 20,000 phone calls.

Approximately 1 in 4 adult women and 1 in 7 adult men report having experienced severe physical violence from an intimate partner in their lifetime, according to the U.S. Centers for Disease Control and Prevention. In addition, 16% of women and 7% of men have experienced sexual violence from an intimate partner.

Carlson’s experience led him to study domestic violence while earning his doctorate, and it remains a career focus for him as he conducts research, does interdisciplinary work and conducts trainings for mental health professionals. “We assume when there’s violence in a couple’s relationship, they will tell us [in counseling]. What I’ve learned is if we don’t ask the right questions, they won’t tell us, and you shouldn’t ask those questions if you’re not ready for their disclosure,” he says. “It’s really complicated and emotionally charged. … A victim’s safety should be at the center of every decision we make as counselors.”

Handle with care

Counselors who notice patterns of maladaptive behavior, self-esteem issues or what appears to be poor decision-making by clients may automatically want to roll up their sleeves and dive into goal-setting and other go-to techniques to foster change and growth. However, engaging in change-focused work when a client is experiencing IPV may be harmful, warns Taylor Cameron, a licensed professional counselor (LPC) and director of transitional housing at Denton County Friends of the Family, a nonprofit agency in Texas that provides support services to victims of domestic violence and sexual assault. It also offers an intervention program for offenders.

The tried-and-true counseling method of talking through clients’ life scenarios, behaviors and choices while asking questions such as “What could you have done differently?” or “What would you want to change if this happens again?” can be hurtful because a counselor may inadvertently be placing the responsibility for the abuse on the victim instead of on the abuser, Cameron says. She cautions that counselors must choose their language carefully to avoid making the client feel that they are somehow to blame for the abuse they have endured.

“Victims of domestic violence do many things to survive or to try to protect themselves within the relationship,” says Cameron, an American Counseling Association member. “However, the partner carrying out the abuse is solely responsible for the violence.” Ultimately, the client can’t control — and should never be made to feel that they shoulder the blame for — what their partner does, she emphasizes.

Carlson, who is also a member of ACA, agrees. He notes that it isn’t helpful for professional clinical counselors to identify client behaviors that could be changed or avoided when clients may have adopted those patterns as a means of self-protection.

“It’s important to be careful about how we phrase things with [these] clients,” says Carlson, director of the Consortium for Family Strengthening Research and coordinator of the Center for Community Counseling at the University of South Carolina. “Avoid anything that has to do with ‘what could you have done differently?’ questions, anything that would allude to how [the client] contributed to their current situation. … It’s a delicate balance, but it’s really important to avoid language that [even inadvertently suggests] a victim is somehow at fault for being in that relationship.”

“It doesn’t matter what they change about themselves because that is not going to change the other person,” says Margaret Bassett, an LPC and deputy director at the Institute on Domestic Violence & Sexual Assault at the University of Texas at Austin. Counselor practitioners must consider the entire context of a client’s behavior to fully understand why they’re making those decisions, she says. Decisions that victims of abuse make — often for reasons of safety — can appear maladaptive from outside the context of the abusive relationship.

Bassett recalls a client who talked about agreeing to meet her estranged husband at a public library. Without understanding the full context of the situation — that if she didn’t meet with him, he had a history of escalating — a counselor might assume that the client was complicit in maintaining the abusive relationship rather than appreciate her layered safety planning, Bassett says.

“It was a brilliant move. It was safe to meet there because he couldn’t escalate without drawing attention,” Bassett explains. “Not meeting him just was not possible. This was meeting on her terms versus his terms. … This ties into [a counselor] listening and really hearing what the person is saying and not judging it out of context. Really being able to say, ‘That is a brilliant idea that you had.’ It’s not a good or a bad choice. Instead say, ‘When I hear that, I hear the safety it creates.’”

Victims of abuse often adopt patterns and behaviors that are the best choices they can make in a bad situation, Bassett notes. Professional clinical counselors should listen carefully to understand the full context of clients’ lives and then validate the choices they are making to safely navigate abusive and potentially violent situations. “Respect that they’re making a decision and really understand their safety concerns so your intervention is helpful and doable,” Bassett says.

Power and control

IPV happens between partners of all cultures and backgrounds — couples who are married and unmarried, heterosexual and homosexual, wealthy and poor, religious and nonreligious, white, Asian, Hispanic, African American and every other race. In addition, IPV often intersects with sexual assault; homelessness or disruptions in housing, schoolwork or employment; financial trouble; parenting issues; and myriad other challenges that spill over into the mental health issues that commonly bring clients to counseling.

Although the terms domestic violence and intimate partner violence both include the word “violence,” the abuse doesn’t always have a physical component, or the violent behavior is combined with emotional, nonphysical manipulation. What defines a behavior or relationship as abusive is a common thread of power and control. In its simplest definition, domestic violence is an intentional pattern of behaviors used by the abuser to gain and maintain power and control over another person, Cameron explains.

“It’s important to recognize that abuse is not an anger management issue,” she says. “People who are truly experiencing an anger management issue will go off on their boss, their cousin, the random guy at 7-Eleven. Abuse is carefully targeted at one person.”

Controlling behaviors are one of the biggest red flags counselors should be listening for to determine if a client might be involved in an abusive relationship, either as a perpetrator or a victim. Examples include checking or monitoring a partner’s cell phone, email or social media, or insisting that a partner text when they arrive at and leave from work every day. Other cues for which Cameron stays alert include:

  • Clients who clam up in session or appear to be afraid of their partner
  • Clients who are isolated from friends and family
  • Clients who feel they can’t go to work, school or social engagements because it upsets their partner
  • If one partner is the sole decision-maker or in complete control of the couple’s finances
  • If one of the partners continually feels guilty for their behavior
  • A partner who exhibits extreme jealousy
  • Clients who mention “walking on eggshells” around their partners
  • Clients who are having thoughts of suicide or threatening to harm themselves or their abuser
  • A partner who pressures the other partner to use drugs or alcohol or to not use contraception (or who lies about their own use of contraceptives)
  • A partner who pressures the other partner to have sex or to perform sexual acts that the person is uncomfortable with
  • Clients who talk about a partner belittling or embarrassing them in front of other people

Control tactics often go hand in hand with perpetrators minimizing or placing blame for their behavior, Cameron adds. Perpetrators of abuse may tell a victim that they wouldn’t have to act this way if the person came home from work on time, paid the bills on time, didn’t talk back, etc. Or, Cameron says, they may tell a partner, “It could have been a lot worse. I only shoved you. I didn’t punch you.”

In counseling, perpetrators may make statements such as, “I didn’t hurt her. I just punched the wall.” The behavior implies, however, that the perpetrator could have hurt the person, Cameron points out.

“Someone who is abusive will try and deflect attention away from the abuse,” Bassett says. “They will try and name what is happening. Maybe they push or strangle or pull their partner’s hair. But they will say, ‘I am not abusive because I never hit you. Have I ever hit you?’ or [point out that] there was no bruise. There’s a lot of crazy-making behavior that goes on. They’ll deny it ever happened or focus on something else. Abuse is a pattern of behavior, and the abuser will rationalize those patterns as something else. Pay attention to that as a therapist and help them to name the behavior [for what it is].”

If a client mentions that they fight a lot with their partner or that the partner has a temper or a “short fuse,” counselors can prompt the client to explain the fights, Cameron says. For example, “Tell me what these fights look like. Are there times [when] it feels unsafe?” Victims may use phrases such as “sometimes he is rough with me” or he “put hands on me,” not fully recognizing the behavior as abuse, she notes.

Carlson also recommends that counselors use carefully worded questions to follow up on statements made by clients to further explore the nature of their relationship experience. For example, ask clients how they handle conflict with an intimate partner and then use leading questions to learn more: When there is a disagreement, is it safe to talk about the disagreement? Is there any type of pushing, shoving, hitting, use of objects, physical violence, threatening language or name calling? Is jealousy a motivating factor? Does one partner place blame on the other, making statements such as, “You made me do this”? Is the partner violent or hostile outside of the relationship?

“Ask questions that determine if there is regret or remorse [after conflict] or if they recognize that there are other ways of handling conflict,” Carlson says.

In sessions with individual clients, Carlson recommends that counselors preface some of their most direct questions — such as “Are you afraid of your partner?” — with dialogue that prepares the client. “Say, ‘I have some questions for you about how you handle conflict in your relationship. They’re going to be very direct, and I wanted to give you a heads up, but it will help me better understand what you’re going through.’ Really tap into your basic counseling skills, the relationship-building skills that we learn early on, and emphasize those when such important questions are being asked,” Carlson says.

At the same time, Bassett adds, clinical counselors shouldn’t be afraid to ask hard questions of a client when appropriate. “Ask not just, ‘Has your partner physically assaulted you?’ but ‘Are you afraid of your partner?’ and be willing to explore that. Explore the emotional piece of abuse.”

Counselors can also supplement their own questions by using a formal questionnaire — Carlson recommends Brian Jory’s Intimate Justice Scale — or including questions on intake forms. Keep in mind, however, that clients may answer “no” to questions that later turn out to be a “yes” when explored in therapy.

Perpetrators of domestic violence often use manipulation to gain and maintain control over a person and keep them in the relationship, Cameron says. When alone with a partner, perpetrators sometimes threaten suicide if the partner ever were to leave them, or they make statements inferring that the partner would be worse off on their own: “If you leave, you won’t get any money”; “You will lose the kids”; “No one will ever love you. I’m the only one who will put up with you.”

“One of the biggest power tools is fear — abusers wield fear,” Cameron says. “They use fear to control their partner. In addition, abusers will often apologize for the abuse and say, ‘It will not happen again,’ without being accountable. Then they continue using control tactics.”

This can be complicated further if the couple’s friends and family take sides or if the victim comes from a culture or faith community that emphasizes submission to a partner, views marriage as an unbreakable bond, or values reconciliation over safety, Cameron adds.

Manipulation by a perpetrator can also extend to sexual assault, which often overlaps with domestic violence, Bassett says. “It’s also common for an abusive person to force or pressure sex [with an intimate partner]. They will define the experience as nonabusive and lay the groundwork for the survivor to agree to sex so that they aren’t forced,” she says. “The abuser is [then] able to say that they agreed to sex, making them complicit in what is actually a sexual assault. The abuser defines the experience, and the survivor needs the space and safety to name their experience [in counseling].”

Hard questions, empathetic listening

Most of all, clients who are currently in or have been in an abusive relationship in the past need a safe space to feel heard and validated and to be connected to resources to address their safety, Cameron says. It’s no surprise that building a therapeutic bond is especially important with these clients.

“Communicate that you believe them,” Cameron urges. “The most restorative thing [for the client to hear is] ‘it’s not your fault, and it’s not OK that they are doing this to you.’”

“It’s incredibly important to be nonjudgmental,” agrees Carlson. “There are so many practitioners who have a personal connection to this topic, it can be an emotive experience. The time of disclosure is a very important moment for the victim and can be filled with a lot of embarrassment and shame. When they are deciding how much to disclose, it’s often based on how they feel it will be received. … It’s important to manage your emotions in that moment because it’s such an important moment.”

“You may leave the room and feel, ‘Oh my gosh, this is an emergency. I have to get this person out.’” Carlson continues. “But remember that this is their daily reality. They’ve been living with this [abuse] for a while. It feels like an emergency to you, but to act on that may put the victim in danger. It’s important that the victim drives the steps of what happens next.”

Bassett agrees: “Be very aware that your goal [as a counselor] is not that they should leave the relationship. That needs to be a goal they make themselves. They have to own it, because any decision they make will potentially have ramifications for them.”

Cameron notes that taking decisions out of the hands of clients is one of the worst mistakes counselors can make when working with victims of IPV. “They’ve already had someone control their life, and we don’t want to step into that role,” she says. “The victim has the best knowledge about what they need.”

It’s vital for practitioners to explore a client’s experience with genuine care, says Paulina Flasch, an ACA member and an assistant professor in the professional counseling program at Texas State University. “Really show concern and empathy and don’t sound like you’re interrogating them,” says Flasch, who runs a family violence research team at Texas State and worked at a domestic violence agency before and during her master’s program. “Focus on the counselor-client relationship, and ask [hard questions] because you really care. Share that what you’re hearing sounds abusive and that it must have been really hard [to go through]. … If you’re hearing that a past relationship was abusive, it’s important to call it that and identify its aftereffects. It can help validate their current experience and help them understand why they’re struggling. Help them look at patterns and how things tie together. … It’s a very powerful moment when the client connects the dots.”

“This is a person whose boundaries have been violated and who has not had safety and security — and we [counselors] have to be careful with that,” Flasch continues. “We have to let them know there will be a different response and they won’t be demeaned. If they went through that, they’re strong. Recognize that.”

All of the counselors interviewed for this article recommend using psychoeducation techniques and the Power and Control Wheel system (available at theduluthmodel.org) to talk through what a healthy relationship looks like (and does not look like) with clients who have experienced IPV. Bassett also stresses that work with IPV clients must be trauma-informed.

Emotionally focused therapy (EFT), expressive therapies, bibliotherapy or cinematherapy, grounding techniques and decision-making exercises can also help IPV clients, Flasch notes, as can attending support groups for IPV survivors in addition to counseling.

Victims of domestic violence often grapple with intense feelings of guilt or shame, sometimes made worse by harmful stereotypes and society’s general misunderstanding of the complexity of abuse. Victims can hear messages such as “Why didn’t you just leave him?” or “Why didn’t you get out sooner?” in both direct and indirect ways in popular culture, from family and friends, or in offhand remarks by acquaintances.

The reality is that it’s not that simple, Flasch notes. Victims of domestic violence are in the most danger when they are ending a relationship with their abuser (see sidebar, below). In addition, domestic violence often creeps into a relationship slowly over time in ways that are unrecognizable to the victim.

The relationship “hasn’t always been dangerous,” says Flasch, who has a private practice in Austin, Texas, and specializes in working with couples and individuals who have experienced trauma. “There have been a lot of pieces that have kept them in the relationship. If they had known this was going to happen, they would have never been in the relationship. Intimate partner violence is the breaking down of a human. They completely lose their sense of self and begin to believe everything the abuser has said about them. It happens smally and slowly.”

Pointing out this trajectory to the client emphasizes that it wasn’t their fault and helps them learn what to look for in future relationships, Flasch adds. “Normalize it with the client. This [IPV] is very common and very similar in the ways it comes to happen,” she says. “It’s a systematic breakdown of a person that happens in very small steps that no one would recognize unless you know what you’re looking for. Helping them understand what and how it happened can help take away some of that fault and blame. Then work on empowerment. Victims have had to ask their abuser for everything. It’s our job to get their voice back.”

Planting seeds

In addition to providing a safe space to be heard and empowered, counseling can be a place for victims of IPV to learn what a healthy relationship looks like. This is especially true for clients whose histories include past trauma (in addition to IPV) or who haven’t been exposed to healthy relationships in their life, Flasch notes.

“The counselor may be that first one, that first good relationship and having a feeling of being in a room with someone who cares,” she says. “Model that through your interaction with clients. Psychoeducation is a big part of working with [IPV] victims and survivors.”

Flasch suggests using the Power and Control Wheel while discussing what it feels like to be in a healthy relationship: What aspects are present? What does respect look like? How do arguments start and end? What does equality look like?

Making a list of the elements in a healthy relationship can also help, Flasch says. “It’s not tangible [to clients] sometimes. There’s so much self-blame and lack of trust of themselves and their own instincts. They often don’t trust themselves to make decisions or recognize if something [in a relationship] is dangerous.”

It can also be helpful for counselors to talk through boundary issues with IPV survivors, including what is and isn’t their responsibility in a relationship, Bassett adds.

“With someone who is abusive, that person will not accept responsibility [for abusive behavior]. The person who is being abused typically will accept full responsibility,” she says. “They may claim, ‘Oh, he’s Dr. Jekyll and Mr. Hyde. He’s so sweet, but when he drinks, or goes off his medication [he turns dangerous].’ That’s just not true: The good parts and the loving parts are part of the [control] strategy. Be very clear about that. … Help them not to buy into it, overtly or covertly.”

Couples counseling and safety

A relationship in which IPV is present has, at its core, an imbalance of power and control. This imbalance makes couples counseling an unsafe environment for the person experiencing the abuse, Carlson stresses. If a counselor is working with a couple exhibiting signs of IPV, he or she should take steps to terminate couples counseling as soon as possible while ensuring the victim’s safety, Carlson says.

“If power and control exist in the couple’s dynamic, it’s generally not safe to be in a setting [i.e., couples counseling] where they’re both on equal ground being asked to practice healthy behaviors and make changes,” he explains. “That can’t happen when there’s inequality.”

Cameron agrees. “Each session is posing a safety risk for the victim. In couples counseling, we’re asking both parties to be accountable for solving problems in the relationship, and part of the control tactics [of IPV] is making the victim feel that it’s their fault.” Perpetrators of abuse may retaliate against their partners after counseling sessions in reaction to what was said or disclosed, she says.

On the flip side, abuse victims may say only what they need to say to keep from “making waves” with their abusers during counseling sessions. In addition, “an abuser may be very charming and manipulate the counselor,” Cameron says. Counselors who don’t recognize the manipulation or other possible indicators of IPV can end up unintentionally colluding with the abuser, she points out.

Both Cameron and Carlson recommend that counselors — whether they work with couples or individuals — seek training on IPV to stay informed on best practices and forge connections with local domestic violence agencies. It is important to establish these working relationships ahead of time so that counselors can readily consult with specialists when they identify signs of IPV with a client (or a couple) on their caseload, Carlson says. “Consultation [with an IPV specialist] helps to create a methodical, well-thought-out plan for that point forward,” says Carlson, noting that any consultation must be done within ethical guidelines and without sharing any identifying details about the individuals involved.

Once a counselor has identified that IPV is present in a relationship, the steps to terminate couples counseling must be handled delicately. Counselors should never let the abuser know that they suspect abuse is taking place, Cameron emphasizes. At the same time, a fine balance must be maintained to ensure that a victim doesn’t lose contact with the counselor and is connected to resources before couples counseling is terminated.

“Never confront abuse head-on with both parties in the room. That will put the survivor at risk,” Cameron says. “Get creative for ways to get the survivor alone. … Come up with a reason to separate them and then check in with the survivor. Ask them if they feel safe at home. Just straight up asking if they are being abused — they are not going to recognize it that way. Often, the abuser has worked really hard to convince the victim that there is no abuse.”

Cameron has known counselors who separate the couple by asking one of the partners to fill out paperwork in the waiting room. Practitioners can also try to speak over the phone outside of session to clients who are suspected targets of abuse, as long as they ensure the client is alone for the call, Cameron adds.

Carlson notes that it’s not uncommon in couples counseling for a practitioner to meet with one of the clients individually to work on an issue. Counselors can fall back on that as an excuse to separate a couple when it is suspected that IPV is present, he says.

“When [you] first meet with a couple, separate them to fill out an intake questionnaire and speak with them individually. That way, you set a precedent of talking separately,” Carlson says. “Then, you can say later, ‘We are going to meet individually to follow up on some of the things we talked about’ [at intake]. There is precedence, and it doesn’t seem out of the ordinary.”

Flasch agrees and suggests that couples counselors do full individual sessions with both partners after the first two or three sessions, regardless of whether IPV is suspected. In these sessions, counselors should always assess for IPV. She suggests asking questions such as “How do you and your partner show respect for each other?” and “Tell me about your arguments: How do they start and end, and who initiates?”

A counselor’s next step should be to connect the victim with local support services. This must also be handled carefully, Cameron says. For instance, a client could put a domestic violence hotline number in their phone under another name, or the counselor could give the information verbally to the client to remember and look up later. Cameron also recommends that counselors leave pamphlets and other information about domestic violence resources in the lobbies and restrooms of their offices for all clients to see and have access to.

If appropriate, Cameron recommends that counselors also connect perpetrators with a local batterer or offender program.

“It’s important to work in collaboration with your local [domestic violence] agency,” Cameron says. “For us to address abuse in our communities, there needs to be community accountability for abusers, and that can’t just come from domestic violence agencies. It needs to come from all aspects of the community. You’re not going to end domestic violence just by dealing with the aftermath.”

Once clients are given information about IPV resources, it’s up to them to seek help when they are ready and feel safe doing so, Carlson adds. It’s not a counselor’s role to ensure the client has followed up with those resources.

“Sometimes nothing happens,” Carlson acknowledges. “You present resources and opportunities and they know they have options, and that’s the biggest step they want to take at this point in time.”

Relationships post-IPV

Dating and forming new relationships can play a part in the healing process for survivors and help them learn more about themselves, their boundaries and their limits, says Flasch, who co-authored the article “Considering and Navigating New Relationships During Recovery From Intimate Partner Violence” in the April issue of the Journal of Counseling & Development. Counselors should be aware that the risk exists for survivors of IPV to find themselves in another abusive relationship. However, forging new healthy relationships — with a counselor as a support and ally — can be a helpful step in the right direction, she notes.

“Survivors have to work through these issues for a lifetime, so waiting for the ‘right time’ to date post-healing may never come,” Flasch says. “A counselor can be a great support for a survivor. We know that most people continue to date. To say that you should be healed completely before you go out, it’s not realistic. And healthy relationships can be incredibly healing. Having a person who is safe and loving and accepting is a huge benefit. We [counselors] shouldn’t necessarily discourage dating but help them navigate the process. Educate them about red flags and warning signs, and celebrate the successes of milestones reached through dating. Also [process] triggers and things that get in the way.”

“Having experiences with other people and then processing it in counseling can be very powerful and helpful to healing,” she continues. “We can be great allies and celebrate with clients when they try something new.”

For the journal article, Flash and her co-authors studied the experiences of IPV survivors who went on to try new relationships, ranging from casual dating to marriage. Through these relationships, participants reported learning to trust themselves and their instincts and “reclaim parts of themselves lost during the IPV relationships,” Flash wrote with her co-authors, David Boote and Edward H. Robinson.

Dating post-IPV “can be a process for survivors to try and find corrective experiences and explore trust, make decisions that are theirs and be their own person, [and] learn about control and boundaries,” Flasch says. “But this is also a very scary process and one that has a lot of layers to it, so it can bring challenges. It can be hard to learn to trust when it’s been taken away from you in the past.”

 

****

 

IPV: Need-to-know points for counselors

One of the most misunderstood aspects of intimate partner violence (IPV) is how complicated and dangerous leaving an abusive partner can be, says Taylor Cameron, a licensed professional counselor (LPC) and director of transitional housing at a Texas nonprofit that provides support services to victims of domestic violence and sexual assault. The power imbalance of abusive relationships often means that one partner has severely restricted the other’s access to finances, friends and family members, and community resources. Separating from an abuser often means starting life over, which is why there is an intersection of IPV and homelessness, she says. These factors are only exacerbated when children are involved or when the victim experiences other forms of systemic oppression such as racism, homophobia or classism.

“They are often trapped between violence and homelessness,” Cameron says. “The abuser has often messed up their credit and finances or totally controlled them, so they’re starting from scratch. The most dangerous time for a victim is during separation and when they are separated [because] the abuser is losing the power they have worked to gain and maintain.”

According to Cameron, IPV victims are at the highest risk of lethality under the following circumstances:

  • When the couple has separated or is in the process of separating
  • If sexual abuse or sexual coercion is present in the relationship
  • If an abuser makes threats of homicide or suicide
  • When a restraining order is filed
  • If the victim is pregnant
  • If strangulation is occurring
  • If violent behavior is occurring outside of the home (which indicates the abuser has escalated to the point where he or she does not care if other people see the behavior, Cameron says)
  • If there is involvement with child protective services
  • If the abuser has access to weapons
  • If the abuser exhibits stalking behaviors
  • If law enforcement is involved

Counselors should also keep in mind that even when victims leave an abusive relationship, they may still come in contact with their abusers — and be put at risk for retraumatization — through legal proceedings, child custody hearings or stalking behavior, adds Paulina Flasch, an assistant professor in the professional counseling program at Texas State University.

“Just because someone is no longer in an IPV relationship doesn’t mean they’re no longer in it. Remember that and equip them with tools [to cope],” Flasch says.

 

****

 

Important resources

 

Margaret Bassett recommends the following books for practitioners:

  • Why Does He Do That? Inside the minds of angry and controlling men by Lundy Bancroft
  • Battered Women’s Protective Strategies: Stronger Than You Know by Sherry Hamby
  • Coercive Control: How Men Entrap women in Personal Life (Interpersonal Violence) by Evan Stark
  • Safety Planning with Battered Women: Complex lives/Difficult Choices by Jill Davies, Eleanor J. Lyon and Diane Monti-Catania
  • The Verbally Abusive Relationship by Patricia Evans
  • Domestic Violence Advocacy: Complex lives/Difficult Choices by Jill Davies and Eleanor J. Lyon

 

Related reading, from Counseling Today:

 

****

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

Letters to the editor: ct@counseling.org

****

 

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

Building a kinder and braver world

By Bethany Bray March 13, 2019

When Cynthia Germanotta discusses how complicated and misunderstood mental illness can be, she speaks from a place of knowing because her family has lived the reality. Germanotta is the mother of two daughters, the oldest of which, Stefani — better known as Oscar and Grammy Award-winning artist Lady Gaga — is open about her struggles with posttraumatic stress disorder, depression and anxiety.

“My husband and I tried our best (and still do!) to be deeply loving and attentive parents, who made sure we had regular family dinners and spent hours talking with our children. But, for all of that communication, we still didn’t really understand exactly what they needed sometimes,” Germanotta wrote in a candid essay last year. “Like many parents, I didn’t know the difference between normal adolescent development and a mental health issue that needed to be addressed, not just waited out. I mistook the depression and anxiety my children were experiencing for the average, if unpleasant, moodiness we all associate with teenagers.”

Cynthia Germanotta

Together, Germanotta and Lady Gaga work to combat the stigma and misunderstanding that often surround mental health issues through the Born This Way Foundation, a nonprofit they co-founded in 2012. Germanotta will speak about mental health and the work of the foundation during her keynote address at the American Counseling Association’s 2019 Conference & Expo in New Orleans later this month.

Through research and youth-focused outreach programs, the Born This Way Foundation works to disseminate information and resources about mental health and help-seeking. Its mission is to “support the wellness of young people and empower them to create a kinder and braver world.”

Counselors, Germanotta asserts, have an important role to play in achieving that goal. She recently shared her thoughts in an email interview with CT Online.

 

Q+A: Cynthia Germanotta, president of the Born This Way Foundation

 

Part of the mission of your foundation is to empower young people to “create a kinder and braver world.” From your perspective, what part do professional counselors have to play in that mission? What do you want them to know?

Building a kinder, braver world takes everyone — including (and especially) counselors. As adults who care about and work with young people, counselors can and do help young people understand how to be kind to themselves, how to cope with the challenges that life will throw their way, and how to take care of their own well-being while they’re busy changing the world.

To us, being brave isn’t something you just have the will to do; it’s something you have to learn how to do and be taught the skills for, and counselors can help young people do that. Counselors are a vital part of the support system that we need to foster for young people so that they are able to lead healthy lives themselves and to build the communities they hope to live and thrive in.

 

What would you share with counselors — from the perspective of a nonpractitioner — about making the decision to seek help for mental health issues or helping a loved one make that decision? How can a practitioner support parents and families in making that decision easier and less associated with shame or stigma?

When you’re struggling with your mental health, asking for help is one of the toughest, bravest and kindest things you can do and, for so many, shame and stigma make these conversations even harder. If that’s going to change (and my team works every day to ensure that it does) we have to normalize discussions of mental health, turning it from something that’s only talked about in moments of crisis to just another regular topic of conversation.

Practitioners can help the people they work with, and their loved ones, learn strategies for talking about mental health, equipping them with the skills they need to communicate about an important part of their lives.

 

What motivated you to accept this speaking engagement to address thousands of professional counselors?

My daughter would be the first one to say, we can’t do this work alone. Fostering the wellness of young people takes all of us working together.

Counselors are such a crucial part of the fabric that surrounds and supports young people, so I was honored to be invited to speak to the American Counseling Association and have the opportunity to not only share our work at Born This Way Foundation, but to hear from (and learn from) this amazing group of practitioners.

 

What can American Counseling Association members expect from your keynote? What might you talk about?

I’m so looking forward to sharing a bit about Born This Way Foundation — why my daughter and I decided to found it, what our mission is and how we’re working toward our goal of building a kinder and braver world, including a couple of new programs we’ve excited to be working on this year.

I’m also excited to share what we’re hearing from young people themselves about mental health. We invest heavily in listening to youth in formal and informal situations, in person, online and through our extensive research. We’ve learned so much through this process, and we have some important insights we’re looking forward to sharing, including the results of our latest round of research where we collected data from more than 2,000 youth about how they perceive their own mental wellness [and] their access to key resources.

 

How have you seen the mental health landscape in the U.S. change since you started the Born This Way Foundation in 2012? Are things changing for the better?

Over the past seven years, we’ve seen real momentum around both the willingness to discuss mental health and the urgency of the challenges that so many young people face. We certainly have a long way to go, but I truly believe we’re starting to move the needle.

There are so many examples of the progress being made on mental health — public figures starting to talk about it, global advocates organizing around it, governments starting to invest in it, schools starting to prioritize it, and so much more.

And, as always, I’m inspired by young people who are so much further ahead on this issue than I think we sometimes give them credit for. In the research we’ve done, about 9 out of 10 young people have consistently said mental health is an important priority. There’s still work to do, but that’s a great foundation to build on.

 

After seven years of working on mental health and the foundation’s youth-focused initiatives, what gives you hope?

Young people give me hope. The youth that we have had the privilege to meet and work with throughout the years are so inspiring, demonstrating time and time again just how innovative, brave and resilient they are.

Young people already recognize mental health as a priority and have the desire and determination to change how society views and treats this fundamental part of our lives. Their bravery and enthusiasm make me excited for the future they will build, and [we are] committed to fostering their leadership and well-being.

 

****

 

Hear Cynthia Germanotta’s keynote talk Friday, March 29, at 9 a.m. at the 2019 ACA Conference & Expo in New Orleans. Find out more at counseling.org/conference.

 

Find out more about the Born This Way Foundation at bornthisway.foundation

 

****

 

In her own words

Read more about Germanotta’s perspective and experience through two articles she has written:

 

 

*****

 

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

 

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

****

 

 

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.